Mountain View Health Services
For profit - Corporation
155 Beds
Independent
Data: November 2025
6 Immediate Jeopardy citations
Trust Grade
0/100
#80 of 97 in UT
Last Inspection: August 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Mountain View Health Services has received a Trust Grade of F, indicating poor performance and significant concerns. It ranks #80 out of 97 nursing homes in Utah, placing it in the bottom half of facilities in the state, and #9 out of 10 in Weber County, meaning only one local option is worse. While the facility is improving, having reduced issues from 49 in 2022 to 41 in 2024, the overall situation is still concerning, especially given the high fines of $100,991, which are greater than 81% of similar facilities. Staffing is a weakness here, with a low rating of 1 out of 5 stars and a turnover rate of 60%, which is above the state average, impacting the quality of care. Specific incidents include failure to adequately address aggressive behaviors in residents and reports of abuse that went uninvestigated, raising serious safety concerns for potential residents.
- Trust Score
- F
- In Utah
- #80/97
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 60% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $100,991 in fines. Lower than most Utah facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 23 minutes of Registered Nurse (RN) attention daily — below average for Utah. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 120 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 18%
Review needed
49 → 41 violations
★★☆☆☆
2.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★★★
5.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2022: 49 issues
2024: 41 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
2-Star Overall Rating
Below Utah average (3.3)
Below average - review inspection findings carefully
Staff Turnover: 60%
14pts above Utah avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $100,991
Well above median ($33,413)
Significant penalties indicating serious issues
Staff turnover is elevated (60%)
12 points above Utah average of 48%
The Ugly 120 deficiencies on record
6 life-threatening 16 actual harm
Aug 2024
41 deficiencies
2 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Quality of Care
(Tag F0684)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 298 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dement...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 298 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dementia, essential hypertension, benign prostatic hyperplasia without lower urinary symptoms, acute kidney failure, weakness, and anxiety disorder.
Resident 298's medical record was reviewed on 8/7/24.
An admission Minimum Data Set (MDS) assessment dated [DATE], documented that resident 298 had a Brief Interview for Mental Status (BIMS) score of 13. A BIMS score of 13 to 15 would suggest intact cognition.
A review of resident 298's paper medical chart revealed an order dated 6/10/24, for a right lower extremity ultrasound to rule out a DVT [deep vein thrombosis].
A review of resident 298's progress notes revealed:
a. On 6/11/24 at 3:22 PM, a health status noted documented, PT [patient] APPT [appointment] C [with] MDR [medical doctor] WAS CANCELLED PER ADMIN [administration] HIS RLE [right lower extremity] IS QUITE A BIT BIGGER THAN PRIOR TO RECENT HOSPITAL STAY. ,D [sic] WAS INT [sic] TO SEE PT AND HE ORDERED THAT HE SEES HIA [sic] ORTHO ASAP [as soon as possible] AND A U/S [ultrasound] TO RLE TO R/O [rule out] DVT SO THIS RN [registered nurse] CALLED TO SET UP MOBILE EXAM WHEN I DID THE [sic] SAID IT WOULD BE DONE UNTIL JUNE 18TH WHICH THAT IS THE [NAME] [sic] DAY THT [sic] HIS APPT WAS RESCHEDULED FOR SO I BUT IT THE MD PHONE THIS INFO MAYBE HE WANTED US TO TAKE PT INTO HOSPITAL FOR EXAM. PT IS ALERT ORIENTED TO TIME AND ABLE TO FEED SELF. ABX [antibiotics] GIVEN AS PER 0RDER [sic] INCISION IS CLEAN DRY ANDEDGES [sic] ARE WELL AOPROXAMATED [sic]. WCTM [will continue to monitor].
b. On 6/18/24 at 2:54 PM, a health status note documented, Resident had a f/t [sic] appointment with [hospital name redacted] for his r [right] hip. An xray was done. Then he went to see his surgeon [name redacted] for f/u [follow up]. New orders are WBAT [weight bearing as tolerated], PT/OT [physical therapy/occupational therapy] to strength, ambulate and balance. Has anterior hip precautions. Anticoagulated for 2 more weeks from other. COntinue [sic] any chronic meds [medications] otherwise. F/U in 6 weeks with xrays to right hip. (around the July 30 or 1st week of August)
c. On 6/18/24 at 4:22 PM, a health status note documented, [name redacted] in for US of RLE. Patient was out on an appointment and I told [name redacted] that they made the appoinment [sic] in the afternoon as he had am [sic] appointments. The rep for [name redacted] took the number and said she would call back and come back if he was available. I told her that it had to be done. No calls were returned from [name redacted].
d. On 6/20/24 at 11:08 AM, a health status note documented, [name redacted] came in to do an US to residents RLE. RESULTS: Thrombus in common femoral. Femoral veins pros[proximal] and dist [distal], popliteal and posterior tibial veins with minimal flow. Veins non compressible. IMPRESSION: RLE DVT MD [medical doctor] notified immediately.
e. On 6/20/24 at 11:30 AM, a health status note documented, MD called and orders to send to ER [emergency room] for tx [treatment] of DVT.
On 8/7/24 at 12:23 PM, an interview was conducted with NP 2. NP 2 stated she saw the resident on 6/14/24 and his right leg was hurting and an ultrasound was ordered to rule out a DVT. NP 2 stated that staff usually did a stat [immediate] order to rule out a DVT. NP 2 stated that with the seriousness of the DVT, she would 100% order STAT.
On 8/7/24 at 1:03 PM, a follow up telephone interview was conducted with NP 2. NP 2 stated that she expected the facility to watch the leg and to get the ultrasound done as soon as possible. NP 2 stated resident 298 should have automatically been put on a blood thinner after he had femur surgery. NP 2 stated they were not advised by the facility that he was not on a blood thinner. NP 2 stated she was unsure if the facility had a policy regarding residents who had a suspected DVT, but she always ordered ultrasounds as STAT if she was ruling it out.
On 8/7/24 at 1:57 PM, an interview was conducted with the Director of Nursing [DON]. The DON stated that if the nursing staff received an order for an ultrasound to rule out a DVT the timeframe for the ultrasound to be done would be immediate and if this was not possible then the resident needed to be sent to the hospital. The DON stated that the nursing staff did not have great critical thinking skills and this caused them to miss important things. The DON stated that the facility did not have a policy regarding residents who had a suspected DVT or required a STAT ultrasound. The DON stated that the facility could do better. The DON stated that resident 298 did not have any anticoagulation after hip surgery. The DON stated that she had spoken with NP 2 and was informed that the resident should have been on anticoagulant therapy after surgery to prevent blood clots.
Based on interview and record review, the facility did not ensure that 2 of 30 sample residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, ongoing monitoring for changes in condition were not provided after one resident experienced ongoing emesis and abdmoninal pain, and a second resident had a deep vein thrombosis. The findings for resident 46 were determined to have resulted in immediate jeopardy for resident 46. Resident identifiers: 46 and 298.
NOTICE
On 8/7/24 at 3:00 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to provide residents quality of care to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This notice was given verbally and in writing to the facility Administrator (ADM), and the Business Office Manager (BOM) regarding resident 46.
On 8/13/24, the facility ADM provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 8/14/24 at 11:00 AM:
Updated Mountain View Health Services Immediate Jeopardy Removal Plan
Date Submitted 8-13-2024
We called and spoke with The Chief Clinical Officer (CCO) of an independent consulting organization as required by UDHHS (Utah Department of Health and Human Services) on 8-9-2024 at approximately 3:05pm regarding the executing an agreement. On 8-13-24, Mountain View Health Services entered into an agreement with the consulting organization. On 8-13-24 consultant(s) with the consulting organization will be onsite at the facility.
F 684 Quality of Care (Communication)
1. On 8-12-2024 the community management team implemented a morning Standup meeting with Nursing to get report from previous day's activities/concerns. If changes in condition are noted from communication notes DON (Director of Nursing) or ADON (Assistant Director of Nursing) will verify MD (Medical Director) team had been notified and if notification has not been made will do so at that time. When in-person visits are conducted, the consultants will attend morning meetings. In addition, when offsite, the consultants will participate in random morning meetings to review and listen to the process to ensure compliance is achieved.
2. On 8-12-2024 the nursing team implemented a new shift communication form that will be relayed at shift change with oncoming nurse for concerns/follow-up items still pending at shift change. All forms will be left in the drawer at nurse's station so management can review relevant items at the next morning standup meeting and follow up accordingly. In addition, the consultants will provide training on this process 8/14/2024.
3. On 8-12-2024 a new CNA (Certified Nursing Assistant) communication program/sheets implemented as a way for CNAs to communicate with oncoming shift and report to nurse. Sheets will be collected daily and reviewed during the daily standup meeting with department managers. The consultants will provide education and training on this process 8/14/2024.
4. On 8-12-2024 nursing implemented a new Communication and Follow-Up book that will remain at the nursing station. The book is a duplicate copy book with highlights and follow-up items from the previous day. The original will be removed and reviewed at daily manager Standup meeting. The consultants will provide education and training on this process 8/14/2024.
5. On 8-13-2024 communication improvements made between the building and MD team by adding the DON and Administrator have both been added to the secure messaging app between the MD group and Facility. Areas of concern or issues that arise will be addressed in the manager stand-up meeting.
6. On 8-13-24 representatives from the consulting organization reviewed and assessed the facility's policies and procedures regarding changes in resident condition. The consultants provided the community with a change of condition policy to adopt. The consultants provided education and training on 8/13/2024 [and]8/14/2024 with licensed nursing and nursing assistants.
The review with licensed nurses addressed expectations for ongoing assessments of each resident's condition, what constitutes a change in condition, expectations for the communication of changed (sic) in resident condition, and ongoing monitoring of residents experiencing a change in condition.
On 8-14-2024 facility in coordination with the consulting organization, the consultants will complete record reviews of all residents for the last 30 days to ensure no resident has experienced a change in condition not previously identified.
Any findings of change of condition will be reported to the resident's attending physician and the resident's representative. This information will be communicated with the DON and Administrator at the manager stand-up meeting.
The consultants ongoing for the next 30 days will review daily progress notes (M-F) (Monday through Friday) to ensure documented changes of condition are timely identified and action steps are taken with resident changes of condition.
Mountain View Health Services has implemented this plan to remove the conditions that constituted immediate jeopardy, and the immediate jeopardy was removed on 8-14-2024.
On 8/14/24, while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 8/14/24 at 11:00 AM.
Findings include:
1. Resident 46 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia and hemiparesis, chronic obstructive pyelonephritis, severe sepsis without shock, aspiration pneumonitis, acute kidney failure, supraventricular tachycardia, and bipolar disorder.
Resident 46's medical record was reviewed from 7/28/24 through 8/14/24.
A History and Physical for resident 46 dated 8/9/22 documented that resident 46 presented to the local emergency room after facility staff observed resident 46 to have some coffee-ground looking emesis and acute hypoxic respiratory failure. The hospital physician documented that resident 46 had a history of deep vein thromboses and was currently receiving a blood-thinning medication. Resident 46 was diagnosed with sepsis with acute hypoxic respiratory failure and a gastrointestinal bleed at that time.
Progress notes for resident 46 revealed the following entries:
a. On 6/16/24, resident 46 was seen by Nurse Practitioner (NP) 2. NP doumented that resident 46 . s a [AGE] year-old male with a history of CVA (cerebrovascular accident), COPD (chronic obstructive pulmonary disease) and multiple previous hospitalizations. Today patient was seen for his recertification visit. He was resting in his bed and appeared comfortable, no signs of distress. Patient reports he is doing fine. He is eating well, sleeping good, no issues with bowels or bladder, no anxiety or depression, no uncontrolled pain, anxiety or depression. He denied any current issues or concerns. Floor staff reports he is doing well. NP 2 did not document any acute health concerns upon assessment of resident 46.
b. On 6/21/24 at 9:30 PM, Registered Nurse (RN) 2 documented that there was a New order for Rocephin 1 Gm (gram) IM (Intramuscular) tonight, Sat (Saturday) [and] Sun (Sunday). for possible cholecystitis. Zofran 4 mg (milligrams) SL (sublingual) q (every) 6 hrs (hours). prn (as needed) N/V (nausea/vomiting). Schedule Tylenol 650 mg TID (three times a day) c (?) 3 days for abdominal pain. Stat (immediate) ultrasound of abdomen RUQ (right upper quadrant) and LLQ (left lower quadrant). No documentation was included in the note to indicate what occurred to prompt staff to contact the physician.
c. On 6/22/24 at 6:15 AM, RN 2 documented, Resident was heard by nurse urping (sic) up fluid. I went into his room and his roommate said he kept doing this. I checked him over and he had some brown- black fluid on the left side of his mouth. I told him not to swallow the fluid and to cough it into an emesis basin which I [NAME] (sic) to him. His VS (vital signs) were taken. T (temperature) 98.1, P (pulse) 112, R (respirations) 16 B/P (blood pressure) 148/74 and 02 (oxygen) sats (saturations) 94% on room air. I could hear bowel sounds in upper quadrant but minimal in lower quads. He stated that his pain was above his right navel and below it. Fluid brought up was a dark brownish color. MD PA (Physician Assistant) notified at 2200 (10:00 PM) with Rocephin, Zofran and scheduled Tylenol order. See MAR (Medication Administration Recrod) and progress noted (sic). Also a stat (immediate) ultrasound was ordered. Call was made to [name of contracted radiology provider] this AM (morning) and they stated that they donot (sic) do ultrasounds on the weekends. MD to be notified by day nurse, which was agreed in report this AM. [Note: The facility had been performing weekly vital signs on Resident 46. Per facility documentation, on 6/16/24, Resident 46's blood pressure was 114/62 and his pulse was 67. Per the facility's vital sign records for Resident 46, between 1/3/24 and 6/16/24, Resident 46's blood pressure was generally consistent with the reading obtained on 6/16/24. Resident 46's pulse had ranged from 58 to 85.]
Although the order for a stat ultrasound for resident 46 was documented to be received at 9:30 PM on 6/21/24, the facility nurse did not document attempts to have the stat ultrasound performed until 6:15 AM on 6/22/24; eight hours and 45 minutes later. Upon receiving notification from the contracted radiology provider that the company did not perform ultrasound tests on the weekend, there were no facility records to document that RN 2 contacted resident 46's physician.
[Note: Review of the written telephone order revealed that RN 2 documented she had obtained the order for the Rocpehin and stat ultrasound from NP 1.]
d. On 6/22/24 at 12:50 PM, RN 3 documented that resident 46 . has vomitted (sic) once this shift, it was a light brown color. He has requested more prune juice, but I denied that request and explained that we want to see why his vomit is brown. [Resident 46] had been laying in his vomit all night, we got him up to the shower and changed his bedding. His entire left arm, side of torso, and hip are very red. Cleaned well and put on hydrocortisone cream and barrier cream. Texted pic (picture) to provider of his inflamed skin. RN 3 did not document whether she had informed resident 46's physician of the ongoing brown emesis that resident 46 was experiencing. In addition, RN 3 did not document any indication that she was aware of the stat ultrasound order, or what the status was in obtaining the ultrasound.
e. On 6/22/24 at 10:54 PM, Licensed Practical Nurse (LPN) 3 documented Order noted for ultrasound of Abdomen, [name of contracted radiology provider] notified and is scheduled for Monday 6/24/24. No indication was made in the note by LPN 3 that he had contacted resident 46's physician regarding the delay in obtaining the stat ultrasound.
f. On 6/23/24 at 10:10 AM, RN 4 documented that resident 46 had an . Ultrasound scheduled for tomorrow r/t (related to) vomiting and abdominal pain.
g. On 6/23/24 at 4:36 PM, RN 4 documented that resident 46 had a Small amount of dark brown emesis early this morning. No other episodes this shift.
h. On 6/24/24 NP 3 documented that he spoke with resident 46 face to face for approximately 17 minutes, and that they discussed resident 46's medical conditions and his code status. NP 3 also documented that . Patient has cholecystitis and was started on on (sic) Rocephin on 6/21/24, we will continue to monitor patient closely to determine if antibiotic treatment has been effective. NP 3 documented that resident 46 was experiencing Right upper quadrant/right lower quadrant pain, but did not document any follow up he did with facility staff regarding the ultrasound order. NP 3 did not document any assessment with regard to resident 46's nausea or vomiting.
i. On 6/24/24 at 10:21 PM, RN 5 documented, Res (resident) currently on ABX (antibiotics) IM, (2nd dose) Medication was administered per MD orders. Res tolerated procedure well, there has been no ASE (adverse side effects) observed or reported. Fluids encouraged. RN 5 did not document any assessment with regard to resident 46's abdominal pain, nausea or vomiting. [Note: This note was entered as a late entry on 6/26/24 at 8:24 AM.]
j. On 6/25/24, at 11:00 AM, RN 4 documented that the contracted radiology provider . cannot ultrasound until 7/1/24. Medical directorship notified and ordered to have ultrasound done at [name of local hospital]. Scheduled with [name of local hospital] 6/26/24 at 0900 (9:00 AM) check in 0845 (8:45 AM). NPO (nothing by mouth) 8hrs (hours) prior to procedure. Medical directorship notified. No emesis on this shift and no reports of emesis on night shift. Resident states he does still have abdominal pain but is able to eat.
k. On 6/25/24 at 8:25 PM, RN 5 documented that resident 46, . continues on ABX IM, (final dose) Medication was administered per MD orders. Res tolerated procedure well, there has been no ASE observed or reported. Res instructed to move RUE (right upper extremity) often to decrease stiffening in the muscle/pain. Fluids encouraged. RN 5 did not document any assessment with regard to resident 46's abdominal pain, nausea or vomiting. [Note: This note was entered as a late entry on 6/26/24 at 8:28 AM.]
l. On 6/26/24 at 3:00 AM, RN 5 documented, CNA (Certified Nursing Assistant) completed rounds at 12:30am at which time resident was A&O (alert and oriented), brief was changed, resident was talking with staff. CNA started rounds at 02:30 (2:30 AM) upon entering residents' room, CNA exited notified nurse via radio to come down to res room. This nurse immediately went down, performed a quick assessment w/ (with) visual observation. Res had no pulse, eyes open, pale/ash color. No heart sounds. resident feet and hands cold with modeling. (02:45) (2:45 AM) Res was upright HOB (head of bed) 30-45-degree, emesis was observed down L (left) side of resident's shirt. There had been no emesis throughout this shift or reported from day shift, resident had no complaints after dinner, other than some abdominal pain, Tylenol offered, res declined. Res took all medication w/o (without) difficulty. Res was scheduled for an abdominal ultrasound this morning at 08:45 (8:45 AM). Appt (appointment) has been cancelled. Facility CNA provided post-mortem care, and reported resident continued to excrete emesis from mouth. Res has emergency contacted listed, who since has passed away. [Name of mortuary] was contacted. Body was received from this facility at 05:45 am (5:45 AM). MD, DON (Director of Nursing) and administrator notified.
On 8/8/24 at 1:45 PM, a telephone interview was conducted the an employee of the contract radiology provider (CRP 1). CRP 1 stated that their company did not receive notification of the ultrasound order for resident 46 until 6/22/24 at 9:50 PM. [Note: This was approximately 24 hours after the ultrasound order had been given to facility staff.] CRP 1 stated that the order was not called in to their comapny as a stat order.
On 8/3/24 at 5:00 PM, a telephone interview was conducted with CNA 7. CNA 7 stated that a week prior to resident 46's death, she only worked with resident 46 on one shift. CNA 7 stated that during that one shift, she observed resident 46 to be covered in throw up. CNA 7 stated that resident 46 obviously wasn't feeling good.
On 8/3/24 at 5:27 PM, a telephone interview was conducted with CNA 5. CNA 5 stated that she had noticed resident 46 vomiting during one of her shifts the week prior to resident 46's death. CNA 5 stated that she had notified the DON. CNA 5 stated that she observed resident 46's vomit to be watery . because he couldn't keep [his food] down. CNA 5 stated that resident 46 was obviously not feeling food. CNA 5 stated that resident 46 was vomiting so much that his shirt was covered in throw up when she checked on the resident.
On 8/3/24 at 7:17 PM, a telephone interview was conducted with CNA 6. CNA 6 stated that she had worked with resident 46 on 6/23/24 and 6/24/24. CNA 6 stated that resident 46 was complaining about abdominal pain during her shifts. CNA 6 stated that resident 46 had been throwing up and did not get out of bed during her shifts. CNA 6 stated that a bunch of us had to go in and clean him up after the resident had vomited. CNA 6 stated that she observed resident 46's emesis and it wasn't normal throw up . it looked black and like chunky and liquids at the same time. It was black and dark brown. CNA 6 stated that other staff reported to her that resident 46 had been constantly throwing up all day on one of the days she worked with him, I wanna say he threw up both nights but it was worse the next night. They said they wanted to get him an ultrasound and they were waiting but they wanted to get the ultrasound first before they sent him out.
On 8/5/24 at 6:25 PM, a telephone interview was conducted with CNA 4. CNA 4 stated that during the last week of resident 46's life, resident 46 was very sick and he was throwing up for two days. CNA 4 stated that on 6/23/24, he observed resident 46 while the resident was being weighed. CNA 4 stated that this was the last time he had seen resident 46 and that the resident didn't look really good. He was very pale, and his eyes were sunken in. CNA 4 stated that other staff had reported to him that resident 46 was vomiting a dark liquid and that the resident's health was getting worse and he wasn't feeling well.
On 8/3/24 at 5:39 PM, a telephone interview was conducted with LPN 3. When asked about the note that LPN 3 entered on 6/22/24, LPN 3 stated that the facility had been having problems with predictability of services with the contracted radiology provider since at least January 2024. LPN 3 stated the the contracted radiology provider kept putting off coming in to the facility to perform resident 46's ultrasound after it was ordered on 6/21/24. LPN 3 stated that he was unsure why there was an order for an ultrasound, or if resident 46 was experiencing a change in condition during the week prior to the resident's death.
On 8/3/24 at 3:55 PM, a telephone interview was conducted with RN 4. RN 4 stated that she worked on Sunday, 6/23/24, and was aware that resident 46 was supposed to have an abdominal ultrasound completed, but that the contracted radioligy company did not provide ultrasounds on the weekends. RN 4 stated that she did not work on Monday 6/24/24, and thought that the ultrasound would be completed that day. RN 4 stated that when she returned to work on 6/25/24, the ultrasound had not been completed so she contacted the contracted radiology company. RN 4 stated that the radiology company told her that they did not have resident 46 on their schedule, and that the earliest they could perform the ultrasound would be on 7/1/24. RN 4 stated that she then contacted the on-call provider for further instruction. RN 4 stated that the on-call provider instructed her to schedule the ultrasound at a local hospital. RN 4 stated that the Medical Director was in the facility on 6/25/24, and she had informed the Medical Director about the delay in getting an ultrasound for resident 46. RN 4 stated that during her shift on 6/23/24, resident 46 was vomiting at times, although she did not observe the emesis produced. RN 4 stated that staff reported to her that resident 46's emesis was brown or dark brown. RN 4 stated that on 6/25/24, resident 46 reported he was still experiencing abdominal pain, but did not pinpoint the exact location of the pain. RN 4 reported that on 6/25/24, resident 46 received a shower, and had consumed at least part of his meals. RN 4 stated that she also worked as the ADON, and that she did not report resident 46's change in condition or delay in obtaining the ultrasound to the DON because we don't have office hours, we just work the floor when we are there.
On 8/5/24 at 2:10 PM, a telephone interview was conducted with RN 5. RN 5 stated that when she arrived for her scheduled night shift on the evening of Monday 6/24/24, she was not given any information about resident 46's condition during the nurse to nurse report. RN 5 stated that there had been a lack of communication between shifts and that she had been unaware of the stat ultrasound order or that resident 46 had been vomiting. RN 5 stated that she was aware that resident 46 was scheduled for an ultrasound at some point, but it was so long out . that bothered me. RN 5 stated she texted the physician on call on 6/24/24 because she was worried about the delay because there was a patient in the unit (memory care unit) that died after waiting a long time for treatment. [Note: This was identifed to be resident 298, who has a finding below.] RN 5 stated that the following day, on 6/25/24, the physician gave an order to schedule the ultrasound with the local hospital. RN 5 stated that at times, the physician on call did not respond timely during the evening and night hours. RN 5 stated that she had been resident 46's assigned nurse on the evening of 6/25/24. RN 5 stated that at approximately 12:40 AM on the morning of 6/26/24, a CNA checked on resident 46 as part of his rounds. RN 5 stated that at that time, the CNA left the resident's room and signaled to the nurse who was at the nurses station that the resident had passed away. RN 5 stated that she then went to resident 46's room to visualize the resident. RN 5 stated that when she saw resident 46, there was no emesis on the resident, but that while providing post mortem care, the CNA reported that emesis came out of resident 46's mouth. RN 5 stated that after resident 46's death, she had reviewed the resident's medical record and realized the resident had been vomiting for a few days. RN 5 stated it was at that time, she discovered that resident 46 had been vomiting, and I didn't see much of an intervention from the facility. RN 5 stated that the lack of communication is concerning because it could have been a different outcome. had I known. Resident 46 stated that the facility has a 24 hour report, but she did not have access to it, and I have to depend on what the nurse tells me during shift change. RN 5 also stated that there was no system of communication between CNAs and nurses. RN 5 stated that for example, she has heard CNAs discussing a resident who had experienced diarrhea, and she told the CNAs they should be reporting those types of things to the nurse on duty also.
On 8/5/4 at 6:32 PM, a telephone interview was conducted with RN 3. RN 3 stated that she had been assigned to resident 46 for one shift after the facility received an order for the resident to have a stat ultrasound on 6/21/24. RN 3 stated that when she came on shift on the morning of Saturday, 6/22/24, resident 36 had been throwing up throughout the night, so I went to give Zofran. RN 3 stated that staff had been texting the physician in an attempt to get the ordered ultrasound completed, because the contract radiology company would not complete the ultrasound on a weekend. RN 3 stated that the contract radiology company would not complete the ultrasound until Monday, 6/23/24. RN 3 stated that when she spoke with resident 46 during her shift, the resident reported that he was in pain and was requesting prune juice. RN 3 stated that she did not provide resident 46 with any prune juice, because resident 46's emesis was a brown color and I was trying to determine if it was brown because of blood or prune juice. RN 3 stated that the resident's emesis looked like prune juice, but did not have anything that looked like coffee grounds. RN 3 stated that resident 46 repeatedly asked for prune juice because he did not feel he was having bowel movements. RN 3 stated that resident 46 had actually had a bowel movement during her shift that she observed, and stated it was huge, and yellowy brown in color and didn't look like it had blood in it. RN 3 stated that she had spoken with LPN 3, who was also working that day, about resident 46's vomiting. RN 3 stated that LPN 3 told her that she should notify the physician, but RN 3 told LPN 3 that RN 5 had already contacted the physician, so LPN 3 told RN 3 to wait and see what the doctor wants to do. RN 3 stated that she texted the physcian during her shift because resident 46 had vomited during the evening of 6/21/24 and night shift hadn't cleaned him up well so he had gotten red on that left side. RN 3 stated that she did not notify the physician about the resident vomiting, only the redness on the resident's skin. RN 3 stated that the physician's response was we will keep an eye on it, and did not provide any new orders. RN 3 stated that the physician did not say anything about the ultrasound. RN 3 stated that she did not realize the ultrasound order had been written as a stat order.
On 7/31/24 at 3:15 PM, an interview was conducted with the DON. The DON stated that she was aware that resident 46 was vomiting during the last week of the resident's life, but could not recall how she received that information. The DON stated that no one had spoken to her about resident 46 and his change of condition. The DON stated that we should have at least sent him to the ER (emergency room) to get evaluated if the stat order was written. The DON stated
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0776
(Tag F0776)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 298 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dement...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 298 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dementia, essential hypertension, benign prostatic hyperplasia without lower urinary symptoms, acute kidney failure, weakness, and anxiety disorder.
Resident 298's medical record was reviewed on 8/7/24.
An admission Minimum Data Set (MDS) assessment dated [DATE], documented that resident 298 had a Brief Interview for Mental Status (BIMS) score of 13. A BIMS score of 13 to 15 would suggest intact cognition.
A review of resident 298's paper medical chart revealed an order dated 6/10/24, for a right lower extremity ultrasound to rule out a DVT [deep vein thrombosis].
A review of resident 298's progress notes revealed:
a. On 6/11/24 at 3:22 PM, a health status noted documented, PT [patient] APPT [appointment] C [with] MDR [medical doctor] WAS CANCELLED PER ADMIN [administration] HIS RLE [right lower extremity] IS QUITE A BIT BIGGER THAN PRIOR TO RECENT HOSPITAL STAY. ,D [sic] WAS INT [sic] TO SEE PT AND HE ORDERED THAT HE SEES HIA [sic] ORTHO [orthopedic doctor] ASAP [as soon as possible] AND A U/S [ultrasound] TO RLE TO R/O [rule out] DVT SO THIS RN [registered nurse] CALLED TO SET UP MOBILE EXAM WHEN I DID THE [sic] SAID IT WOULD BE DONE UNTIL JUNE 18TH WHICH THAT IS THE [NAME] [sic] DAY THT [sic] HIS APPT WAS RESCHEDULED FOR SO I BUT IT THE MD PHONE THIS INFO MAYBE HE WANTED US TO TAKE PT INTO HOSPITAL FOR EXAM. PT IS ALERT ORIENTED TO TIME AND ABLE TO FEED SELF. ABX [antibiotics] GIVEN AS PER 0RDER [sic] INCISION IS CLEAN DRY ANDEDGES [sic] ARE WELL AOPROXAMATED [sic]. WCTM [will continue to monitor]
b. On 6/18/24 at 4:22 PM, a health status note documented, [name redacted] in for US of RLE. Patient was out on an appointment and I told [name redacted] that they made the appoinment [sic] in the afternoon as he had am [sic] appointments. The rep for [name redacted] took the number and said she would call back and come back if he was available. I told her that it had to be done. No calls were returned from [name redacted].
c. On 6/20/24 at 11:08 AM, a health status note documented, [name redacted] came in to do an US to residents RLE. RESULTS: Thrombus in common femoral. Femoral veins pros[proximal] and dist [distal], popliteal and posterior tibial veins with minimal flow. Veins non compressible. IMPRESSION: RLE DVT MD [medical doctor] notified immediately.
d. On 6/20/24 at 11:30 AM, a health status note documented, MD called and orders to send to ER [emergency room] for tx [treatment] of DVT.
On 8/7/24 at 12:23 PM, an interview was conducted with NP 2. NP 2 stated she saw him on the 14th [ 6/14/24] and his right leg was hurting and an ultrasound was ordered to rule out a DVT. We usually did a stat [immediately] order to rule out. NP 2 stated with the seriousness of the DVT she would 100% order STAT.
On 8/7/24 at 1:03 PM, a follow up telephone interview was conducted with NP 2. NP 2 stated that she expected the facility to watch the leg and to get the ultrasound done as soon as possible. NP 2 stated resident 298 should have automatically been put on a blood thinner after he had femur surgery. NP 2 stated they were not advised by the facility that he was not on a blood thinner. NP 2 stated she was unsure if the facility had a policy regarding residents who had a suspected DVT, but she always ordered ultrasounds as STAT if she was ruling it out.
On 8/7/24 at 1:57 PM, an interview was conducted with the Director of Nursing [DON]. The DON stated that if the nursing staff received an order for an ultrasound to rule out a DVT the timeframe for the ultrasound to be done would be immediate and if this was not possible then the resident needed to be sent to the hospital. The DON stated that the nursing staff don't have great critical thinking skills and this caused them to miss important things. The DON stated that the facility did not have a policy regarding residents who had a suspected DVT or required a STAT ultrasound. The DON stated that the facility could do better.
.
Based on interview and record review, the facility did not ensure for 2 of 30 sample residents that radiology and other diagnostic services were provided to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services. Specifically, residents were not provided with ultrasounds as ordered by the physician. This resulted in a finding of Immediate Jeopardy for resident 46. Resident identifiers: 46 and 298.
NOTICE
On 8/7/24 at 3:00 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to provide residents with radiology and other diagnostic services to meet the needs of the residents. This notice was given verbally and in writing to the facility Administrator (ADM), and the Business Office Manager (BOM) regarding resident 46.
On 8/13/24, the facility ADM provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 8/14/24 at 11:00 AM:
Updated Mountain View Health Services Immediate Jeopardy Removal Plan
Date Submitted 8-13-2024
We called and spoke with The Chief Clinical Officer (CCO) of an independent consulting organization as required by UDHHS (Utah Department of Health and Human Services) on 8-9-2024 at approximately 3:05pm regarding the executing an agreement. On 8-13-24, Mountain View Health Services entered into an agreement with the consulting organization. On 8-13-24 consultant(s) with the consulting organization will be onsite at the facility.
F 776 Radiology and Other Diagnostic Services
1. Facility executed a contract 8-8-24 with a new Imaging Vendor for all radiological and diagnostic services. The Imaging Vendor has started service 8-9-2024 and nursing staff has been trained on new vendor and process to obtain services from said vendor. Processes for obtaining services from imaging vendor were evaluated by the contracting organization on 8-13-2024
2. 8-13-24, facility has completed a 100% audit of all facility residents' appointments and orders in the last 3 months to ensure all residents radiological and diagnostic needs and physician referrals have been followed up on. Audit did not identify any outstanding orders or concerns
3. In-serviced all Nurses on new procedures for Obtaining Radiological Services for residents was conducted on 8-13-2024. Nurses not available to sign the in-service book will have the new procedures sent to them via messaging and will respond that they understand the new process and will physically sign the in-service book on their next shift in the building.
4. On 8-13-24 representatives with the consulting organization will review and assess the facility policies and procedures regarding radiology and other diagnostic services, policies and procedures will be developed.
* The facility shall ensure radiology and other diagnostic services are available to meet the needs of the facility residents, including timeliness, accuracy and communication of results.
* Facility policies shall ensure expectations for terms such as Stat, immediate, urgent or other qualifiers associated with radiology and other diagnostic tests.
* The review shall address procedures or processes for obtaining radiology and other diagnostic tests, communicated to the radiology or other diagnostic test provider/supplier/vendor, action to take when a radiology or other diagnostic test providers/supplier/vendor is unable to provide the specified service, and communication of the results.
5. Policy changes for Radiology and Diagnostic Service orders as seen below.
* The community has contracted with [name of radiology provider]. The physician will identify, and order diagnostic testing based on resident assessment and needs.
* The community will obtain a physician order in the event a resident assessment would warrant radiology/diagnostic testing.
* If a resident requires immediate diagnostic testing, the licensed nurse will order a STAT diagnostic test. STAT diagnostic testing will be completed per [name of radiology provider]within four (4) hours.
* If the diagnostic testing is not completed with four (4) [hours], the licensed nurse will notify the physician for further orders.
* If the residents condition worsens, the nurse will notify the physician and resident will be sent out via 911 for further evaluation and treatment.
* Once routine or STAT diagnostic testing is completed, the physician will be notified of the results and the results will be placed in the resident's medical record.
Mountain View Health Services has implemented this plan to remove the conditions that constituted immediate jeopardy, and the immediate jeopardy was removed on 8-14-2024.
On 8/14/24, while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 8/14/24 at 11:00 AM.
Findings include:
1. Resident 46 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia and hemiparesis, chronic obstructive pyelonephritis, severe sepsis without shock, aspiration pneumonitis, acute kidney failure, supraventricular tachycardia, and bipolar disorder.
Resident 46's medical record was reviewed from 7/28/24 through 8/14/24.
A History and Physical for resident 46 dated 8/9/22 documented that resident 46 presented to the local emergency room after facility staff observed resident 46 to have some coffee-ground looking emesis and acute hypoxic respiratory failure. The hospital physician documented that resident 46 had a history of deep vein thromboses and was currently receiving a blood-thinning medication. Resident 46 was diagnosed with sepsis with acute hypoxic respiratory failure and a gastrointestinal bleed at that time.
Progress notes for resident 46 revealed the following entries:
a. On 6/16/24, resident 46 was seen by Nurse Practitioner (NP) 2. NP doumented that resident 46 . s a [AGE] year-old male with a history of CVA (cerebrovascular accident), COPD (chronic obstructive pulmonary disease) and multiple previous hospitalizations. Today patient was seen for his recertification visit. He was resting in his bed and appeared comfortable, no signs of distress. Patient reports he is doing fine. He is eating well, sleeping good, no issues with bowels or bladder, no anxiety or depression, no uncontrolled pain, anxiety or depression. He denied any current issues or concerns. Floor staff reports he is doing well. NP 2 did not document any acute health concerns upon assessment of resident 46.
b. On 6/21/24 at 9:30 PM, Registered Nurse (RN) 2 documented that there was a New order for Rocephin 1 Gm (gram) IM (Intramuscular) tonight, Sat (Saturday) [and] Sun (Sunday). for possible cholecystitis. Zofran 4 mg (milligrams) SL (sublingual) q (every) 6 hrs (hours). prn (as needed) N/V (nausea/vomiting). Schedule Tylenol 650 mg TID (three times a day) c (?) 3 days for abdominal pain. Stat (immediate) ultrasound of abdomen RUQ (right upper quadrant) and LLQ (left lower quadrant). No documentation was included in the note to indicate what occurred to prompt staff to contact the physician.
c. On 6/22/24 at 6:15 AM, RN 2 documented, Resident was heard by nurse urping (sic) up fluid. I went into his room and his roommate said he kept doing this. I checked him over and he had some brown- black fluid on the left side of his mouth. I told him not to swallow the fluid and to cough it into an emesis basin which I [NAME] (sic) to him. His VS (vital signs) were taken. T (temperature) 98.1, P (pulse) 112, R (respirations) 16 B/P (blood pressure) 148/74 and 02 (oxygen) sats (saturations) 94% on room air. I could hear bowel sounds in upper quadrant but minimal in lower quads. He stated that his pain was above his right navel and below it. Fluid brought up was a dark brownish color. MD PA (Physician Assistant) notified at 2200 (10:00 PM) with Rocephin, Zofran and scheduled Tylenol order. See MAR (Medication Administration Recrod) and progress noted (sic). Also a stat (immediate) ultrasound was ordered. Call was made to [name of contracted radiology provider] this AM (morning) and they stated that they donot (sic) do ultrasounds on the weekends. MD to be notified by day nurse, which was agreed in report this AM. [Note: The facility had been performing weekly vital signs on Resident 46. Per facility documentation, on 6/16/24, Resident 46's blood pressure was 114/62 and his pulse was 67. Per the facility's vital sign records for Resident 46, between 1/3/24 and 6/16/24, Resident 46's blood pressure was generally consistent with the reading obtained on 6/16/24. Resident 46's pulse had ranged from 58 to 85.]
Although the order for a stat ultrasound for resident 46 was documented to be received at 9:30 PM on 6/21/24, the facility nurse did not document attempts to have the stat ultrasound performed until 6:15 AM on 6/22/24; eight hours and 45 minutes later. Upon receiving notification from the contracted radiology provider that the company did not perform ultrasound tests on the weekend, there were no facility records to document that RN 2 contacted resident 46's physician.
[Note: Review of the written telephone order revealed that RN 2 documented she had obtained the order for the Rocpehin and stat ultrasound from NP 1.]
d. On 6/22/24 at 12:50 PM, RN 3 documented that resident 46 . has vomitted (sic) once this shift, it was a light brown color. He has requested more prune juice, but I denied that request and explained that we want to see why his vomit is brown. [Resident 46] had been laying in his vomit all night, we got him up to the shower and changed his bedding. His entire left arm, side of torso, and hip are very red. Cleaned well and put on hydrocortisone cream and barrier cream. Texted pic (picture) to provider of his inflamed skin. RN 3 did not document whether she had informed resident 46's physician of the ongoing brown emesis that resident 46 was experiencing. In addition, RN 3 did not document any indication that she was aware of the stat ultrasound order, or what the status was in obtaining the ultrasound.
e. On 6/22/24 at 10:54 PM, Licensed Practical Nurse (LPN) 3 documented Order noted for ultrasound of Abdomen, [name of contracted radiology provider] notified and is scheduled for Monday 6/24/24. No indication was made in the note by LPN 3 that he had contacted resident 46's physician regarding the delay in obtaining the stat ultrasound.
f. On 6/23/24 at 10:10 AM, RN 4 documented that resident 46 had an . Ultrasound scheduled for tomorrow r/t (related to) vomiting and abdominal pain.
g. On 6/23/24 at 4:36 PM, RN 4 documented that resident 46 had a Small amount of dark brown emesis early this morning. No other episodes this shift.
h. On 6/24/24 NP 3 documented that he spoke with resident 46 face to face for approximately 17 minutes, and that they discussed resident 46's medical conditions and his code status. NP 3 also documented that . Patient has cholecystitis and was started on on (sic) Rocephin on 6/21/24, we will continue to monitor patient closely to determine if antibiotic treatment has been effective. NP 3 documented that resident 46 was experiencing Right upper quadrant/right lower quadrant pain, but did not document any follow up he did with facility staff regarding the ultrasound order. NP 3 did not document any assessment with regard to resident 46's nausea or vomiting.
i. On 6/24/24 at 10:21 PM, RN 5 documented, Res (resident) currently on ABX (antibiotics) IM, (2nd dose) Medication was administered per MD orders. Res tolerated procedure well, there has been no ASE (adverse side effects) observed or reported. Fluids encouraged. RN 5 did not document any assessment with regard to resident 46's abdominal pain, nausea or vomiting. [Note: This note was entered as a late entry on 6/26/24 at 8:24 AM.]
j. On 6/25/24, at 11:00 AM, RN 4 documented that the contracted radiology provider . cannot ultrasound until 7/1/24. Medical directorship notified and ordered to have ultrasound done at [name of local hospital]. Scheduled with [name of local hospital] 6/26/24 at 0900 (9:00 AM) check in 0845 (8:45 AM). NPO (nothing by mouth) 8hrs (hours) prior to procedure. Medical directorship notified. No emesis on this shift and no reports of emesis on night shift. Resident states he does still have abdominal pain but is able to eat.
k. On 6/25/24 at 8:25 PM, RN 5 documented that resident 46, . continues on ABX IM, (final dose) Medication was administered per MD orders. Res tolerated procedure well, there has been no ASE observed or reported. Res instructed to move RUE (right upper extremity) often to decrease stiffening in the muscle/pain. Fluids encouraged. RN 5 did not document any assessment with regard to resident 46's abdominal pain, nausea or vomiting. [Note: This note was entered as a late entry on 6/26/24 at 8:28 AM.]
l. On 6/26/24 at 3:00 AM, RN 5 documented, CNA (Certified Nursing Assistant) completed rounds at 12:30am at which time resident was A&O (alert and oriented), brief was changed, resident was talking with staff. CNA started rounds at 02:30 (2:30 AM) upon entering residents' room, CNA exited notified nurse via radio to come down to res room. This nurse immediately went down, performed a quick assessment w/ (with) visual observation. Res had no pulse, eyes open, pale/ash color. No heart sounds. resident feet and hands cold with modeling. (02:45) (2:45 AM) Res was upright HOB (head of bed) 30-45-degree, emesis was observed down L (left) side of resident's shirt. There had been no emesis throughout this shift or reported from day shift, resident had no complaints after dinner, other than some abdominal pain, Tylenol offered, res declined. Res took all medication w/o (without) difficulty. Res was scheduled for an abdominal ultrasound this morning at 08:45 (8:45 AM). Appt (appointment) has been cancelled. Facility CNA provided post-mortem care, and reported resident continued to excrete emesis from mouth. Res has emergency contacted listed, who since has passed away. [Name of mortuary] was contacted. Body was received from this facility at 05:45 am (5:45 AM). MD, DON (Director of Nursing) and administrator notified.
On 8/8/24 at 1:45 PM, a telephone interview was conducted the an employee of the contract radiology provider (CRP 1). CRP 1 stated that their company did not receive notification of the ultrasound order for resident 46 until 6/22/24 at 9:50 PM. [Note: This was approximately 24 hours after the ultrasound order had been given to facility staff.] CRP 1 stated that the order was not called in to their comapny as a stat order.
On 8/3/24 at 5:00 PM, a telephone interview was conducted with CNA 7. CNA 7 stated that a week prior to resident 46's death, she only worked with resident 46 on one shift. CNA 7 stated that during that one shift, she observed resident 46 to be covered in throw up. CNA 7 stated that resident 46 obviously wasn't feeling good.
On 8/3/24 at 5:27 PM, a telephone interview was conducted with CNA 5. CNA 5 stated that she had noticed resident 46 vomiting during one of her shifts the week prior to resident 46's death. CNA 5 stated that she had notified the DON. CNA 5 stated that she observed resident 46's vomit to be watery . because he couldn't keep [his food] down. CNA 5 stated that resident 46 was obviously not feeling food. CNA 5 stated that resident 46 was vomiting so much that his shirt was covered in throw up when she checked on the resident.
On 8/3/24 at 7:17 PM, a telephone interview was conducted with CNA 6. CNA 6 stated that she had worked with resident 46 on 6/23/24 and 6/24/24. CNA 6 stated that resident 46 was complaining about abdominal pain during her shifts. CNA 6 stated that resident 46 had been throwing up and did not get out of bed during her shifts. CNA 6 stated that a bunch of us had to go in and clean him up after the resident had vomited. CNA 6 stated that she observed resident 46's emesis and it wasn't normal throw up . it looked black and like chunky and liquids at the same time. It was black and dark brown. CNA 6 stated that other staff reported to her that resident 46 had been constantly throwing up all day on one of the days she worked with him, I wanna say he threw up both nights but it was worse the next night. They said they wanted to get him an ultrasound and they were waiting but they wanted to get the ultrasound first before they sent him out.
On 8/5/24 at 6:25 PM, a telephone interview was conducted with CNA 4. CNA 4 stated that during the last week of resident 46's life, resident 46 was very sick and he was throwing up for two days. CNA 4 stated that on 6/23/24, he observed resident 46 while the resident was being weighed. CNA 4 stated that this was the last time he had seen resident 46 and that the resident didn't look really good. He was very pale, and his eyes were sunken in. CNA 4 stated that other staff had reported to him that resident 46 was vomiting a dark liquid and that the resident's health was getting worse and he wasn't feeling well.
On 8/3/24 at 5:39 PM, a telephone interview was conducted with LPN 3. When asked about the note that LPN 3 entered on 6/22/24, LPN 3 stated that the facility had been having problems with predictability of services with the contracted radiology provider since at least January 2024. LPN 3 stated the the contracted radiology provider kept putting off coming in to the facility to perform resident 46's ultrasound after it was ordered on 6/21/24. LPN 3 stated that he was unsure why there was an order for an ultrasound, or if resident 46 was experiencing a change in condition during the week prior to the resident's death.
On 8/3/24 at 3:55 PM, a telephone interview was conducted with RN 4. RN 4 stated that she worked on Sunday, 6/23/24, and was aware that resident 46 was supposed to have an abdominal ultrasound completed, but that the contracted radioligy company did not provide ultrasounds on the weekends. RN 4 stated that she did not work on Monday 6/24/24, and thought that the ultrasound would be completed that day. RN 4 stated that when she returned to work on 6/25/24, the ultrasound had not been completed so she contacted the contracted radiology company. RN 4 stated that the radiology company told her that they did not have resident 46 on their schedule, and that the earliest they could perform the ultrasound would be on 7/1/24. RN 4 stated that she then contacted the on-call provider for further instruction. RN 4 stated that the on-call provider instructed her to schedule the ultrasound at a local hospital. RN 4 stated that the Medical Director was in the facility on 6/25/24, and she had informed the Medical Director about the delay in getting an ultrasound for resident 46. RN 4 stated that during her shift on 6/23/24, resident 46 was vomiting at times, although she did not observe the emesis produced. RN 4 stated that staff reported to her that resident 46's emesis was brown or dark brown. RN 4 stated that on 6/25/24, resident 46 reported he was still experiencing abdominal pain, but did not pinpoint the exact location of the pain. RN 4 reported that on 6/25/24, resident 46 received a shower, and had consumed at least part of his meals. RN 4 stated that she also worked as the ADON, and that she did not report resident 46's change in condition or delay in obtaining the ultrasound to the DON because we don't have office hours, we just work the floor when we are there.
On 8/5/24 at 2:10 PM, a telephone interview was conducted with RN 5. RN 5 stated that when she arrived for her scheduled night shift on the evening of Monday 6/24/24, she was not given any information about resident 46's condition during the nurse to nurse report. RN 5 stated that there had been a lack of communication between shifts and that she had been unaware of the stat ultrasound order or that resident 46 had been vomiting. RN 5 stated that she was aware that resident 46 was scheduled for an ultrasound at some point, but it was so long out . that bothered me. RN 5 stated she texted the physician on call on 6/24/24 because she was worried about the delay because there was a patient in the unit (memory care unit) that died after waiting a long time for treatment. [Note: This was identifed to be resident 298, who has a finding below.] RN 5 stated that the following day, on 6/25/24, the physician gave an order to schedule the ultrasound with the local hospital. RN 5 stated that at times, the physician on call did not respond timely during the evening and night hours. RN 5 stated that she had been resident 46's assigned nurse on the evening of 6/25/24. RN 5 stated that at approximately 12:40 AM on the morning of 6/26/24, a CNA checked on resident 46 as part of his rounds. RN 5 stated that at that time, the CNA left the resident's room and signaled to the nurse who was at the nurses station that the resident had passed away. RN 5 stated that she then went to resident 46's room to visualize the resident. RN 5 stated that when she saw resident 46, there was no emesis on the resident, but that while providing post mortem care, the CNA reported that emesis came out of resident 46's mouth. RN 5 stated that after resident 46's death, she had reviewed the resident's medical record and realized the resident had been vomiting for a few days. RN 5 stated it was at that time, she discovered that resident 46 had been vomiting, and I didn't see much of an intervention from the facility. RN 5 stated that the lack of communication is concerning because it could have been a different outcome. had I known. Resident 46 stated that the facility has a 24 hour report, but she did not have access to it, and I have to depend on what the nurse tells me during shift change. RN 5 also stated that there was no system of communication between CNAs and nurses. RN 5 stated that for example, she has heard CNAs discussing a resident who had experienced diarrhea, and she told the CNAs they should be reporting those types of things to the nurse on duty also.
On 8/5/4 at 6:32 PM, a telephone interview was conducted with RN 3. RN 3 stated that she had been assigned to resident 46 for one shift after the facility received an order for the resident to have a stat ultrasound on 6/21/24. RN 3 stated that when she came on shift on the morning of Saturday, 6/22/24, resident 36 had been throwing up throughout the night, so I went to give Zofran. RN 3 stated that staff had been texting the physician in an attempt to get the ordered ultrasound completed, because the contract radiology company would not complete the ultrasound on a weekend. RN 3 stated that the contract radiology company would not complete the ultrasound until Monday, 6/23/24. RN 3 stated that when she spoke with resident 46 during her shift, the resident reported that he was in pain and was requesting prune juice. RN 3 stated that she did not provide resident 46 with any prune juice, because resident 46's emesis was a brown color and I was trying to determine if it was brown because of blood or prune juice. RN 3 stated that the resident's emesis looked like prune juice, but did not have anything that looked like coffee grounds. RN 3 stated that resident 46 repeatedly asked for prune juice because he did not feel he was having bowel movements. RN 3 stated that resident 46 had actually had a bowel movement during her shift that she observed, and stated it was huge, and yellowy brown in color and didn't look like it had blood in it. RN 3 stated that she had spoken with LPN 3, who was also working that day, about resident 46's vomiting. RN 3 stated that LPN 3 told her that she should notify the physician, but RN 3 told LPN 3 that RN 5 had already contacted the physician, so LPN 3 told RN 3 to wait and see what the doctor wants to do. RN 3 stated that she texted the physcian during her shift because resident 46 had vomited during the evening of 6/21/24 and night shift hadn't cleaned him up well so he had gotten red on that left side. RN 3 stated that she did not notify the physician about the resident vomiting, only the redness on the resident's skin. RN 3 stated that the physician's response was we will keep an eye on it, and did not provide any new orders. RN 3 stated that the physician did not say anything about the ultrasound. RN 3 stated that she did not realize the ultrasound order had been written as a stat order.
On 7/31/24 at 3:15 PM, an interview was conducted with the DON. The DON stated that she was aware that resident 46 was vomiting during the last week of the resident's life, but could not recall how she received that information. The DON stated that no one had spoken to her about resident 46 and his change of condition. The DON stated that we should have at least sent him to the ER (emergency room) to get evaluated if the stat order was written. The DON stated that they did complete 24 hour reports, but she was unable to locate any of them.
On 8/6/23 at 11:17 AM, a telephone interview was conducted with NP 3. NP 3 stated that his first day at the facility was on 6/24/24, the same day he saw and evaluated resident 46 for the first time. NP 3 stated that he was unable to comment on the resident, because he could not locate the resident in the electronic health record system he was using.
On 8/6/24 at 11:31 AM, a telephone interview was conducted with NP 2. NP 2 stated that she had visited with resident 46 on 6/1[TRUNCATED]
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 observation, interview, and record review, the facility did not ensure that each resident received adequate supervision...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents and the resident environment did not remain as free of accident hazards as was possible. Specifically, for 1 out of 30 sampled residents, a resident was not provided adequate supervision and interventions to reduce hazards and risks that resulted in an acute complete femoral neck fracture with partial displacement. Resident identifiers: 298.
Findings included:
1. Resident 298 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, dementia, essential hypertension, acute kidney failure, and anxiety disorder.
Resident 298's medical record was reviewed on 8/7/24.
A Baseline Care Plan signed by the Director of Nursing (DON) on 3/28/24, documented that resident 298 did not have a history of falls and a Fall Management Care Plan was not implemented.
On 3/29/24, a Morse Fall Scale documented that resident 298 was a High Risk for Falling with a score of 50. A resident was considered a High Risk with a score of 45 and higher.
An admission Minimum Data Set (MDS) assessment dated [DATE], documented that resident 298 had a Brief Interview for Mental Status (BIMS) score of 13. A BIMS score of 13 to 15 would indicate intact cognition. The Care Area Assessment Summary of the MDS documented that falls had triggered to be care planned.
On 4/11/24 at 8:29 AM, a Fall Incident Report documented Staff radio nurse, to report resident fell. Nurse knocked and entered res [resident] room. Staff reported fall was witnessed. Res was assessed, res cognitive to baseline, A&O [alert and oriented] x2, name and situation. PERRLA [pupils are equal, round, and reactive to light and accommodation] WNL [within normal limits], ROM [range of motion] completed without difficulty, res assisted into bed. Res was painful r/t [related to] skin tear to R [right] elbow., res had a reddened area R lateral side just below hair line. Staff reported that redness to forehead was there earlier before the fall. Res had a large skin tear to R elbow, wound Tx [treatment] provided, affected area was cleansed with wound cleaner, pat dry. using steri strips tear was close and approximated well. Bacitracin applied, covered with non-adherent dressing, and wrapped. Neuro's [neurological's] started per protocol. MD [Medical Director], family notified via voicemail, and DON 04/12/2023. Res stated his feet fell out from under him and he fell to the ground. Res stated he hit head and touched over red area to R side of forehead. [Note: Neuro's were unable to be located.]
A care plan Focus initiated on 4/12/24, documented The resident has had an actual fall with minor injury d/t [due to] Hypotension and Unsteady gait. The interventions included:
a. Anticipate patients needs and monitor for unsteady balance. Date Initiated 4/11/24.
b. Continue interventions on the at-risk plan. Date initiated 4/12/24. [Note: The at-risk plan was unable to be located.]
On 5/18/24 at 3:59 AM, a Health Status Note documented Note Text: Resident fell in his room about 1900 [7:00 PM]. It was an unwitnessed fall lost his balance and went down on his left side. Able to move all his extremities without pain. A small red mark was found on his left back shoulder. He was too weak to get up on his own. Three maximum assist to left [sic] him onto his lounge chair. Vital signs taken and T [temperature] 98.0, P [pulse] 64, R [respirations] 28 B/P [blood pressure] 96/56 and 02 [oxygen] sats [saturations] 92% on room air. MD notified of low B/P and fall at 2238 [10:38 PM]. Administrator and DON notified at 0345 [3:45 AM] and 0348 [3:48 AM] this morning. Morning nurse to be notified in am and family. Neuro checks and VS [vital signs] doing well no changes.
[Note: No new interventions were implemented to prevent falls after the fall 5/18/24.]
On 5/19/24 at 9:00 AM, an Incident Follow up documented Date of Incident: 5/19/2024 Type of Incident: Fall Root Cause: Unsteady gait Treatment Required: None Interventions put into place: Neuros, call light given to resident, rounds every 15 minutes Referrals Made: None.
[Note: No new interventions were implemented to prevent falls after the fall on 5/19/24. An assessment after the fall was unable to be located.]
On 5/19/24 at 11:00 PM, an encounter documented Date of Service: 05/20/2024 Visit Type: Acute Transition of Care: No transition occurred. Progress Note . Chief Complaint / Nature of Presenting Problem: Fall History Of Present Illness: Patient is a [AGE] year-old male with a past medical history significant for Alzheimer's dementia. He was previously a resident at the [name redacted] and was admitted here one month ago. He has tried to escape multiple times and constantly packs his things to leave. He often waits by the locked door of the unit to leave. Today CNA [Certified Nursing Assistant] reported that patient had 2 falls over the weekend. Denied hitting his head. Patient reports that he is fine. He denied any uncontrolled pain. He denied any issues or concerns. The Nurse Practitioner (NP) signed the note on 5/20/24 at 8:39 AM.
On 5/19/24 at 4:45 PM, a Fall Incident Report documented . Client had an unobserved fall out of dining room chair. Client pulled tablecloth halfway off. When CNA walked into dining room to check on clients, other residents were helping client off of floor. Client stated 'I feel. I am okay.' Client was put on neuros and observed every 15 minutes.
[Note: No new interventions were implemented to prevent falls after the second fall on 5/19/24.]
On 5/20/24 at 2:50 PM, an Orders - General Note from electronic record (eRecord) documented Note Text: CNA comes to nurse and stated resident had an assisted fall and was lowered to ground after being toileted. He lost his balance and she grabbed him and lowered him. Both South and North nurse in to assist resident and transfer him to his w/c [wheel chair]. He did not appear to be in pain but rather confused. He sustained a small r elbow tear to his arm from the w/c during transfer. Cleaned and dressed. He then rested quietly throughout the rest of the shift.
[Note: No new interventions were implemented to prevent falls after the fall on 5/20/24.]
On 5/20/24 at 11:00 PM, an encounter documented Date of Service: 05/21/2024 Visit Type: Acute Transition of Care: No transition occurred. Progress Note . Chief Complaint / Nature of Presenting Problem: Right hip pain History Of Present Illness: [Resident 298] is a [AGE] year-old long-term care resident here at [name redacted]. Per the nurses report he has had a couple of falls over the weekend. He was evaluated yesterday but denied any significant pain. It is unclear if he had another fall since yesterday's evaluation but currently he has complaints of right hip pain. He has been unable to stand. Most of his pain is localized to the anterior and lateral right hip. General: Elderly male in mild distress. Does appear confused which is his baseline Musculoskeletal: Patient does have tenderness to palpation over the right hip laterally anteriorly. He does have pain with internal and external rotation of the right hip. This localizes anteriorly. Acute right hip pain Patient's right hip pain appears to be acute and it is unclear whether this is related to a fall over the weekend or a new fall today. Given his acute right hip pain and evaluation today I do recommend x-rays of the right hip stat [immediately]. These were ordered today. Plan to follow-up after x-rays. Fall On fall precautions. The MD signed the note on 5/21/24 at 11:17 AM.
On 5/21/24 at 11:40 AM, a Health Status Note documented Note Text: NEW ORDER: Pt [patient] is not bearing any wt [weight] on rt [right] leg has a lg [large] skin tear on rt elbow. md notified ordered a xray it has been ordered and they stated it wil [sic[ be done today. pt had a shr [shower] today.
On 5/21/24, the Diagnostics report documented . Right hip, 2 views Comparison: None. Findings: There is an acute complete femoral neck fracture with partial displacement compatible with a Garden Classification III fracture. IMPRESSION: 1. Garden classification III acute femoral neck fracture. The diagnostics report was signed by the diagnostics radiologist on 5/21/24 at 6:23 PM.
On 5/22/24 at 2:51 AM, a Health Status Note documented Note Text: Follow up on res x-ray: Impressions noted; There is an acute complete femoral neck Fx [fracture] with partial displacement compatible with a Garden class III. Mild degree of osteopenia. Moderate osteoarthritis. X-ray results sent to MD, response pending. WCTM [will continue to monitor].
On 5/22/24 at 5:30 AM, a Health Status Note documented Note Text: Staff reported res, has been up all night did not sleep a wink, trying to wiggle his way out of bed. Staff has continuously throughout shift had to re center res into bed and remind resident that he, could not walk d/t broken femur. will pass on to upcoming shift nurse for monitoring and follow-up.
On 5/22/24 at 6:54 AM, an Orders - General Note from eRecord documented Note Text: MD notified of results of Xray and new order for resident to be sent to ER [emergency room] for eval/tx [evaluation and treatment]. Preparing paperwork.
On 5/22/24 at 3:01 PM, a Health Status Note documented Note Text: Received call from [hospital name redacted]. They will do surgergy [sic] this afternoon and resident to be admitted to med [medical] surg [surgical] floor.
On 8/7/24 at 12:23 PM, an interview was conducted with NP 2. NP 2 stated she saw resident 298 because he had a fall. NP 2 stated that resident 298 was walking around pushing his recliner around and had no pain. NP 2 stated the MD came in the next day and said that resident 298 had a broken femur. NP 2 stated that she did not do a full hip exam because resident 298 was moving fine. NP 2 stated that she did not expect a break. NP 2 stated that the MD sent resident 298 out and resident 298 did have a break.
On 8/8/24 at 11:50 AM, an interview was conducted with the DON. The DON stated that resident 298 had an unwitnessed fall on 5/18/24 at about 3:00 AM. The DON stated that resident 298 had another fall on 5/19/24 at 9:00 AM. The DON stated the fall on 5/20/24, was an assisted fall at 3:00 PM. The DON stated at that time herself and the CNA lowered resident 298 to the floor and the DON stated that she did not notice anything. The DON stated that the NP saw resident 298 the morning of 5/21/24, and noted we need an xray. The DON stated that resident 298 somehow had a shower during that time on 5/21/24. The DON stated the facility called the x-ray company at 11:34 AM, and they arrived at the facility at 5:41 PM, to do the x-ray on 5/21/24. The DON stated at 6:23 PM, the x-ray company either faxed the results or notified the facility of the results. The DON stated that the nurse on 5/22/24, made a progress note that results were pending from the doctor. The DON stated at the end of the shift the nurse made a note that resident 298 was up all night and passed the information to the oncoming nurse which was the DON. The DON stated at 6:55 AM, she notified the doctor and resident 298 was sent out to the hospital.
On 8/14/24 at 7:29 AM, an interview was conducted with CNA 3. CNA 3 stated that if a resident was a fall risk the resident would have something on there door like a color indicating if they were a fall risk or a runaway risk. CNA 3 stated that she started at the facility in May or June 2024. CNA 3 stated that she met resident 298 after her second day and resident 298 had fallen and broken his femur. CNA 3 stated resident 298 would try and roll out of bed or get up. CNA 3 stated there were interventions after the fracture to keep resident 298 in bed and resident 298 had a wedge pillow. CNA 3 stated that resident 298 would try and get up even though he had a broken femur. CNA 3 stated that she would get in report if a resident was a fall risk. CNA 3 stated that she did not know if there was a [NAME] for residents or where to see interventions. CNA 3 stated that 15 minute checks were done with neuros. CNA 3 stated that 15 minute checks we done for the first hour, then 30 minute checks, then 45 minute checks, and then every hour for three days. CNA 3 stated the nurse had a form at the nurses station that the CNAs would document the neuro checks. CNA 3 stated that neuros were done after every fall. CNA 3 stated if a resident had an intervention to anticipate needs she would observe what the resident was like and what the resident needed. CNA 3 stated if the resident was cold then she would get them a blanket, if the resident was dirty she would give them a shower regardless if it was the residents shower day.
On 8/14/24 at 7:39 AM, an interview was conducted with the DON. The State Survey Agency (SSA) Lead Licensor asked the DON what an At Risk Plan was and how was that a fall care plan intervention. The DON stated why was that there and that should not be there. The DON stated that was assuming that the nurses knew what the at risk plan was for the resident. The DON stated that she had no idea why that was on the care plan. The DON stated to her an at risk plan was why the resident fell. The DON stated the at risk plan did not tell her anything if that was on the care plan as an intervention. The DON stated where did they get that. The DON stated the facility used to have a form that was stapled to the incident form and would document why the resident was falling and would go more in depth. The DON stated that she would not recommend the at risk plan as an intervention because you need to fix the problem. The DON stated the at risk told the staff nothing. The SSA Lead Licensor asked the DON what the intervention 15 minute checks meant. The DON stated that 15 minute checks meant neuros and vital signs every 15 minutes. The DON stated that neuros were conducted with an unwitnessed fall. The DON stated that 15 minute checks were done in four sets. The DON stated that anticipate needs meant that the resident was a high fall risk and the staff need to have eyes more on the resident. The DON stated to have eyes more on the resident meant to make sure staff were watching the resident and a little bit more eyes on the resident. The DON stated it was impossible to do a one on one in the facility. The DON stated that all the nurses should be doing the care plans. The DON stated that interventions could be customized. The DON stated that staff needed to find out why the fall happened and if the fall fell into any of the categories on the computer then great if not the intervention could be customized.
On 8/14/24 at 8:42 AM, a follow up interview was conducted with the DON. The SSA Lead Licensor asked the DON if she had details regarding resident 298's fracture. The DON stated that resident 298 was not in any pain that day and had no signs of a fracture. The DON stated the CNA was getting resident 298 ready to toilet and the DON went in to assist and resident 298 was lowered to the ground. The DON stated that she had been told if the fall was assisted she did not have to do a fall. The DON stated there may have been a fall the next day also but she was not sure. The DON stated that neuro checks were only done if the resident hit their head. The DON stated that she usually kept the neuro checks and she had record of them.
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
Deficiency F0692
(Tag F0692)
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 did not ensure that residents maintained acceptable parameters of nutritional...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range. Specifically, for 1 out of 30 sampled residents, a resident was not provided their ordered nutritional supplement shake and the resident had weight loss. Resident identifier: 298.
Findings included:
Resident 298 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia, essential hypertension, benign prostatic hyperplasia without lower urinary symptoms, acute kidney failure, weakness, and anxiety disorder.
Resident 298's medical record was reviewed on 8/7/24.
An admission Minimum Data Set assessment date 4/10/24, documented that resident 298 had a Brief Interview for Mental Status (BIMS) score of 13. A BIMS score of 13 to 15 would suggest intact cognition.
A care plan Focus addressing nutrition initiated on 4/12/24, documented New resident with potential nutrition defects r/t [related to] : advanced age, dementia. The interventions included:
a. Diet order: Regular, regular, thins
b. Supplements/snacks as ordered
A review of resident 298's electronic medical record documented the following weights for resident 298:
a. 165.2 pounds on 3/28/24.
b. 163.6 pounds on 3/31/24.
c. 166.8 pounds on 4/7/24.
d. 199.8 pounds on 4/8/24.
e. 168.6 pounds on 5/10/24.
f. 167.0 pounds on 5/27/24.
g. 156.6 pounds on 6/2/24.
h. 140.3 pounds on 7/11/24.
From 6/2/24 to 7/11/24, resident 298 had a 10.41% loss of weight. It was to be noted, no revisions to the care plan were made to address the weight loss.
A review of resident 298's paper medical chart revealed the following dietary orders:
a. Mighty shakes three times a day (TID) with]meals. Order date 5/31/24.
b. Fortify diet. Order date 6/14/24.
c. Fortify diet. Add mighty shakes TID with meals. Order date 6/28/24.
A review of resident 298's electronic medical record revealed the following orders:
a. REGULAR diet MECHANICAL SOFT texture, Regular consistency, Mechanical Soft Fortified. Start date 6/15/24.
b. REGULAR diet MECHANICAL SOFT texture, Regular consistency, Add mighty shakes TID with meals for Fortified diet related to post hip surgery replacement. Start date 6/29/24.
On 6/28/24, a physician progress note documented, Malnutrition, unspecified type. Patient has had a decrease in weight by 9.1% of entire body weight. He weighed 156.6 pounds on 6/16/24 and his most recent weight on 6/23/24 was 143.2 pounds. I am concerned about patient's rapid weight loss and believe that he is experiencing malnutrition. Dietitian in to eval [evaluate] and treat. Push for increase if daily nutritional PO [oral] intake.
On 8/7/24 at 1:42 PM, an interview was conducted via text messaging with the Registered Dietitian (RD). The RD texted that resident 298 had a fortified diet ordered and health shakes to help with his weight loss. The RD texted that the facility had a weekly weight list and weekly meetings to discuss residents that had weight loss.
On 8/8/24 at 10:45 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the residents received the mighty shakes with the medication pass three times a day. The DON stated that the order for mighty shakes was located on the Medication Administration Record (MAR). The DON stated that it was checked off in the MAR when the resident received their mighty shake. The DON stated that the facility did not record the amount of mighty shake consumed by the residents.
A review of resident 298's MAR revealed that resident 298 did not receive mighty shakes from 6/1/24 to 7/12/24.
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
Deficiency F0697
(Tag F0697)
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 did not ensure that pain management was provided to residents who required su...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that pain management was provided to residents who required such services. Specifically, for 1 out of 30 sampled residents, a resident with an acute complete femoral neck fracture was not provided pain management prior to being discharged to the hospital. Resident identifiers: 298.
Findings included:
Resident 298 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, dementia, essential hypertension, acute kidney failure, and anxiety disorder.
Resident 298's medical record was reviewed on 8/7/24.
A care plan Focus initiate on 3/29/24, documented Resident has pain related to general body aches. The Goal included Resident will suffer no unrelieved episodes of pain during facility stay. The interventions initiated on 3/29/24, included:
a. Assess intensity of pain using pain scale.
b. Assess type, duration, and frequency of pain.
c. Discuss with resident effective and ineffective measures.
d. Encourage verbalization of feelings about the pain.
e. Medications as ordered.
An admission Minimum Data Set assessment dated [DATE], documented that resident 298 had a Brief Interview for Mental Status (BIMS) score of 13. A BIMS score of 13 to 15 would indicate intact cognition.
On 4/11/24 at 8:29 AM, a Fall Incident Report documented Staff radio nurse, to report resident fell. Nurse knocked and entered res [resident] room. Staff reported fall was witnessed. Res was assessed, res cognitive to baseline, A&O [alert and oriented] x2, name and situation. PERRLA [pupils are equal, round, and reactive to light and accommodation] WNL [within normal limits], ROM [range of motion] completed without difficulty, res assisted into bed. Res was painful r/t [related to] skin tear to R [right] elbow., res had a reddened area R lateral side just below hair line. Staff reported that redness to forehead was there earlier before the fall. Res had a large skin tear to R elbow, wound Tx [treatment] provided, affected area was cleansed with wound cleaner, pat dry. using steri strips tear was close and approximated well. Bacitracin applied, covered with non-adherent dressing, and wrapped. Neuro's [neurological's] started per protocol. MD [Medical Director], family notified via voicemail, and DON [Director of Nursing] 04/12/2023. Res stated his feet fell out from under him and he fell to the ground. Res stated he hit head and touched over red area to R side of forehead.
On 5/18/24 at 3:59 AM, a Health Status Note documented Note Text: Resident fell in his room about 1900 [7:00 PM]. It was an unwitnessed fall lost his balance and went down on his left side. Able to move all his extremities without pain. A small red mark was found on his left back shoulder. He was too weak to get up on his own. Three maximum assist to left [sic] him onto his lounge chair. Vital signs taken and T [temperature] 98.0, P [pulse] 64, R [respirations] 28 B/P [blood pressure] 96/56 and 02 [oxygen] sats [saturations] 92% on room air. MD notified of low B/P and fall at 2238 [10:38 PM]. Administrator and DON notified at 0345 [3:45 AM] and 0348 [3:48 AM] this morning. Morning nurse to be notified in am and family. Neuro checks and VS [vital signs] doing well no changes.
On 5/19/24 at 9:00 AM, an Incident Follow up documented Date of Incident: 5/19/2024 Type of Incident: Fall Root Cause: Unsteady gait Treatment Required: None Interventions put into place: Neuros, call light given to resident, rounds every 15 minutes Referrals Made: None.
On 5/19/24 at 11:00 PM, an encounter documented Date of Service: 05/20/2024 Visit Type: Acute Transition of Care: No transition occurred. Progress Note . Chief Complaint / Nature of Presenting Problem: Fall History Of Present Illness: Patient is a [AGE] year-old male with a past medical history significant for Alzheimer's dementia. He was previously a resident at the [name redacted] and was admitted here one month ago. He has tried to escape multiple times and constantly packs his things to leave. He often waits by the locked door of the unit to leave. Today CNA [Certified Nursing Assistant] reported that patient had 2 falls over the weekend. Denied hitting his head. Patient reports that he is fine. He denied any uncontrolled pain. He denied any issues or concerns. The Nurse Practitioner (NP) signed the note on 5/20/24 at 8:39 AM.
On 5/19/24 at 4:45 PM, a Fall Incident Report documented . Client had an unobserved fall out of dining room chair. Client pulled tablecloth halfway off. When CNA walked into dining room to check on clients, other residents were helping client off of floor. Client stated 'I feel. I am okay.' Client was put on neuros and observed every 15 minutes.
On 5/20/24 at 2:50 PM, an Orders - General Note from electronic record (eRecord) documented Note Text: CNA comes to nurse and stated resident had an assisted fall and was lowered to ground after being toileted. He lost his balance and she grabbed him and lowered him. Both South and North nurse in to assist resident and transfer him to his w/c [wheel chair]. He did not appear to be in pain but rather confused. He sustained a small r elbow tear to his arm from the w/c during transfer. Cleaned and dressed. He then rested quietly throughout the rest of the shift.
On 5/20/24 at 11:00 PM, an encounter documented Date of Service: 05/21/2024 Visit Type: Acute Transition of Care: No transition occurred. Progress Note . Chief Complaint / Nature of Presenting Problem: Right hip pain History Of Present Illness: [Resident 298] is a [AGE] year-old long-term care resident here at [name redacted]. Per the nurses report he has had a couple of falls over the weekend. He was evaluated yesterday but denied any significant pain. It is unclear if he had another fall since yesterday's evaluation but currently he has complaints of right hip pain. He has been unable to stand. Most of his pain is localized to the anterior and lateral right hip. General: Elderly male in mild distress. Does appear confused which is his baseline Musculoskeletal: Patient does have tenderness to palpation over the right hip laterally anteriorly. He does have pain with internal and external rotation of the right hip. This localizes anteriorly. Acute right hip pain Patient's right hip pain appears to be acute and it is unclear whether this is related to a fall over the weekend or a new fall today. Given his acute right hip pain and evaluation today I do recommend x-rays of the right hip stat [immediately]. These were ordered today. Plan to follow-up after x-rays. Fall On fall precautions. The MD signed the note on 5/21/24 at 11:17 AM.
On 5/21/24 at 11:40 AM, a Health Status Note documented Note Text: NEW ORDER: Pt [patient] is not bearing any wt [weight] on rt [right] leg has a lg [large] skin tear on rt elbow. md notified ordered a xray it has been ordered and they stated it wil [sic[ be done today. pt had a shr [shower] today.
On 5/21/24, the Diagnostics report documented . Right hip, 2 views Comparison: None. Findings: There is an acute complete femoral neck fracture with partial displacement compatible with a Garden Classification III fracture. IMPRESSION: 1. Garden classification III acute femoral neck fracture. The diagnostics report was signed by the diagnostics radiologist on 5/21/24 at 6:23 PM.
On 5/22/24 at 2:51 AM, a Health Status Note documented Note Text: Follow up on res x-ray: Impressions noted; There is an acute complete femoral neck Fx [fracture] with partial displacement compatible with a Garden class III. Mild degree of osteopenia. Moderate osteoarthritis. X-ray results sent to MD, response pending. WCTM [will continue to monitor].
On 5/22/24 at 5:30 AM, a Health Status Note documented Note Text: Staff reported res, has been up all night did not sleep a wink, trying to wiggle his way out of bed. Staff has continuously throughout shift had to re center res into bed and remind resident that he, could not walk d/t broken femur. will pass on to upcoming shift nurse for monitoring and follow-up.
On 5/22/24 at 6:54 AM, an Orders - General Note from eRecord documented Note Text: MD notified of results of Xray and new order for resident to be sent to ER [emergency room] for eval/tx [evaluation and treatment]. Preparing paperwork.
On 5/22/24 at 3:01 PM, a Health Status Note documented Note Text: Received call from [hospital name redacted]. They will do surgergy [sic] this afternoon and resident to be admitted to med [medical] surg [surgical] floor.
The May 2024 Medication Administration Record was reviewed. A physician's order dated 3/28/24, documented PAIN SCALE ASSESS PAIN BID [twice daily] USING VERBAL SCALE (0-10) every day and night shift. Resident 298 had no reported pain until 5/20/24.
a. On 5/20/24 at 6:00 PM, verbal scale 5.
b. On 5/21/24 at 6:00 AM, verbal scale 5.
c. On 5/21/24 at 6:00 PM, Face, Legs, Activity, Cry, and Consolability (FLACC) scale 7.
d. On 5/22/24 at 6:00 AM, FLACC scale 7.
(Note: The Order Summary Report was reviewed and resident 298 did not have any pain management medications available prior to being discharged to the hospital on 5/22/24.)
On 8/5/24 at 2:10 PM, a telephone interview was conducted with Registered Nurse (RN) 5. RN 5 stated that she had identified that resident 298 was not receiving any pain medication, and that other staff did not identify the issue sooner. RN 5 stated that after she brought this to the physician's attention, the resident was prescribed Tramadol. RN 5 stated, I don't think anybody should be in pain.
On 8/7/24 at 12:23 PM, an interview was conducted with NP 2. NP 2 stated she saw resident 298 because he had a fall. NP 2 stated that resident 298 was walking around pushing his recliner around and had no pain. NP 2 stated the MD came in the next day and said that resident 298 had a broken femur. NP 2 stated that she did not do a full hip exam because resident 298 was moving fine. NP 2 stated that she did not expect a break. NP 2 stated that the MD sent resident 298 out and resident 298 did have a break.
On 8/8/24 at 11:50 AM, an interview was conducted with the DON. The DON stated that resident 298 had an unwitnessed fall on 5/18/24 at about 3:00 AM. The DON stated that resident 298 had another fall on 5/19/24 at 9:00 AM. The DON stated the fall on 5/20/24, was an assisted fall at 3:00 PM. The DON stated that herself and the CNA lowered resident 298 to the floor and the DON stated that she did not notice anything. The DON stated that the NP saw resident 298 the morning of 5/21/24, and noted we need an xray. The DON stated that resident 298 somehow had a shower during that time on 5/21/24. The DON stated the facility called the x-ray company at 11:34 AM, and they arrived at the facility at 5:41 PM, to do the x-ray on 5/21/24. The DON stated at 6:23 PM, the x-ray company either faxed the results or notified the facility of the results. The DON stated that the nurse on 5/22/24, made a progress note that results were pending from the doctor. The DON stated at the end of the shift the nurse made a note that resident 298 was up all night and passed the information to the oncoming nurse which was the DON. The DON stated at 6:55 AM, she notified the doctor and resident 298 was sent out to the hospital.
On 8/14/24 at 8:42 AM, an interview was conducted with the DON. The State Survey Agency Lead Licensor asked the DON if she had details regarding resident 298's fracture. The DON stated that resident 298 was not in any pain that day and had no signs of a fracture. The DON stated the CNA was getting resident 298 ready to toilet and the DON went in to assist and resident 298 was lowered to the ground. The DON stated that she had been told if the fall was assisted she did not have to record it as a fall. The DON stated there may have been a fall the next day also but she was not sure. The DON stated that neuro checks were only done if the resident hit their head. The DON stated that she usually kept the neuro checks and she had record of them.
SERIOUS
(H)
📢 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
QAPI Program
(Tag F0867)
A resident was harmed · This affected multiple residents
Based on interview, observation and record review, the facility did not ensure that policies were established and implemented to ensure that identified quality deficiencies were corrected. Specificall...
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Based on interview, observation and record review, the facility did not ensure that policies were established and implemented to ensure that identified quality deficiencies were corrected. Specifically, multiple areas of immediate jeopardy and harm were identified. In addition, multiple areas of non compliance were cited on the previous survey and again during the current recertification survey. Resident identifiers: 46 and 298.
Findings include:
1. Based on interview and record review, the facility did not ensure that 2 of 30 sample residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, ongoing monitoring for changes in condition were not provided after one resident experienced ongoing emesis and abdominal pain, and a second resident had a deep vein thrombosis. The findings for resident 46 were determined to have resulted in immediate jeopardy for resident 46. Resident identifiers: 46 and 298.
[Cross refer to F684]
2. Based on observation, interview, and record review, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents and the resident environment did not remain as free of accident hazards as was possible. Specifically, for 1 out of 30 sampled residents, a resident was not provided adequate supervision and interventions to reduce hazards and risks that resulted in an acute complete femoral neck fracture with partial displacement. Resident identifiers: 298.
[Cross refer to F689]
3. Based on interview and record review, the facility did not ensure for 2 of 30 sample residents that radiology and other diagnostic services were provided to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services. Specifically, residents were not provided with ultrasounds as ordered by the physician. This resulted in a finding of Immediate Jeopardy for resident 46. Resident identifiers: 46 and 298.
[Cross refer to F776]
4. Based on interview and record review, the facility did not ensure that pain management was provided to residents who required such services. Specifically, for 1 out of 30 sampled residents, a resident with an acute complete femoral neck fracture was not provided pain management prior to being discharged to the hospital. Resident identifiers: 298.
[Cross refer to F697]
5. In addition, during the October 2022 recertification survey, the facility was cited F550, F580, F584, F609, F610, F641, F656, F684, F689, F692, F697, F755, F760, F761, F773, F812, F835, F840, F842, F867, F880, F882, and F923 among other areas of non-compliance. These same areas were again identified during the current recertificaiton survey.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 25 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses which included sepsis, acute resp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 25 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses which included sepsis, acute respiratory failure, type 2 diabetes mellitus, vascular dementia, pneumonia, pressure ulcer of left heal, metabolic encephalopathy, hypertension, and atrial fibrillation.
Resident 25's medical record was reviewed from [DATE] through [DATE].
A Health Status Note dated [DATE] at 10:33 PM indicated, Res [resident] lungs assessed this shift, resident c/o [complained of] pain with inhalation, lower lobes junky to auscultation, wheezing heard from chest, resident unable to maintain 02 [oxygen] sats [saturation] above 90 w/o [without] use of oxygen concentrator 02 91% 3L [liters]/min [minute]. MD [medical doctor] notified, Order given, routine CXR [chest xray] to r/o [rule out] pneumonia. [Company name redacted] notified; X-ray technician will be out to facility in the morning [DATE], to perform diagnostic request. Order has been written, unable to print, copy saved under documents for day shift to print. Will pass on to upcoming shift nurse to forward results to MD.
An Administration Note dated [DATE] at 8:40 AM indicated, sent to hosp [hospital].
On [DATE] at 1:42 PM, an interview with the Director of Nursing (DON) was conducted. The DON stated when she came in on [DATE] at 6:00 AM, resident 25 was ashen and struggling to breathe. The DON stated she notified the nurse practitioner and he was sent to the hospital at 7:30 AM. The DON stated she should have done a progress note for his change of condition and transfer, but she did not have time.
There was no documentation provided in the medical record that indicated the resident's physician and resident's representative was notified of the change of condition and transfer.
Based on interview and record review, the facility did not inform the resident representative for 2 of 30 sample residents when there was a significant change in the residents' physical, mental or psychosocial status; or when there was a need to alter treatment significantly. Specifically, two residents had a change in condition, but the facility did not attempt to contact the representative when the change of condition occurred. Resident identifiers: 25 and 46.
Findings include:
1. Resident 46 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia and hemiparesis, chronic obstructive pyelonephritis, severe sepsis without shock, aspiration pneumonitis, acute kidney failure, supraventricular tachycardia, and bipolar disorder.
Resident 46's medical record was reviewed from [DATE] through [DATE].
Progress notes for resident 46 indicated that on [DATE] at 9:24 AM, resident 46 was .having black tarry vomit, constant diarrhea, respirations 40, hunched over more than usual . MD notified and ordered resident to be sent to hospital for eval (evaluation). attempted to notify family with no response from only contact.
A History and Physical for resident 46 dated [DATE] documented that resident 46 presented to the local emergency room after facility staff observed resident 46 to have some coffee-ground looking emesis and acute hypoxic respiratory failure. The hospital physician documented that resident 46 had a history of deep vein thromboses and was currently receiving a blood-thinning medication. Resident 46 was diagnosed with sepsis with acute hypoxic respiratory failure and a gastrointestinal bleed at that time. The document also stated, Patients (sic) previous power of attorney was his sister, but we are being told she has unfortunately passed away. SW (social work) looking into other family members.
Progress notes for resident 46 revealed the following entries:
a. On [DATE], resident 46 was seen by Nurse Practitioner (NP) 2. NP documented that resident 46 . is a [AGE] year-old male with a history of CVA (cerebrovascular accident), COPD (chronic obstructive pulmonary disease) and multiple previous hospitalizations. Today patient was seen for his recertification visit. He was resting in his bed and appeared comfortable, no signs of distress. Patient reports he is doing fine. He is eating well, sleeping good, no issues with bowels or bladder, no anxiety or depression, no uncontrolled pain, anxiety or depression. He denied any current issues or concerns. Floor staff reports he is doing well. NP 2 did not document any acute health concerns upon assessment of resident 46.
b. On [DATE] at 9:30 PM, Registered Nurse (RN) 2 documented that there was a New order for Rocephin 1 Gm (gram) IM (Intramuscular) tonight, Sat (Saturday) [and] Sun (Sunday). for possible cholecystitis. Zofran 4 mg (milligrams) SL (sublingual) q (every) 6 hrs (hours). prn (as needed) N/V (nausea/vomiting). Schedule Tylenol 650 mg TID (three times a day) c (?) 3 days for abdominal pain. Stat (immediate) ultrasound of abdomen RUQ (right upper quadrant) and LLQ (left lower quadrant). No documentation was included in the note to indicate what occurred to prompt staff to contact the physician.
c. On [DATE] at 6:15 AM, RN 2 documented, Resident was heard by nurse urping (sic) up fluid. I went into his room and his roommate said he kept doing this. I checked him over and he had some brown- black fluid on the left side of his mouth. I told him not to swallow the fluid and to cough it into an emesis basin which I [NAME] (sic) to him. His VS (vital signs) were taken. T (temperature) 98.1, P (pulse) 112, R (respirations) 16 B/P (blood pressure) 148/74 and 02 (oxygen) sats (saturations) 94% on room air. I could hear bowel sounds in upper quadrant but minimal in lower quads. He stated that his pain was above his right navel and below it. Fluid brought up was a dark brownish color. MD PA (Physician Assistant) notified at 2200 (10:00 PM) with Rocephin, Zofran and scheduled Tylenol order. See MAR (Medication Administration Record) and progress noted (sic). Also a stat (immediate) ultrasound was ordered. Call was made to [name of contracted radiology provider] this AM (morning) and they stated that they donot (sic) do ultrasounds on the weekends. MD to be notified by day nurse, which was agreed in report this AM. [Note: The facility had been performing weekly vital signs on Resident 46. Per facility documentation, on [DATE], Resident 46's blood pressure was 114/62 and his pulse was 67. Per the facility's vital sign records for Resident 46, between [DATE] and [DATE], Resident 46's blood pressure was generally consistent with the reading obtained on [DATE]. Resident 46's pulse had ranged from 58 to 85.]
d. On [DATE] at 12:50 PM, RN 3 documented that resident 46 . has vomitted (sic) once this shift, it was a light brown color. He has requested more prune juice, but I denied that request and explained that we want to see why his vomit is brown. [Resident 46] had been laying in his vomit all night, we got him up to the shower and changed his bedding. His entire left arm, side of torso, and hip are very red. Cleaned well and put on hydrocortisone cream and barrier cream. Texted pic (picture) to provider of his inflamed skin. RN 3 did not document whether she had informed resident 46's physician of the ongoing brown emesis that resident 46 was experiencing. In addition, RN 3 did not document any indication that she was aware of the stat ultrasound order, or what the status was in obtaining the ultrasound.
e. On [DATE] at 4:36 PM, RN 4 documented that resident 46 had a Small amount of dark brown emesis early this morning. No other episodes this shift.
f. On [DATE] at 10:21 PM, RN 5 documented, Res (resident) currently on ABX (antibiotics) IM, (2nd dose) Medication was administered per MD orders. Res tolerated procedure well, there has been no ASE (adverse side effects) observed or reported. Fluids encouraged. RN 5 did not document any assessment with regard to resident 46's abdominal pain, nausea or vomiting. [Note: This note was entered as a late entry on [DATE] at 8:24 AM.]
g. On [DATE], at 11:00 AM, RN 4 documented that the contracted radiology provider . cannot ultrasound until [DATE]. Medical directorship notified and ordered to have ultrasound done at [name of local hospital]. Scheduled with [name of local hospital] [DATE] at 0900 (9:00 AM) check in 0845 (8:45 AM). NPO (nothing by mouth) 8hrs (hours) prior to procedure. Medical directorship notified. No emesis on this shift and no reports of emesis on night shift. Resident states he does still have abdominal pain but is able to eat.
h. On [DATE] at 8:25 PM, RN 5 documented that resident 46, . continues on ABX IM, (final dose) Medication was administered per MD orders. Res tolerated procedure well, there has been no ASE observed or reported. Res instructed to move RUE (right upper extremity) often to decrease stiffening in the muscle/pain. Fluids encouraged. RN 5 did not document any assessment with regard to resident 46's abdominal pain, nausea or vomiting. [Note: This note was entered as a late entry on [DATE] at 8:28 AM.]
i. On [DATE] at 3:00 AM, RN 5 documented, CNA (Certified Nursing Assistant) completed rounds at 12:30am at which time resident was A&O (alert and oriented), brief was changed, resident was talking with staff. CNA started rounds at 02:30 (2:30 AM) upon entering residents' room, CNA exited notified nurse via radio to come down to res room. This nurse immediately went down, performed a quick assessment w/ (with) visual observation. Res had no pulse, eyes open, pale/ash color. No heart sounds. resident feet and hands cold with modeling. (02:45) (2:45 AM) Res was upright HOB (head of bed) 30-45-degree, emesis was observed down L (left) side of resident's shirt. There had been no emesis throughout this shift or reported from day shift, resident had no complaints after dinner, other than some abdominal pain, Tylenol offered, res declined. Res took all medication w/o (without) difficulty. Res was scheduled for an abdominal ultrasound this morning at 08:45 (8:45 AM). Appt (appointment) has been cancelled. Facility CNA provided post-mortem care, and reported resident continued to excrete emesis from mouth. Res has emergency contacted listed, who since has passed away. [Name of mortuary] was contacted. Body was received from this facility at 05:45 am (5:45 AM). MD, DON (Director of Nursing) and administrator notified.
Progress notes documented that the facility staff had not attempted to contact the resident's power of attorney (POA)/only family member about resident 46 between [DATE] and [DATE]. In addition, the facility did not attempt to contact the resident's power of attorney/only family member about resident 46's change in condition preceding his death. No progress notes were located to indicate that the facility was aware that the resident's POA was deceased or made any attempts to identify another POA.
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** 2. Resident 29 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, dysarthria and anarthri...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 29 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, dysarthria and anarthria, gastro-esophageal reflux disease without esophagitis, dysphagia, nonruptured cerebral aneurysm, major depressive disorder, chronic kidney disease, anemia in chronic kidney disease, muscle weakness, cognitive communication deficit, and history of falling.
Resident 29's medical record was reviewed on 7/29/24.
On 5/27/24 at 12:13 AM, a general note documented, Resident yelling at staff. She thinks she didn't get her HS [at bedtime] medications. This nurse explained to her she did, and another resident told her she witnessed her getting her HS meds [medications]. Resident then put herself on the floor. Unwitnessed fall, This nurse and CNA tried to start neuro [neurological] checks and vitals and she refused. Night CNA on 100 Hall signed refusal on neuro check sheet with this nurse. Assessment done and no injuries and no c/o [complaining of] pain. Resident put back to bed and she is calm now. WCTM [will continue to monitor].
On 5/27/24 at 12:36 AM, a general note documented, [Nurse Practitioner 2] Notified VIA phone text message of fall. Day nurse to notify family.
On 6/10/24 at 5:05 PM, facility exhibit 358 entity report documented, that on 6/6/2024 the Resident's nephew began yelling at staff and stated staff were abusing the Resident because of a bruise on the Resident's buttocks from a fall. The Resident had an unwitnessed fall on 5/26/2024 at 11:55 PM and was found on the floor next to her bed. No injuries were noted after the fall and the Resident refused neuro checks. Resident is [resident 29's name redacted].
On 6/18/24 at 4:40 PM, facility exhibit 359 was submitted to the SSA. Facility exhibit 359 entity report documented, no evidence was found of neglect based on the interviews with Nurse and Multiple CNAs.
Facility exhibit 358 entity report documented that the Administrator was notified of the incident on 5/26/24, via text message and the incident was not reported to the SSA until 6/10/24 at 5:05 PM.
Facility exhibit 359 entity report was not submitted to the SSA until 6/18/24 at 4:40 PM.
On 7/31/24 at 7:17 AM, an interview was completed with the DON. The DON stated that the Administrator was supposed to do thorough investigations when there were allegations of neglect with residents. The DON stated that she was unsure of the facts regarding the allegation.
On 7/31/24 at 2:55 PM, an interview was conducted with the ADM. The ADM stated that this became a reportable incident because the resident did not get her medications and threw a fit and ended up on her floor and the nephew came in a week and a half later and screamed at staff about abusing and neglecting the resident. The ADM stated that based off of what was told the resident was found on the floor and staff tried to assist her back into bed. The ADM stated that he viewed the incident as just a fall and wondered if he really needed to report it to the SSA. The ADM stated that he had five calendar days to submit the 359.
Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two hours after the allegation was made if the events that cause the allegation involve abuse or result in serious bodily injury. Specifically, for 2 out of 30 sampled residents, an entity report of a physical abuse allegation was not submitted to the State Survey Agency (SSA) until three days after the incident and an entity report of a neglect allegation was not reported to the SSA until 14 days after the incident. Resident Identifiers: 29 and 41.
Findings Included:
1. Resident 41 was admitted to the facility on [DATE] with diagnoses including cellulitis of left lower limb, methicillin resistant staphylococcus aureus infection unspecified site, malaise, venous insufficiency, localized edema, morbid severe obesity due to excess calories, chronic atrial fibrillation unspecified, essential hypertension, anxiety disorder, and obsessive-compulsive disorder.
Resident 41's medical record was reviewed from 7/28/24 through 8/14/24.
On 6/14/24 at 12:28 PM, a nursing progress note documented, CNA [Certified Nursing Assistant] in to give resident a shower and resident was agitated. Relieved CNA and finished shower and had no issues. Patient does refuse showers and this was an exceptional opportunity for her as she did her own with min [minimum] assist. No other issues and she currently has a visitor at this time.
On 6/17/24 at 1:01 PM, a facility initial notification, form 358, was submitted to the SSA. The form documented an incident of physical abuse. The form documented that staff had become aware of the incident on 6/14/24 at 12:00 PM. The form documented that the incident was reported by CNA 2 to Licensed Nurse 4 that CNA 2 had attempted to shower resident 41. During the shower, resident 41 became resistant and started to hit and scratch at CNA 2. Resident 41 slapped CNA 2 in the face and scratched the tops of both of CNA 2's arms.
Documentation showed that Adult Protective Services, police, and the ombudsman were not notified of the incident.
On 6/21/24 at 4:32 PM, a facility follow-up notification, form 359, was submitted to the SSA. The form indicated that the allegation of physical abuse was not substantiated. The form documented that the incident was, . a series of events that quickly escalated out of control. The form documented that resident 41 had become upset during her shower because she wanted to wash herself using baking soda instead of soap provided by the facility.
On 7/31/24 at 11:32 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that during the incident she had been called into the shower room to de-escalate resident 41 and CNA 2. The DON stated that she was able to calm resident 41 down and complete the shower. The DON stated that after the incident, she wrote up an incident report and reported the incident to the facility Administration.
Documentation showed that an incident report was completed for the incident on 6/14/24 at 5:55 PM. Documentation showed that the nursing home Administrator was notified of the incident on 6/14/24 at 12:00 PM.
On 7/31/24 at 2:50 PM, an interview was conducted with the Administrator (ADM). The ADM stated that the incident was submitted late because the online submission portal did not provide him with a confirmation email when it was first submitted, so he later resubmitted the form. (Note: Documentation showed that the SSA provided an incident intake number to the facility through email on 6/20/24 at 9:02 AM.) The ADM stated that during the incident resident 41 became aggressive and told CNA 2 to stop. The ADM stated that CNA 2 tried to rinse the soap off of resident 41, but resident 41 slapped CNA 2 in the stomach and face, then scratched CNA 2's arms. The ADM stated that after the incident staff were provided training on bathing, resident rights, encouragement, and conflict resolution.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, in response to allegations of neglect the facility did not have evidence that all alleged ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, in response to allegations of neglect the facility did not have evidence that all alleged violations were thoroughly investigated. Specifically, for 1 out of 30 sampled residents, a resident that had multiple falls and sustained an acute complete femoral neck fracture with partial displacement did not have the fracture investigated for neglect. Resident identifiers: 298.
Findings included:
Resident 298 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, dementia, essential hypertension, acute kidney failure, and anxiety disorder.
Resident 298's medical record was reviewed on 8/7/24.
A Baseline Care Plan signed by the Director of Nursing (DON) on 3/28/24, documented that resident 298 did not have a history of falls and a Fall Management Care Plan was not implemented.
On 3/29/24, a Morse Fall Scale documented that resident 298 was a High Risk for Falling with a score of 50. A resident was considered a High Risk with a score of 45 and higher.
An admission Minimum Data Set (MDS) assessment dated [DATE], documented that resident 298 had a Brief Interview for Mental Status (BIMS) score of 13. A BIMS score of 13 to 15 would indicate intact cognition. The Care Area Assessment Summary of the MDS documented that falls had triggered to be care planned.
On 4/11/24 at 8:29 AM, a Fall Incident Report documented Staff radio nurse, to report resident fell. Nurse knocked and entered res [resident] room. Staff reported fall was witnessed. Res was assessed, res cognitive to baseline, A&O [alert and oriented] x2, name and situation. PERRLA [pupils are equal, round, and reactive to light and accommodation] WNL [within normal limits], ROM [range of motion] completed without difficulty, res assisted into bed. Res was painful r/t [related to] skin tear to R [right] elbow., res had a reddened area R lateral side just below hair line. Staff reported that redness to forehead was there earlier before the fall. Res had a large skin tear to R elbow, wound Tx [treatment] provided, affected area was cleansed with wound cleaner, pat dry. using steri strips tear was close and approximated well. Bacitracin applied, covered with non-adherent dressing, and wrapped. Neuro's [neurological's] started per protocol. MD [Medical Director], family notified via voicemail, and DON 04/12/2023. Res stated his feet fell out from under him and he fell to the ground. Res stated he hit head and touched over red area to R side of forehead. [Note: Neuro's were unable to be located.]
A care plan Focus initiated on 4/12/24, documented The resident has had an actual fall with minor injury d/t [due to] Hypotension and Unsteady gait. The interventions included:
a. Anticipate patients needs and monitor for unsteady balance. Date Initiated 4/11/24.
b. Continue interventions on the at-risk plan. Date initiated 4/12/24. [Note: The at-risk plan was unable to be located.]
On 5/18/24 at 3:59 AM, a Health Status Note documented Note Text: Resident fell in his room about 1900 [7:00 PM]. It was an unwitnessed fall lost his balance and went down on his left side. Able to move all his extremities without pain. A small red mark was found on his left back shoulder. He was too weak to get up on his own. Three maximum assist to left [sic] him onto his lounge chair. Vital signs taken and T [temperature] 98.0, P [pulse] 64, R [respirations] 28 B/P [blood pressure] 96/56 and 02 [oxygen] sats [saturations] 92% on room air. MD notified of low B/P and fall at 2238 [10:38 PM]. Administrator and DON notified at 0345 [3:45 AM] and 0348 [3:48 AM] this morning. Morning nurse to be notified in am and family. Neuro checks and VS [vital signs] doing well no changes.
[Note: No new interventions were implemented to prevent falls after the fall 5/18/24.]
On 5/19/24 at 9:00 AM, an Incident Follow up documented Date of Incident: 5/19/2024 Type of Incident: Fall Root Cause: Unsteady gait Treatment Required: None Interventions put into place: Neuros, call light given to resident, rounds every 15 minutes Referrals Made: None.
[Note: No new interventions were implemented to prevent falls after the fall on 5/19/24. An assessment after the fall was unable to be located.]
On 5/19/24 at 11:00 PM, an encounter documented Date of Service: 05/20/2024 Visit Type: Acute Transition of Care: No transition occurred. Progress Note . Chief Complaint / Nature of Presenting Problem: Fall History Of Present Illness: Patient is a [AGE] year-old male with a past medical history significant for Alzheimer's dementia. He was previously a resident at the [name redacted] and was admitted here one month ago. He has tried to escape multiple times and constantly packs his things to leave. He often waits by the locked door of the unit to leave. Today CNA [Certified Nursing Assistant] reported that patient had 2 falls over the weekend. Denied hitting his head. Patient reports that he is fine. He denied any uncontrolled pain. He denied any issues or concerns. The Nurse Practitioner (NP) signed the note on 5/20/24 at 8:39 AM.
On 5/19/24 at 4:45 PM, a Fall Incident Report documented . Client had an unobserved fall out of dining room chair. Client pulled tablecloth halfway off. When CNA walked into dining room to check on clients, other residents were helping client off of floor. Client stated 'I feel. I am okay.' Client was put on neuros and observed every 15 minutes.
[Note: No new interventions were implemented to prevent falls after the second fall on 5/19/24.]
On 5/20/24 at 2:50 PM, an Orders - General Note from electronic record (eRecord) documented Note Text: CNA comes to nurse and stated resident had an assisted fall and was lowered to ground after being toileted. He lost his balance and she grabbed him and lowered him. Both South and North nurse in to assist resident and transfer him to his w/c [wheel chair]. He did not appear to be in pain but rather confused. He sustained a small r elbow tear to his arm from the w/c during transfer. Cleaned and dressed. He then rested quietly throughout the rest of the shift.
[Note: No new interventions were implemented to prevent falls after the fall on 5/20/24.]
On 5/20/24 at 11:00 PM, an encounter documented Date of Service: 05/21/2024 Visit Type: Acute Transition of Care: No transition occurred. Progress Note . Chief Complaint / Nature of Presenting Problem: Right hip pain History Of Present Illness: [Resident 298] is a [AGE] year-old long-term care resident here at [name redacted]. Per the nurses report he has had a couple of falls over the weekend. He was evaluated yesterday but denied any significant pain. It is unclear if he had another fall since yesterday's evaluation but currently he has complaints of right hip pain. He has been unable to stand. Most of his pain is localized to the anterior and lateral right hip. General: Elderly male in mild distress. Does appear confused which is his baseline Musculoskeletal: Patient does have tenderness to palpation over the right hip laterally anteriorly. He does have pain with internal and external rotation of the right hip. This localizes anteriorly. Acute right hip pain Patient's right hip pain appears to be acute and it is unclear whether this is related to a fall over the weekend or a new fall today. Given his acute right hip pain and evaluation today I do recommend x-rays of the right hip stat [immediately]. These were ordered today. Plan to follow-up after x-rays. Fall On fall precautions. The MD signed the note on 5/21/24 at 11:17 AM.
On 5/21/24 at 11:40 AM, a Health Status Note documented Note Text: NEW ORDER: Pt [patient] is not bearing any wt [weight] on rt [right] leg has a lg [large] skin tear on rt elbow. md notified ordered a xray it has been ordered and they stated it wil [sic[ be done today. pt had a shr [shower] today.
On 5/21/24, the Diagnostics report documented . Right hip, 2 views Comparison: None. Findings: There is an acute complete femoral neck fracture with partial displacement compatible with a Garden Classification III fracture. IMPRESSION: 1. Garden classification III acute femoral neck fracture. The diagnostics report was signed by the diagnostics radiologist on 5/21/24 at 6:23 PM.
On 5/22/24 at 2:51 AM, a Health Status Note documented Note Text: Follow up on res x-ray: Impressions noted; There is an acute complete femoral neck Fx [fracture] with partial displacement compatible with a Garden class III. Mild degree of osteopenia. Moderate osteoarthritis. X-ray results sent to MD, response pending. WCTM [will continue to monitor].
On 5/22/24 at 5:30 AM, a Health Status Note documented Note Text: Staff reported res, has been up all night did not sleep a wink, trying to wiggle his way out of bed. Staff has continuously throughout shift had to re center res into bed and remind resident that he, could not walk d/t broken femur. will pass on to upcoming shift nurse for monitoring and follow-up.
On 5/22/24 at 6:54 AM, an Orders - General Note from eRecord documented Note Text: MD notified of results of Xray and new order for resident to be sent to ER [emergency room] for eval/tx [evaluation and treatment]. Preparing paperwork.
On 5/22/24 at 3:01 PM, a Health Status Note documented Note Text: Received call from [hospital name redacted]. They will do surgergy [sic] this afternoon and resident to be admitted to med [medical] surg [surgical] floor.
On 8/7/24 at 12:23 PM, an interview was conducted with NP 2. NP 2 stated she saw resident 298 because he had a fall. NP 2 stated that resident 298 was walking around pushing his recliner around and had no pain. NP 2 stated the MD came in the next day and said that resident 298 had a broken femur. NP 2 stated that she did not do a full hip exam because resident 298 was moving fine. NP 2 stated that she did not expect a break. NP 2 stated that the MD sent resident 298 out and resident 298 did have a break.
On 8/8/24 at 11:50 AM, an interview was conducted with the DON. The DON stated that resident 298 had an unwitnessed fall on 5/18/24 at about 3:00 AM. The DON stated that resident 298 had another fall on 5/19/24 at 9:00 AM. The DON stated the fall on 5/20/24, was an assisted fall at 3:00 PM. The DON stated at that time herself and the CNA lowered resident 298 to the floor and the DON stated that she did not notice anything. The DON stated that the NP saw resident 298 the morning of 5/21/24, and noted we need an xray. The DON stated that resident 298 somehow had a shower during that time on 5/21/24. The DON stated the facility called the x-ray company at 11:34 AM, and they arrived at the facility at 5:41 PM, to do the x-ray on 5/21/24. The DON stated at 6:23 PM, the x-ray company either faxed the results or notified the facility of the results. The DON stated that the nurse on 5/22/24, made a progress note that results were pending from the doctor. The DON stated at the end of the shift the nurse made a note that resident 298 was up all night and passed the information to the oncoming nurse which was the DON. The DON stated at 6:55 AM, she notified the doctor and resident 298 was sent out to the hospital.
On 8/14/24 at 7:29 AM, an interview was conducted with CNA 3. CNA 3 stated that if a resident was a fall risk the resident would have something on there door like a color indicating if they were a fall risk or a runaway risk. CNA 3 stated that she started at the facility in May or June 2024. CNA 3 stated that she met resident 298 after her second day and resident 298 had fallen and broken his femur. CNA 3 stated resident 298 would try and roll out of bed or get up. CNA 3 stated there were interventions after the fracture to keep resident 298 in bed and resident 298 had a wedge pillow. CNA 3 stated that resident 298 would try and get up even though he had a broken femur. CNA 3 stated that she would get in report if a resident was a fall risk. CNA 3 stated that she did not know if there was a [NAME] for residents or where to see interventions. CNA 3 stated that 15 minute checks were done with neuros. CNA 3 stated that 15 minute checks we done for the first hour, then 30 minute checks, then 45 minute checks, and then every hour for three days. CNA 3 stated the nurse had a form at the nurses station that the CNAs would document the neuro checks. CNA 3 stated that neuros were done after every fall. CNA 3 stated if a resident had an intervention to anticipate needs she would observe what the resident was like and what the resident needed. CNA 3 stated if the resident was cold then she would get them a blanket, if the resident was dirty she would give them a shower regardless if it was the residents shower day.
On 8/14/24 at 7:39 AM, an interview was conducted with the DON. The State Survey Agency (SSA) Lead Licensor asked the DON what an At Risk Plan was and how was that a fall care plan intervention. The DON stated why was that there and that should not be there. The DON stated that was assuming that the nurses knew what the at risk plan was for the resident. The DON stated that she had no idea why that was on the care plan. The DON stated to her an at risk plan was why the resident fell. The DON stated the at risk plan did not tell her anything if that was on the care plan as an intervention. The DON stated where did they get that. The DON stated the facility used to have a form that was stapled to the incident form and would document why the resident was falling and would go more in depth. The DON stated that she would not recommend the at risk plan as an intervention because you need to fix the problem. The DON stated the at risk told the staff nothing. The SSA Lead Licensor asked the DON what the intervention 15 minute checks meant. The DON stated that 15 minute checks meant neuros and vital signs every 15 minutes. The DON stated that neuros were conducted with an unwitnessed fall. The DON stated that 15 minute checks were done in four sets. The DON stated that anticipate needs meant that the resident was a high fall risk and the staff need to have eyes more on the resident. The DON stated to have eyes more on the resident meant to make sure staff were watching the resident and a little bit more eyes on the resident. The DON stated it was impossible to do a one on one in the facility. The DON stated that all the nurses should be doing the care plans. The DON stated that interventions could be customized. The DON stated that staff needed to find out why the fall happened and if the fall fell into any of the categories on the computer then great if not the intervention could be customized.
On 8/14/24 at 8:42 AM, a follow up interview was conducted with the DON. The SSA Lead Licensor asked the DON if she had details regarding resident 298's fracture. The DON stated that resident 298 was not in any pain that day and had no signs of a fracture. The DON stated the CNA was getting resident 298 ready to toilet and the DON went in to assist and resident 298 was lowered to the ground. The DON stated that she had been told if the fall was assisted she did not have to do a fall. The DON stated there may have been a fall the next day also but she was not sure. The DON stated that neuro checks were only done if the resident hit their head. The DON stated that she usually kept the neuro checks and she had record of them.
On 8/14/24 at 9:14 AM, an interview was conducted with the Administrator. The SSA Lead Licensor asked the Administrator if he considered investigating resident 298's fall as neglect. The Administrator stated his reasoning for not investigating for neglect was due to resident 298 had a fall and the NP was in the building, assessed resident 298, and there were no injuries or complaints of pain. The Administrator stated that resident 298 had a lot of falls. The Administrator stated that resident 298 had an assisted fall prior to the fracture. The Administrator stated that resident 298 had a fall matt but resident 298 would roll out of bed. The Administrator stated that resident 298 would roll out of bed frequently.
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
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 did not accurately assess residents. Specifically, for 1 out of 30 sampled re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not accurately assess residents. Specifically, for 1 out of 30 sampled residents, range of motion impairment was not documented on the Minimum Data Set (MDS) assessment. Resident identifier: 3.
Findings included:
Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which include, paranoid schizophrenia, chronic obstructive pulmonary disease, chronic viral Hepatitis C, major depressive disorder, suicidal ideations, gastro-esophageal reflux disease, essential hypertension, hypothyroidism, chronic pain, type 2 diabetes mellitus, post traumatic stress disorder, low back pain, and hypo-osmolality and hyponatremia.
On 7/29/24 at 8:30 AM, an interview was conducted with resident 3. Resident 3 stated that she could not get out of bed without extensive assistance from facility staff due to a stroke that she had which left her with weakness on the left side of her body. Resident 3 stated that she was unable to walk or use her left hand or arm.
On 7/29/24 at 8:35 AM, an observation was made of resident 3's left hand which showed a contracture.
Resident 3's medical record was reviewed on 7/29/24.
On 6/14/24, a quarterly MDS assessment revealed that resident 3 had no impairment with range of motion for both upper and lower extremities.
On 7/29/24 at 3:09 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that resident 3 always stayed in bed and had to be hoyer lifted anytime she needed to get out of bed.
On 7/29/24 at 3:43 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated resident 3 liked to stay in bed. RN 1 stated that resident 3 could not position herself and did not have use of their lower legs. RN 1 stated that resident 3 had to be lifted with the hoyer lift. RN 1 stated that resident 3 had bilateral shoulder weakness, and both wrists and hands had arthritis. RN 1 stated that resident 3 had a contracture with her left hand.
On 7/30/24 at 12:36 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that she submitted the MDS assessments to the state. The ADON stated that she did not count an impairment if the facility helped the resident move. The ADON stated that when she filled out the assessments and it applied to range of motion questions and staff assisted the resident with movement, she counted it as no impairment with the resident.
On 7/30/24 at 1:35 PM, a follow up interview was conducted with the ADON. The ADON stated that she had not read any guidelines with regards to range of motion with the MDS assessment. The ADON stated she thought it would count as no limitation if staff were helping with range of motion. The ADON stated that if it meant that resident 3 had to do things on her own then it would be an impairment and should be submitted as an impairment.
On 7/31/24 at 7:13 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 3 had physical therapy for increased strengthening. The DON stated that resident 3 had a contracture in her left hand and that had caused an impairment in range of motion.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 248 was admitted to the facility on [DATE] with diagnoses which included rheumatoid arthritis, chronic pulmonary ede...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 248 was admitted to the facility on [DATE] with diagnoses which included rheumatoid arthritis, chronic pulmonary edema, cellulitis, sarcopenia, anxiety disorder, opioid use, and repeated falls.
Resident 248's medical record was reviewed from 7/28/24 through 8/14/24.
An encounter progress note dated 4/18/23 at 11:00 PM indicated, Patient is a [AGE] year-old female who has been admitted to [facility name redacted] for increasing weakness. She has severe arthritis in her extremities making it difficulty for her to even hold things. She has chronic pain, HTN [hypertension], opioid abuse and non compliance with her medications. Today she was seen for her admit visit and she reports that she is discharging to another facility later today. Floor staff stated that she has not been compliant with facility rules since has has been here and wanted to leave the movement she arrived.
A General Note dated 4/18/24 at 11:12 PM indicated, Late Entry: Note Text: 72 Hour Admit Charting: Res [resident] returned to facility appx [approximately] 16:00 [4:00 PM], pleasant and cooperative with cares, all medications taken as prescribed, res tolerated well. Res asks for assistance as needed, re-directed to use call light as needed for assistance. Call light within res reach.
It should be noted that there were no following progress notes or discharge summary in the medical record.
On 8/7/24 at 9:49 AM, an interview was conducted with the Administrator (ADM). The ADM stated resident 248 was discharged to another skilled nursing facility (SNF). The ADM stated, It just says discharged to SNF. The ADM stated he did not have any more information
Based on interview and record review, the facility did not ensure that for 2 of 30 sample residents, a discharge summary was included in the residents' medical records. Resident identifiers: 47 and 248.
Findings include:
1. Resident 47 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, edema, hyperlipidemia, major depressive disorder, pain in right hip, spinal stenosis, hypertension, low back pain, history of malignant neoplasm of prostate, and and genetic related intellectual disability.
Resident 47's medical record was reviewed on 7/31/24.
Resident 47's medical record that the resident discharged from the facility on 5/15/24. No discharge summary or basis for the discharge could be located in resident 47's medical record.
On 7/31/24 at 3:25 PM, an interview was conducted with the Director of Nursing. (DON). The DON stated that
the Administrator and Social Services Worker worker had a handy [NAME] discharge summary they would provide to the nurse and the nurse would complete the appropriate paperwork. The DON stated that this process has been sporadic since January of 2024. The DON stated that there was a discharge summary that could be completed in the electronic health record that could have been filled out as well.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
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 with limited range of motion receiv...
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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 with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, for 2 out of 30 sampled residents, recommended treatments of daily prolonged stretching were not followed up on, occupational therapy orders were not implemented, and splints were not being provided. Resident identifiers: 1 and 35.
Findings included:
1. Resident 35 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included artherosclerotic heart disease, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, gout, memory deficit following cerebral infarction, repeated falls, type 2 diabetes mellitus with diabetic polyneuropathy, cerebral infarction, dysphagia, Charcot's Arthropathy, and acquired absence of other right toe.
On 7/28/24 at 1:05 PM, an observation and interview were conducted with resident 35. Resident 35 was observed sitting in his wheelchair in the dining room, he wore a white sock on his left foot with no brace. Resident 35's left foot appeared severely impaired and was rotated medially. Resident 35 stated he did wear a brace on his ankle, sometimes. Resident 35 stated that he did not currently receive physical or occupational therapy, nor did anyone do range of motion exercises with him for his left foot.
On 7/29/24 at 11:03 AM, an observation of resident 35 was conducted. Resident 35 was in a manual wheelchair and self-propelled himself with the use of his right arm and foot around the nurse's station. Resident 35 wore a white sock on his left foot with no brace and his left hand and wrist had a contracture.
Resident 35's medical record was reviewed from 7/28/24 through 8/14/24.
A Clinical Summary dated 6/12/24 at 8:00 AM, indicated resident 35 was seen by an outside orthotic clinic for his ankle foot orthosis (AFO). It further indicated, Device History . Start Date: 2021. End Date: current/present. Comments: This AFO is a generic off the shelf design that of which doesn [sic] not cater to his serve externally rotated ankle foot complex. Increased risk for adverse skin shear with continued use. Custom AFO pursuit necessary in assurance of patient safety/skeletal informational stabilization. It further indicated, Comments: Minor adjustments/repairs pursued as described today. I informed the tending facility staff to pursue daily prolonged stretching of his ankle foot complex in avoiding deformational varus tendency, concern with fixated external rotational deformation at the ankle complex should this not be put in place at his care facility. Written recommendations provided to facility staff present today. All adjustments requested by [resident name redacted] pursued today were found proper. Follow up as needed. It should be noted that this document was not found in the medical record and was provided after it was requested by the State Survey Agency. The fax server date on this document was 7/30/24 at 4:31 PM from the clinic.
The quarterly Minimum Data Set assessment Section GG Functional Abilities and Goals dated 6/13/24, indicated, Functional Limitation in Range of Motion to the Lower extremity (hip, knee, ankle, foot with Impairment to one side. It further indicated resident 35 used a wheelchair.
An Encounter Progress Note dated 7/4//24 at 11:00 PM, indicated, [Resident name redacted] is a [AGE] year-old male who is a long-term resident at [Facility name redacted]. He has a history of a cerebral infarction resulting in left-sided weakness, diabetes, obstructive sleep apnea as well as Charcot's arthropathy. When is at the nurses station today patient came to me to discuss his left foot pain and malformation. Patient states that years ago he hurt his foot and it never healed back to normal position properly. The foot is turned inward and a brace is in place at this time. Patient states that he is able to hold the foot or the toes back and push them down but with very poor range of motion. He stated that he needs to have the foot casted to help him get the foot back into normal position. The brace does not appear to be keeping the footin [sic] a normal anatomical alignment position. I am going to refer the patient to an orthopedic specialist to works on her feet and ankles. I informed patient that I would write the referral and patient was very grateful. Patient was sitting in his wheelchair when I left him by the nurses station.
The care plan focus, The resident had a cerebral vascular accident (CVA/Stroke) affecting the left side was initiated on 8/5/21. It indicated the goal of, The resident will be free from s/sx [signs and symptoms] of complications of CVA (DVT [deep vein thrombosis], contractures, aspiration pneumonia, dehydration) through review date. It further indicated Interventions/Tasks of, Monitor/document mobility status. If resident is presenting with problems or paralysis, obtain order for Physical therapy and Occupational therapy to evaluate and treat.
The care plan focus, The resident has hemiplegia r/t [related to] CVA was initiated on 8/5/21, with a Target Date of 6/5/24. It indicated the goals, The resident will remain free of complications or discomfort related to hemiplegia through review date and The resident will maintain optimal status and quality of life within limitations imposed by Hemiplegia through review date. It indicated the Interventions/Tasks, Discuss with resident/resident and family any concerns, fears, issues regarding diagnosis or treatments and PT [physical therapy], OT [occupational therapy], ST [speech therapy] evaluate and treat as ordered.
On 7/29/24 at 3:51 PM, an interview was conducted with the Director of Nursing (DON). The DON stated there was no Restorative Nursing Assistant (RNA) program and that nursing did not do passive range of motion for residents. The DON stated occupational or physical therapy should provide those services if a resident had that ordered.
On 7/30/24 at 11:42 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated resident 35 had an AFO that he used to wear every day but had been refusing to wear it since his last appointment several weeks ago with the outside orthotic clinic. The ADON stated if that clinic sent any notes back it would be filed in the chart. The ADON stated the resident was not on physical therapy treatments at that time.
On 7/30/24 at 12:38 PM, an interview was conducted with the Physical Therapy Assistant (PTA). The PTA stated she had worked with resident 35 in the past but not in the last six months or so. The PTA was reviewing the medical chart and stated resident 35 was last seen by physical therapy April 2023.
On 7/30/24 at 2:01 PM, an interview was conducted with the Occupational Therapist (OT). The OT stated resident 35 was last seen by OT on 8/23/24, for his hand. The OT stated he did know that resident 35 had an AFO for his foot and that the fit rubbed and bothered him. The OT stated he still had trouble with his AFO.
On 7/31/24 at 11:18 PM, a follow up interview was conducted with the DON. The DON stated she had not seen the outside orthotic clinic summary from 6/12/24. The DON stated she needed to look at it and notify the physician. The DON stated his assigned nurse should have put that order in.
2. Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, acute myocardial infarction, acute respiratory failure with hypoxia, age-related cognitive decline, type 2 diabetes mellitus, non-pressure chronic ulcer of foot, rheumatoid arthritis, acquired deformity of lower leg, muscle wasting and atrophy, dysphagia, and difficulty in walking.
On 7/28/24 at 11:59 AM, an observation was conducted of resident 1. Resident 1 was laying in bed and appeared to have contractures to her hands and fingers bilateral. There were no splints or rolled hand towels observed in resident 1's room and resident 1 did not have splints or rolled hand towels in or on her hands.
On 7/28/24 at 12:17 AM, an observation was conducted of resident 1. Resident 1 was observed eating lunch in her room. Resident 1 was observed with contractures to her hands bilateral.
Resident 1's medical record was reviewed on 7/29/24.
A care plan Focus initiated on 6/19/13, documented The resident has limited physical mobility r/t Neurological deficits, osteoporosis, Weakness, contractures which can lead to falls. The interventions included, but were not limited to, prom [passive range of motion] to bilateral hands, splint to hands as tolerated. The intervention was initiated on 5/31/14.
On 1/26/22, a physician's order documented OT Clarification: OT to tx [treat] 3-5 x/wk [times per week] x [times] 8 weeks for self cares, x-fers [transfers], ROM [range of motion], contracture mgnt [management], pt [patient]/caregiver ed [education], their [sic] [therapeutic] ex [exercise], there [therapeutic] act [activity].
An OT Discharge Summary with services dates from 10/17/23 to 3/12/24, documented that resident 1 had contractures of the right and left hand. The reason for discharge was due to resident 1 meeting maximum potential at that time. The discharge disposition was Nursing. A short term goal included, but was not limited to, 5. [Met]: Pt will tolerate air splint in R [right] hand x 2 hrs [hours]/day to [sic] for contracture management and prevent skin breakdown. The start status documented not tolerating splint currently. The concluding status documented Towel roll placement - not tolerating air splint. It should be noted that the OT Discharge Summary did not address resident 1's left hand contracture.
On 7/29/24 at 8:45 AM, an observation was conducted of resident 1. Resident 1 was observed at the medication cart and her right foot was observed to be turned inward. Resident 1 did not have a brace or splint on the foot.
On 7/29/24 at 11:59 AM, an interview was conducted with resident 1. Resident 1 stated that therapy or staff did not do exercises with her hands. Resident 1 stated that she did not have braces or splints for her hands and could not remember if she ever had them.
On 7/29/24 at 1:08 PM, an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated that she was not aware of any exercises or a split that resident 1 was to be wearing. CNA 3 stated that resident 1's hands did not really open and resident 1 would use her wrist to grab things. CNA 3 stated that resident 1's fingers were always in the down direction towards the palm of the hand and resident 1 was unable to move her fingers. CNA 3 stated that she was not sure if therapy was working with resident 1 or if the CNAs were to be doing that. CNA 3 stated that she was not aware of any exercises.
On 7/29/24 at 1:37 PM, an interview was conducted with the DON. The DON stated that resident 1 had arthritis that was causing the contractures. The DON stated the staff had tried to use rolled towels in resident 1's hands and resident 1 had refused them. The DON stated that resident 1 wanted to do as much as possible for herself. The DON stated that resident 1 used special spoons to eat. The DON stated that resident 1 could not grasp and did not have that fine motor movement. The DON stated that PT and OT did not work with resident 1 that she knew of. The DON stated that resident 1 used splints in the past and resident 1 would use the splints every once in awhile when resident 1 had pain but resident 1 would refuse the splints. The DON stated that resident 1 used to have a splint on her foot but resident 1 did not like to wear the splint and resident 1 had a wound on her foot currently. An observation was conducted of resident 1's room with the DON. The DON removed a foot splint from resident 1's closet. Resident 1 stated the foot brace belonged to her roommate and the brace was not hers. There were no hand splints in resident 1's closet or the dresser drawers. Resident 1 stated that she did not have a hand splint and the hand splints were from a long time ago. The DON stated there were no exercises like PROM for resident 1's hands. The DON stated there was nothing that she was aware of that staff were doing to ensure that resident 1's contractures did not get worse. The DON stated the staff would make sure that resident 1's finger nails were clipped and clean.
Documentation was unable to be located regarding resident 1's refusals of the splints and hand towels.
On 7/29/24 at 3:51 PM, a follow up interview was conducted with the DON. The DON stated the facility did not have a RNA program. The DON stated if the referral from PT or OT was to Nursing then by all means we should be doing that. The DON stated the staff just watch the resident and if the resident were to fall we would make the referral to PT and OT. The DON stated they had a meeting every Friday and would talk about the residents, if the residents were falling, and if the residents needed PT or OT. The DON stated that OT would do the ROM exercises with the residents.
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
Incontinence Care
(Tag F0690)
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 did not ensure that a resident who enters the facility with an indwelling cat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that a resident who enters the facility with an indwelling catheter or subsequently received one was assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrated that catheterization was necessary. Specifically, for 1 out of 30 sampled residents, a resident continued to have an indwelling catheter without having a diagnosis for keeping it in place. Resident identifiers: 298.
Findings included:
Resident 298 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia, essential hypertension, benign prostatic hyperplasia without lower urinary symptoms, acute kidney failure, weakness, and anxiety disorder.
Resident 298's medical record was reviewed on 8/7/24.
An admission Minimum Data Set assessment date 4/10/24, documented that resident 298 had a Brief Interview for Mental Status (BIMS) score of 13. A BIMS score of 13 to 15 would suggest intact cognition.
On 5/25/24 at 3:38 PM, a health status note documented, Spoke with [name redacted] RN [registered nurse] at [name of hospital redacted] regarding discharge from hospital back to facility prior to 1700 [5:00 PM]. Resident admitted to hospital on [DATE]. res [resident] underwent R [right] hemiarthroplasty, silver long dressing placed over incision. Res is a 1-2 person assist ambulating with walker and transfers. Res was straight Cath [urinary catheter] this morning, there was trauma that caused bleeding, res is returning with a indwelling catheter d/t [due to] retention. Res VS [vital signs] BP [blood pressure] 114/62, HR [heart rate] **, Temp [temperature] 36.6, RR [respiratory rate] 18, O2 [oxygen] 94% RA [room air]. Res has dentures with self, Abductor pillow, res not tolerating well, HS/NOC [bedtime/nighttime] use. Res has been on a reg [regular] diet, has tolerated well.
On 6/3/24 at 8:49 PM, a health status note documented, Staff reported resident scrotum and testicles were red. This nurse assessed, affected area was observed, scrotum and testicles very red. This nurse provided and educated staff present, of proper perineal care, wiping front to back of both bowel and urine. Barrier cream applied. Resident has an indwelling catheter.
On 6/9/24 at 1:46 PM, a health status note documented, Resident tolerating oral ABX [antibiotics] d/t sepsis, no ASE [adverse side effects] noted. Foley intact and was placed during resident's stay in Hospital. 200ml [milliliters] in down drain bag and fluids encouraged .
On 6/23/24 at 1:15 PM, a health status note documented, Resident slipped from wheelchair to floor, CNA [Certified Nursing Assistant] was able to prevent resident from hitting the floor hard. Did not hit head, no injuries, but Foley catheter was pulled out. Resident denies pain, Removed wheelchair cushion to prevent sliding again, No bleeding from Foley being pulled out, however resident has been having hematuria since at least yesterday. 10ml balloon intact but appears to have deflated some. Medical directorship and family notified. Resident is incontinent without the Foley, will assess through the shift if resident is urinating and straight cath for retention.
On 6/23/24 at 5:12 PM, a health note documented. Resident had barely any urine in brief. Cathed using sterile technique, only a few drops of urine output. No longer hematuria like yesterday and earlier this morning. Due to resident having little output, unable to determine if resident is retaining or not. Foley catheter in, resident tolerated procedure well. Medical directorship notified.
On 6/24/24 at 8:08 PM, a physician note documented, . during pt [patient] fall his foley catheter was pulled out. He was not able to void due to urinary retention so a foley catheter was place [sic] again .Pt was having dark, cloudy, and foul smelling urine over the weekend. He was started on Macrobid 100mg [milligrams] PO [by mouth] BID [two times daily] X [times] 7 days to treat UTI [urinary tract infection] .Pt had a ground level fall over the weekend. No injuries were noted during my assessment. His foley catheter was pulled out during the fall. We are leaving the catheterout [sic] due to pt not having a dx [diagnosis] for keeping it in place.
On 8/8/24 at 8:31 AM, an interview was conducted with Licensed Nurse (LN) 5. LN 5 stated that an order was required for a resident to have a urinary catheter. LN 5 stated that she was unsure if the facility had a policy regarding residents and urinary catheters.
On 8/8/24 at 1:57 PM, an interview was conducted with the Director of Nursing (DON). The DON stated there was not a policy or procedure regarding residents with urinary catheters. The DON stated she could not recall why resident 298 had a urinary catheter or if he ever saw a urologist regarding the continued use of a urinary catheter.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
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 did not ensure that it was free of medication error rates of fi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of five percent or greater. Observations of 35 medication opportunities on 7/29/2024, revealed two medication errors which resulted in a 5.71% medication error rate. Specifically, for 1 out of 30 sampled residents, a resident was administered a medication after they had consumed their meal and the physician's order documented to administer the medication before meals. In addition, the resident was administered a medication two hours after the time specified on the physician's order. Resident identifier: 4.
Findings included:
Resident 4 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Huntington's disease, psychotic disorder with delusions, mood disorder due to known physiological condition, bipolar II disorder, conversion disorder with seizures or convulsions, migraine, chronic pain, essential hypertension, and gastro-esophageal reflux disease.
On 7/29/24 at 7:51 AM, Registered Nurse (RN) 1 was observed to prepare and administer medications to resident 4. RN 1 administered Carafate suspension 10 milliliters (ml) and pregabalin capsule 200 milligrams (mg) with the other morning medications that were prepared. Resident 4 was observed in the main dining room and had already consumed the breakfast meal.
Resident 4's medical record was reviewed for the reconciliation of medications on 7/29/24.
A physician's order dated 10/25/17, documented Carafate Suspension (Sucralfate) Give 10 ml by mouth before meals and at bedtime for Dyspepsia.
A physician's order dated 5/7/20, documented Pregabalin Capsule 200 MG Give 1 capsule by mouth one time a day for GIVE AT 0600 [6:00 AM] am ONLY (time sensitive).
On 7/29/24 at 10:30 AM, an interview was conducted with RN 1. RN 1 stated that the Carafate should be administered 30 minutes before meals. RN 1 reviewed the physician's order for the Carafate and stated that the physician's order indicated to administer the Carafate before meals. RN 1 stated that resident 4's pregabalin on the Medication Administration Record documented to administer at ARISE. RN 1 stated that ARISE was a flex time for medication administration but the physician's order documented to give the pregabalin at 6:00 AM. RN 1 stated the physician's order indicated 6:00 AM, because resident 4 would receive a noon dose of the pregabalin. RN 1 stated that the noon dose of the pregabalin was on a flex time also. RN 1 stated that resident 4 got three doses of pregabalin a day. RN 1 stated the morning dose of pregabalin was 200 mg and the other doses were 100 mg. RN 1 stated the facility had the noon dose of pregabalin coded to give at 1:00 PM, but the physician's order documented to give the pregabalin at 2:00 PM. RN 1 stated that she would give the noon dose of pregabalin closer to 2:00 PM.
On 7/29/24 at 11:13 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the facility had flex times to administer the medications but the nurse should have given the pregabalin between 6:00 AM and 7:00 AM. The DON stated that pregabalin was a narcotic and the staff liked to watch resident 4 because resident 4 took a lot of narcotics. The DON stated that resident 4 would have another dose of the pregabalin at 2:00 PM, so the staff needed to be conscious about the medication timing. The DON stated that the nurse should have given the Carafate 30 minutes before resident 4 ate her meal.
A facility Memorandum dated 1/22/2013, documented the following Medication Pass Times.
To allow the residents here at [facility name redacted] more autonomy and flexibility we are changing medication pass times. The new times are as follows:
Early AM (5am to 9am)
Arise (7am to 11am)
Noon (11 am to 2 pm)
PM (4pm to 7 pm)
HS [at bed time] (7pm to 10pm)
BID [two times a day] = arise & pm
TID [three times a day] = arise, noon, & pm
QID [four times a day] = arise, noon, pm, & hs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure that all drugs and biologicals were stored and l...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure that all drugs and biologicals were stored and labeled in accordance with accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date as possible. Specifically, for 1 out of 30 residents, a resident's narcotic medication was being cut in half and then one-half was being placed back in the bubble pack and sealed with tape. Resident identifier: 22.
Findings included:
Resident 22 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, paranoid schizophrenia, major depressive disorder, type 2 diabetes mellitus without complications, essential hypertension, low back pain, asthma, and cirrhosis of liver.
Resident 22's medical record was reviewed on 8/8/24.
A physician order with a start date of 6/25/21, documented oxyCODONE HCl [hydrochloride] Tablet 5 mg [milligrams] Give 1 tablet by mouth every 6 hours as needed for Pain related to LOW BACK PAIN.
On 8/8/24 at 1:23 PM, it was observed that Licensed Nurse (LN) 5 and the Director of Nursing (DON) were doing a narcotic count reconciliation. It was observed that resident 22 had 34 and one half tablets of Oxycodone 10 mg.
On 8/8/24 at 1:25 PM, an interview was conducted with LN 5. LN 5 stated that resident 22 only took half of the Oxycodone and the other half was placed back in the bubble pack and sealed with tape. LN 5 stated that was what she was taught to do.
On 8/8/24 at 1:28 PM, an interview was conducted with the DON. The DON stated that for narcotic storage, medications should never be put back into a bubble pack once they have been removed. The DON stated that the half of the Oxycodone 10 mg should have been wasted with a witness. The DON stated that in all honesty they should not have been doing what they were doing and should not have retaped medications back into the cards, but that was what they have done. The DON stated that resident 22 did not take his narcotic medication on a regular basis and the pharmacy sent Oxycodone 10 mg, but the order was for 5 mg and cutting it in half made the medication last longer.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0773
(Tag F0773)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 18 was admitted to the facility on [DATE] with diagnoses which included schizophrenia, other stimulant abuse with st...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 18 was admitted to the facility on [DATE] with diagnoses which included schizophrenia, other stimulant abuse with stimulant-induced psychotic disorder, and mycosis.
Resident 18's medical record was reviewed from 7/28/24 through 8/14/24.
An Encounter progress note dated 8/8/24 at 11:00 PM, indicated, Patient is a [AGE] year-old male who was homeless and is now admitted to [Facility name redacted] and is in the memory unit. Today patient was seen to review his recent lab work. Patient had a CBC with auto differential performed on 8/7/2024. Patient's platelet level is slightly decreased at 147.8, normal level is above 150.50. I am going to encourage patient to eat a well-balanced diet and stay well-hydrated. I educated our nursing staff to continue to push nutrition and hydration to help in patient's rehabilitation/recovery. Will recheck patient's CBC with auto differential again and 1 month.
It should be noted that there was no physician order for a CBC around the date of 8/7/24, or lab results in the medical record.
On 8/12/24 at 2:47 PM, an interview was conducted with the DON. The DON stated she had no idea where the order or results of the CBC blood test referred to in the Encounter progress note dated 8/8/24 at 11:00 PM, was.
Based on interview and record review, the facility did not obtain laboratory (lab) services only when ordered by a physician; physician assistant; nurse practitioner (NP), or clinical nurse specialist. Specifically, for 2 out of 30 sampled residents, a resident had a urinalysis (UA) collected without a physician's order and a resident had a Complete Blood Count (CBC) blood lab collected without a physician's order. Resident identifiers: 8 and 18.
Findings included:
1. Resident 8 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, schizoaffective disorder, chronic kidney disease stage 3, cannabis abuse, essential hypertension, polycystic kidney, type 2 diabetes mellitus without complications, mental disorders, stimulant dependence, and urinary tract infection.
Resident 8's medical record was reviewed on 8/11/24.
On 8/10/24 at 2:16 PM, a Health Status Note documented Note Text: Resident assisted with her shower before lunch. I obtained a UA sample from resident d/t [due to] complaints of burning upon urinations [sic]. Resident has redness in groin area, will see about order for Nystatin powder. Notified NP.
On 8/10/24 at 6:10 PM, a Health Status Note documented Note Text: Order noted to obtain UA-C&S [culture and sensitivity] if indicated. I collected the UA from resident and specimen is in med [medication] room specimen fridge. [Name of lab redacted] informed. Will continue to monitor.
A physician's order for the UA collected on 8/10/24, was unable to be located.
On 8/11/24 at 9:11 AM, an interview was conducted with the Director of Nursing (DON) and Licensed Nurse (LN) 3. LN 3 stated there had not been any residents with a change of condition in the last 24 hours. The DON stated there had not been any residents with a change of condition in the last 24 hours but three urinalyses were collected. The DON stated the staff could not send the urinalyses out because the staff did not have a printer. The DON stated she was waiting for the Business Officer Manager (BOM) to come to the facility so she could print the orders. The DON stated that staff did not have access to the printer on the weekends. The DON stated that Administration needed to provide staff with a printer so they could print orders. The DON stated that when the NP was getting ready to leave the facility LN 3 needed to see if there were any orders. The DON stated if you know your patient needed a UA and has had a change of condition you need to take care of it and change the change of condition. The DON stated that LN 3 needed to get the labs out. LN 3 stated that he needed the paperwork. The DON stated there was only one order for the urinalyses that were collected. The DON stated when the UA was collected staff were to put in the order, get a copy of the order, and send the order with the UA. The DON stated she was waiting for the BOM to come to the facility so she could print the order and complete the process. The DON stated that the BOM would have to come in every time if Administration did not want staff to have access to the printer. LN 3 stated that he needed to get a hold of the lab company to see what they were doing. LN 3 stated that the lab company messaged the night nurse last night and stated they needed to reschedule the pick up to Monday for the urinalyses. LN 3 and the DON stated that a UA was good in the fridge for 24 hours. The DON stated that staff had been trained on the lab company. The DON stated that she thought the training was in April 2024. LN 3 stated that mid Saturday he sent a message to the lab company, dated and time stamped the UA. LN 3 stated that when the UA was time stamped the 24 hour time frame for results started. LN 3 stated that resident 8 fell under the change of condition. LN 3 stated he notified the Medical Director (MD) and dipped the urine. LN 3 stated the urine had signs of nitrates and the MD wanted to collect a UA. LN 3 stated the urinalyses were collected on Saturday. LN 3 stated he contacted the lab company and was told the lab company would be to the facility to pick up the urinalyses. LN 3 stated he stayed last night and let the night shift nurse know. LN 3 stated he could run the urinalyses over to the local hospital and the Administrator was going to do that yesterday but the lab company said that they would pick up the urinalyses and the lab company never showed up. LN 3 stated that he could still run the urinalyses over to the local hospital today but he was waiting to print the information. LN 3 stated on the weekends it could be difficult because staff had to clarify things. LN 3 stated the MD came in late on Friday at 3:30 PM, and was at the facility until at least 6:00 PM. LN 3 stated it was hard when you get all these orders and then the weekend was coming. LN 3 stated that he decided to get a UA on resident 8 because the resident was having the same symptoms as another resident.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0777
(Tag F0777)
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 did not promptly notify the ordering physician, physician assistant, nurse pr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not promptly notify the ordering physician, physician assistant, nurse practitioner (NP), or clinical nurse specialist of results that fell outside of clinical reference ranges. Specifically, for 1 out of 30 sampled residents, the Medical Director (MD) was not notified timely when the x-ray results documented that the resident had an acute complete femoral neck fracture with partial displacement. Resident identifier: 298.
Findings included:
Resident 298 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, dementia, essential hypertension, acute kidney failure, and anxiety disorder.
Resident 298's medical record was reviewed on 8/7/24.
On 5/20/24 at 11:00 PM, an encounter documented Date of Service: 05/21/2024 Visit Type: Acute Transition of Care: No transition occurred. Progress Note . Chief Complaint / Nature of Presenting Problem: Right hip pain History Of Present Illness: [Resident 298] is a [AGE] year-old long-term care resident here at [name redacted]. Per the nurses report he has had a couple of falls over the weekend. He was evaluated yesterday but denied any significant pain. It is unclear if he had another fall since yesterday's evaluation but currently he has complaints of right hip pain. He has been unable to stand. Most of his pain is localized to the anterior and lateral right hip. General: Elderly male in mild distress. Does appear confused which is his baseline Musculoskeletal: Patient does have tenderness to palpation over the right hip laterally anteriorly. He does have pain with internal and external rotation of the right hip. This localizes anteriorly. Acute right hip pain Patient's right hip pain appears to be acute and it is unclear whether this is related to a fall over the weekend or a new fall today. Given his acute right hip pain and evaluation today I do recommend x-rays of the right hip stat [immediately]. These were ordered today. Plan to follow-up after x-rays. Fall On fall precautions. The MD signed the note on 5/21/24 at 11:17 AM.
On 5/21/24 at 11:40 AM, a Health Status Note documented Note Text: NEW ORDER: Pt [patient] is not bearing any wt [weight] on rt [right] leg has a lg [large] skin tear on rt elbow. md notified ordered a xray it has been ordered and they stated it wil [sic] be done today. pt had a shr [shower] today.
On 5/21/24, the Diagnostics report documented . Right hip, 2 views Comparison: None. Findings: There is an acute complete femoral neck fracture with partial displacement compatible with a Garden Classification III fracture. IMPRESSION: 1. Garden classification III acute femoral neck fracture. The diagnostics report was signed by the diagnostics radiologist on 5/21/24 at 6:23 PM.
On 5/22/24 at 2:51 AM, a Health Status Note documented Note Text: Follow up on res [resident] x-ray: Impressions noted; There is an acute complete femoral neck Fx [fracture] with partial displacement compatible with a Garden class III. Mild degree of osteopenia. Moderate osteoarthritis. X-ray results sent to MD, response pending. WCTM [will continue to monitor].
On 5/22/24 at 5:30 AM, a Health Status Note documented Note Text: Staff reported res, has been up all night did not sleep a wink, trying to wiggle his way out of bed. Staff has continuously throughout shift had to re center res into bed and remind resident that he, could not walk d/t [due to] broken femur. will pass on to upcoming shift nurse for monitoring and follow-up.
On 5/22/24 at 6:54 AM, an Orders - General Note from electronic Record documented Note Text: MD notified of results of Xray and new order for resident to be sent to ER [emergency room] for eval/tx [evaluation and treatment]. Preparing paperwork.
On 8/8/24 at 9:46 AM, an interview was conducted with the Director of Nursing (DON). The DON stated when staff received an order for an x-ray they were to call the mobile x-ray company. The DON stated the mobile x-ray company would tell the staff when they could be out to do the x-ray because the staff would want to know how long it would take. The DON stated that she was thinking that STAT would mean four to eight hours. The DON stated that she believed that was what the mobile x-ray company had told her. The DON stated that once the order was in and she had a time the mobile x-ray company would be at the facility the staff would fax a face sheet and the order to the mobile x-ray company. The DON stated it was up to the nurse at that time to see how important the x-ray was and the nurse would decide to send the resident out or wait for the mobile x-ray company. The DON stated that once the mobile x-ray company was at the facility the staff would let the MD know. The DON stated that once the x-ray report was back the staff were to document the MD was notified, date and time, and put the results in the computer. The DON stated that once the MD called back the staff were to go back into the computer and document what the MD wanted done and put the x-ray results in the DON office. The DON stated she would look into the computer to see if the steps had been done and the DON would make sure the MD signed the x-ray results. The DON stated with a STAT order the staff could sometimes take the resident over to the local hospital. The DON stated the process was not as secure as she would like it to be. The DON stated as a nurse STAT would mean the dire situation of the person. The DON stated that she might go four hours with a fracture. The DON stated that it would be a nurse call and if she had to call the MD to get additional orders she would.
On 8/8/24 at 11:50 AM, an interview was conducted with the DON. The DON stated that resident 298 had an unwitnessed fall on 5/18/24 at about 3:00 AM. The DON stated that resident 298 had another fall on 5/19/24 at 9:00 AM. The DON stated the fall on 5/20/24, was an assisted fall at 3:00 PM. The DON stated at that time herself and the Certified Nursing Assistant lowered resident 298 to the floor and the DON stated that she did not notice anything. The DON stated that the NP saw resident 298 the morning of 5/21/24, and noted we need an x-ray. The DON stated that resident 298 somehow had a shower during that time on 5/21/24. The DON stated the facility called the x-ray company at 11:34 AM, and the x-ray company arrived at the facility at 5:41 PM, to do the x-ray on 5/21/24. The DON stated at 6:23 PM, the x-ray company either faxed the results or notified the facility of the results. The DON stated that the nurse on 5/22/24, made a progress note that results were pending from the doctor. The DON stated at the end of the shift the nurse made a note that resident 298 was up all night and passed the information to the oncoming nurse which was the DON. The DON stated at 6:55 AM, she notified the doctor and resident 298 was sent out to the hospital.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0779
(Tag F0779)
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 did not file in the resident's clinical record the signed and dated reports o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not file in the resident's clinical record the signed and dated reports of radiological and other diagnostic services. Specifically, for 1 out of 30 sampled residents, a resident's ultrasound and x-ray reports were not filed in the medical record. Resident identifier: 298
Findings included:
Resident 298 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, dementia, essential hypertension, acute kidney failure, and anxiety disorder.
Resident 298's medical record was reviewed on 8/7/24.
A. On 6/20/24 at 11:08 AM, a health status note documented, [Name redacted] came in to do an US [ultrasound] to residents RLE [right lower extremity]. RESULTS: Thrombus in common femoral. Femoral vein pros and dist, popliteal and posterior tibial veins with minimal flow. Veins non compressible. IMPRESSION: RLE DVT [deep vein thrombosis] MD [Medical Doctor] notified immediately.
A review of the medical record revealed no ultrasound report in resident 298's medical record.
On 8/7/24 at 1:57 PM, an interview was conducted with the Director of Nursing [DON]. The DON stated that if the nursing staff received an order for an ultrasound to rule out a DVT the timeframe for the ultrasound to be done would be immediate and if that was not possible then the resident needed to be sent to the hospital. The DON stated that all radiology reports came to her and she would have the physician review, sign, and the paper copy would be filed in the resident's paper medical record. The DON stated that the nursing staff did not have great critical thinking skills and that caused them to miss important things. The DON stated that the facility did not have a policy regarding residents who had a suspected DVT or required an urgent (STAT) ultrasound. The DON stated that the facility could do better. The DON stated that resident 298 did not have any anticoagulation therapy after hip surgery. The DON stated that she had spoken with Nurse Practitioner 2 and was informed that the resident should have been on anticoagulant therapy after surgery to prevent blood clots.
B. On 5/20/24 at 11:00 PM, an encounter documented Date of Service: 05/21/2024 Visit Type: Acute Transition of Care: No transition occurred. Progress Note . Chief Complaint / Nature of Presenting Problem: Right hip pain History Of Present Illness: [Resident 298] is a [AGE] year-old long-term care resident here at [name redacted]. Per the nurses report he has had a couple of falls over the weekend. He was evaluated yesterday but denied any significant pain. It is unclear if he had another fall since yesterday's evaluation but currently he has complaints of right hip pain. He has been unable to stand. Most of his pain is localized to the anterior and lateral right hip. General: Elderly male in mild distress. Does appear confused which is his baseline Musculoskeletal: Patient does have tenderness to palpation over the right hip laterally anteriorly. He does have pain with internal and external rotation of the right hip. This localizes anteriorly. Acute right hip pain Patient's right hip pain appears to be acute and it is unclear whether this is related to a fall over the weekend or a new fall today. Given his acute right hip pain and evaluation today I do recommend x-rays of the right hip stat. These were ordered today. Plan to follow-up after x-rays. Fall On fall precautions. The MD signed the note on 5/21/24 at 11:17 AM.
On 5/21/24 at 11:40 AM, a Health Status Note documented Note Text: NEW ORDER: Pt [patient] is not bearing any wt [weight] on rt [right] leg has a lg [large] skin tear on rt elbow. md notified ordered a xray it has been ordered and they stated it wil [sic[ be done today. pt had a shr [shower] today.
On 5/21/24, the Diagnostics report documented . Right hip, 2 views Comparison: None. Findings: There is an acute complete femoral neck fracture with partial displacement compatible with a Garden Classification III fracture. IMPRESSION: 1. Garden classification III acute femoral neck fracture. The diagnostics report was signed by the diagnostics radiologist on 5/21/24 at 6:23 PM.
(Note: The x-ray results were requested from the Administrator. The x-ray results were faxed to the facility on 8/7/24 at 3:16 PM. The x-ray results were not in resident 298's medical record and the x-ray results were not signed or dated.)
On 5/22/24 at 2:51 AM, a Health Status Note documented Note Text: Follow up on res [resident] x-ray: Impressions noted; There is an acute complete femoral neck Fx [fracture] with partial displacement compatible with a Garden class III. Mild degree of osteopenia. Moderate osteoarthritis. X-ray results sent to MD, response pending. WCTM [will continue to monitor].
On 8/8/24 at 9:46 AM, an interview was conducted with the DON. The DON stated when staff received an order for an x-ray they were to call the mobile x-ray company. The DON stated the mobile x-ray company would tell the staff when they could be out to do the x-ray because the staff would want to know how long it would take. The DON stated that she was thinking that STAT would mean four to eight hours. The DON stated that she believed that was what the mobile x-ray company had told her. The DON stated that once the order was in and she had a time the mobile x-ray company would be at the facility the staff would fax a face sheet and the order to the mobile x-ray company. The DON stated it was up to the nurse at that time to see how important the x-ray was and the nurse would decide to send the resident out or wait for the mobile x-ray company. The DON stated that once the mobile x-ray company was at the facility the staff would let the MD know. The DON stated that once the x-ray report was back the staff were to document the MD was notified, date and time, and put the results in the computer. The DON stated that once the MD called back the staff were to go back into the computer and document what the MD wanted done and put the x-ray results in the DON office. The DON stated she would look into the computer to see if the steps had been done and the DON would make sure the MD signed the x-ray results. The DON stated with a STAT order the staff could sometimes take the resident over to the local hospital. The DON stated the process was not as secure as she would like it to be. The DON stated as a nurse STAT would mean the dire situation of the person. The DON stated that she might go four hours with a fracture. The DON stated that it would be a nurse call and if she had to call the MD to get additional orders she would.
On 8/8/24 at 11:50 AM, an interview was conducted with the DON. The DON stated the facility called the x-ray company at 11:34 AM, and the x-ray company arrived at the facility at 5:41 PM, to do the x-ray on 5/21/24. The DON stated at 6:23 PM, the x-ray company either faxed the results or notified the facility of the results. The DON stated that the nurse on 5/22/24, made a progress note that results were pending from the doctor. The DON stated at the end of the shift the nurse made a note that resident 298 was up all night and passed the information to the oncoming nurse which was the DON. The DON stated at 6:55 AM, she notified the doctor and resident 298 was sent out to the hospital.
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
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility did not dispose of garbage and refuse properly. Specifically, the facility was found to have stored uncovered, used aluminum soda cans outdoors directl...
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Based on observation and interview, the facility did not dispose of garbage and refuse properly. Specifically, the facility was found to have stored uncovered, used aluminum soda cans outdoors directly outside of the kitchen.
Findings included:
On 7/30/24 at 11:49 AM, an observation was made of the facility kitchen. There was a large black plastic garbage bag stored outdoors directly outside the entrance to the kitchen. The garbage bag was torn open and empty aluminum soda cans were spilling out of the bag and onto the concrete ground.
On 7/30/24 at 1:52 PM, an interview was conducted with the Dietary Manager (DM). The DM stated that she was aware of the empty soda cans being stored outside the kitchen. The DM stated that a resident of the facility was collecting the cans to be recycled. The DM stated that the bags of soda cans had been torn open by a recent windstorm.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0840
(Tag F0840)
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 did not arrange services with an outside agency. Specifically, for 2 out of 3...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not arrange services with an outside agency. Specifically, for 2 out of 30 sampled residents, residents had physician's orders to follow up with a specialist and the facility staff had not made the appointments. Resident identifiers: 25 and 35.
Findings included:
1. Resident 35 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included artherosclerotic heart disease, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, gout, memory deficit following cerebral infarction, repeated falls, type 2 diabetes mellitus with diabetic polyneuropathy, cerebral infarction, dysphagia, Charcot's Arthropathy, and acquired absence of other right toe.
Resident 35's medical record was reviewed from 7/28/24 through 8/14/24.
A Minimum Data Sheet assessment Section GG Functional Abilities and Goals dated 6/13/24, indicated, Functional Limitation in Range of Motion to the Lower extremity (hip, knee, ankle, foot with Impairment to one side. It further indicated resident 35 used a wheelchair.
An Encounter Progress Note dated 7/4//24 at 11:00 PM, indicated, [Resident name redacted] is a [AGE] year-old male who is a long-term resident at [Facility name redacted]. He has a history of a cerebral infarction resulting in left-sided weakness, diabetes, obstructive sleep apnea as well as Charcot's arthropathy. When is at the nurses station today patient came to me to discuss his left foot pain and malformation. Patient states that years ago he hurt his foot and it never healed back to normal position properly. The foot is turned inward and a brace is in place at this time. Patient states that he is able to hold the foot or the toes back and push them down but with very poor range of motion. He stated that he needs to have the foot casted to help him get the foot back into normal position. The brace does not appear to be keeping the footin [sic] a normal anatomical alignment position. I am going to refer the patient to an orthopedic specialist to works on her feet and ankles. I informed patient that I would write the referral and patient was very grateful. Patient was sitting in his wheelchair when I left him by the nurses station.
A Physician's Order dated 7/5/24, indicated, Please refer pt [patient] to an orthopedic foot + [and] ankle surgeon (specialist) for pt's L [left] foot.
On 7/30/24 at 2:48 PM, an interview was conducted with the Receptionist. The Receptionist stated she scheduled the referral appointments for residents and that she did not have an appointment scheduled for an orthopedic specialist for resident 35.
On 7/31/24 at 11:18 AM, an interview was conducted with the Director of Nursing (DON). The DON stated when a physician orders a consult, verbally or however, the nurse should put it in the appointment book, and then the receptionist will make the appointment.
On 8/7/24 at 1:39 PM, a follow-up interview was conducted with the Receptionist. The Receptionist reviewed the appointment book that was located at the nurse's station and stated she reviewed it daily. The Receptionist stated the nurses were responsible for putting any referrals or orders in the appointment book.
2. Resident 25 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses which included sepsis, acute respiratory failure, type 2 diabetes mellitus, vascular dementia, pneumonia, pressure ulcer of left heal, metabolic encephalopathy, hypertension, and atrial fibrillation.
Resident 25's medical record was reviewed from 7/28/24 through 8/14/24.
A physician's order dated 6/4/24, indicated, Pulmonary function test [PFT]- eval [evaluate] COPD [chronic obstructive pulmonary disease].
On 8/7/24 at 1:39 PM, an interview was conducted with the Receptionist. The Receptionist stated that she would have been the person to make the PFT appointment. The Receptionist stated the order was not in the appointment book, so she did not make the appointment for resident 25's PFT.
On 8/7/24 at 1:44 PM, an interview was conducted with the DON. The DON stated she did not know if resident 25 had his PFT appointment yet. The DON stated resident 25 had previously had Covid and had issues with his COPD. The DON stated, he was so sick and was not getting better. The DON stated the appointment should have been made as soon as possible.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
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 did not ensure that each resident's medical record included documentation tha...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that each resident's medical record included documentation that indicated that the resident or resident's representative was provided education regarding the benefits and potential side effects of the pneumococcal immunization; and that the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindications or refusal. Specifically, for 2 out of 30 sampled residents, residents were not provided education regarding the benefits and potential side effects of the pneumococcal immunization. In addition, the medical record did not include the administration or refusal of the pneumococcal immunization. Resident identifiers: 7 and 24.
Findings included:
1. Resident 7 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, dementia with other behavioral disturbance, schizoaffective disorder bipolar type, paroxysmal atrial fibrillation, obsessive-compulsive disorder, mile cognitive impairment, essential hypertension, adult failure to thrive, and encephalopathy.
Resident 7's medical record was reviewed on 7/29/24.
A review of the Immunization section of the medical record revealed no documentation regarding resident 7's pneumococcal status.
Resident 7's Immunization record within the paper medical record revealed no documentation regarding resident 7's pneumococcal status.
2. Resident 24 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, chronic viral hepatitis C, type 2 diabetes mellitus without complications, major depressive disorder, essential hypertension, and inflammatory disease of prostate.
Resident 24's medical record was reviewed on 7/29/24.
A review of the Immunization section of the medical record revealed no documentation regarding resident 24's pneumococcal status.
Resident 24's Immunization record within the paper medical record revealed no documentation regarding resident 24's pneumococcal status.
On 7/29/24 at 1:27 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the pharmacy would give her a list of the residents that were vaccinated for the Coronavirus Disease 2019 (COVID) and the Receptionist would input the information into the resident's medical record. The DON stated the resident pneumococcal information was missing. The DON stated that some residents were not over the age of 65 or the resident had refused the pneumococcal immunization. The DON stated the pneumococcal immunization was to be done every five years. The DON stated the facility offered the pneumococcal immunization on admission. The DON stated the pneumococcal immunization should be on the resident's paper immunizations record. The DON was observed to look at resident 7's medical record and stated that resident 7 had not had the pneumococcal immunization. The DON stated that she thought she had ordered the pneumococcal vaccine from the pharmacy and offered the pneumococcal immunization to the residents.
On 7/29/24 at 3:51 PM, a follow up interview was conducted with the DON. The DON stated that she needed to go through all the resident medical records and see who needed the pneumococcal immunization. The DON stated that resident 7 and resident 24 want the pneumococcal immunization. The DON stated the immunization consents were completed today for resident 7 and resident 24.
The facility policy POLICY & PROCEDURE For Resident and Staff Immunizations documented the following.
. RESIDENT:
1. Standing orders will be in place for all residents of the facility for influenza and pneumococcal vaccines and COVID.
2. Influenza vaccine is offered to Residents ([DATE] through March 31). If a resident is admitted to the facility during the above dates, they will be offered the flu vaccine upon admission. It will be documented the reason the resident declines the vaccine. If accepted, the date the vaccine was administered will be in the resident chart.
3. Residents will be offered the pneumococcal vaccine as outlined:
a. If a resident is [AGE] years old or older, the facility designated nursing staff will attempt to find out if the resident has already received the pneumovaccine. If no record can be obtained, or family does not know, we will give the vaccine. The facility will keep a record in the resident chart and in a facility record book.
b. If a resident is younger than age [AGE] and has a Chronic disease, Respiratory disease or heart disease then the resident may be given the pneumovaccine upon doctor's order. High risk residents will be designated by the house MD [Medical Director].
4. Long term care residents who have received a pneumovaccine and who remain in this facility, will receive a repeat pneumovaccine every 5 years with the MD order.
5. All residents will receive the Mantoux TB [tuberculosis] test upon admission and each year thereafter.
REPORTING
The designated person will complete the online Immunization Report by January 31. The policy was updated on 2/23.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 8/10/24 at 1:53 PM, an observation was made of the call light on for resident room [ROOM NUMBER]. At 2:16 PM, an observation ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 8/10/24 at 1:53 PM, an observation was made of the call light on for resident room [ROOM NUMBER]. At 2:16 PM, an observation was made of the call light answered for resident room [ROOM NUMBER].
On 8/12/24 at 10:28 AM, an observation was made of the call light on for resident room [ROOM NUMBER].
On 8/12/24 at 10:36 AM, an observation was made of CNA 3 stating she needed to pass ice to the other hall before she could help the resident in room [ROOM NUMBER]. The call light for resident room [ROOM NUMBER] remained on.
On 8/12/24 at 10:40 AM, an observation was made of the resident from room [ROOM NUMBER] leaving their room and coming to answer a phone call.
On 8/12/24 at 10:54 AM, an observation was made of CNA 1 turning off the call light for resident room [ROOM NUMBER] and assisting the resident from room [ROOM NUMBER].
On 8/13/24 at 9:25 AM, an observation was made of the call light on for resident room [ROOM NUMBER]. At 9:45 AM, an observation was made of the call light being answered for room [ROOM NUMBER].
Based on observation and interview, the facility did not ensure that residents have a right to a dignified existence. Specifically, for 3 out of 30 sampled residents, the facility served resident meals on disposable dishware, there were long call lights, there was a resident with socks with holes, and there were observations of staff talking down to residents in the facility. Resident identifiers: 12, 15, and 22.
Findings Included:
1. On 7/28/24 at 11:46 AM, an observation was conducted of the lunch meal tray service. The mobile hot buffet was observed in the 300 hallway. Staff were observed preparing the lunch meal for residents eating in their rooms. The lunch meal was served on Styrofoam plates, disposable plastic cups, Styrofoam cups, and disposable cutlery.
On 7/30/24 at 12:18 PM, an observation was made of the lunchtime hallway meal tray service. It was noted that residents that chose to eat in their bedroom received their meal on a Styrofoam plate with disposable cutlery.
On 8/10/24 at 1:56 PM, an observation was made of resident 22. Resident 22 was observed to be eating in his room from a Styrofoam plate and disposable utensils. Resident 22 stated it was alright to eat off of Styrofoam.
On 7/30/24 at 13:33 PM, an interview was conducted with Dietary Aide (DA) 1. DA 1 stated that residents who eat in their room were always served meals on disposable plates with disposable cutlery because it was easier for the residents and the Certified Nursing Assistants (CNA). DA 1 stated that sometimes normal dishware would get thrown away or go missing when it was used for residents that eat in their rooms. DA 1 stated that residents that eat in the dining room received their meal on reusable dishware and with reusable utensils.
4. On 8/9/24 at 8:00 PM, an observation was made of a call light illuminated at resident room [ROOM NUMBER]. At 9:04 PM, the call light was observed to still be illuminated.
On 8/9/24 at 8:00 PM, on observation was made of a call light illuminated at resident room [ROOM NUMBER]. At 9:04 PM, the call light was observed to still be illuminated.
2. Resident 15 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, type 2 diabetes mellitus with foot ulcer, schizoaffective disorder bipolar type, generalized anxiety disorder, post-traumatic stress disorder, borderline intellectual functioning, stimulant dependence, and attention-deficit hyperactivity disorder.
On 8/12/24 at 1:53 PM, an observation was conducted of resident 15. Resident 15 was observed to walk to the nurses station and asked the Business Office Manager (BOM) if she would check her account to see how much money she had in the account. The BOM stated to resident 15, the account that you have almost spent everything. Resident 15 stated to the BOM that she did not need to be lectured by her and she just needed to know. The BOM stated to resident 15 that she needed the receipts and that resident 15 and the case worker had been spending down resident 15's money. Resident 15 stated to the BOM that she had never asked for receipts. The BOM was observed to walk away from resident 15 towards the front entrance of the facility. Resident 15 stated to the State Survey Agency (SSA) Lead Licensor that the BOM would not even talk to her and the BOM just walks off. Resident 15 stated to the SSA Lead Licensor that she had been at the facility for eight months before she got any of her money and the BOM had not asked for receipts ever. Resident 15 stated to the SSA Lead Licensor that the doctor had only been to the facility once in the last few months and the Nurse Practitioner never came and visited with her.
3. On 8/10/24 at 1:40 PM, an observation was made of resident 12. Resident 12 was observed to have non-skid socks on that had holes and resident 12's heels and bottom of his feet were exposed. Resident 12 stated that he had those socks for a while and it was hard to get his socks over his heel.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 7/28/24 at 10:26 AM, an observation was made of resident room [ROOM NUMBER]. There was a large discolored area under the air ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 7/28/24 at 10:26 AM, an observation was made of resident room [ROOM NUMBER]. There was a large discolored area under the air conditioner near the window. There was a brownish stain on the carpet to the right side of the bed.
On 7/28/24 at 12:15 PM, an observation was made of a brown substance on the floor of the bathroom in resident room [ROOM NUMBER] which had been run over by the wheelchair. The brown substance was observed to be on the wheelchair tires.
On 7/28/24 at 12:30 PM, an observation was made of the floors throughout the 100 hallway to be sticky.
On 7/28/24 at 12:32 PM, an observation was made of a television antenna box hanging from a curtain hook in resident room [ROOM NUMBER].
On 7/28/24 at 12:50 PM, an observation was made of the brown substance to be removed from the bathroom floor but remained on the wheelchair tires.
On 7/29/24 at 7:54 AM, an observation was made of resident room [ROOM NUMBER]. The carpet had a brownish stain on the right side of the bed. The carpet had multiple stains of varying size and food debris scattered throughout.
On 7/29/24 at 8:15 AM, the window blinds in resident room [ROOM NUMBER] were observed to broken and missing pieces.
On 7/29/24 at 1:11 PM, an observation was made of resident room [ROOM NUMBER]. The carpet had a brownish stain on the right side of the bed. The carpet had multiple stains of varying size and food debris scattered throughout and the resident's nasal cannula was on the floor.
On 7/30/24 at 7:36 AM, an observation was made of the carpet of resident room [ROOM NUMBER]. The carpet had a brownish stain on the right side of the bed. The carpet had multiple stains of varying size and food debris scattered throughout.
On 7/30/24 at 10:42 AM, an observation was made of the carpet in resident room [ROOM NUMBER]. The carpet had a brownish stain on the right side of the bed. The carpet had multiple stains of varying size and food debris scattered throughout.
On 7/31/24 at 7:31 AM, an observation was made of the carpet in resident room [ROOM NUMBER]. The carpet had a brownish stain on the right side of the bed and multiple stains of varying sizes.
On 8/10/24 at 1:45 PM, an observation was made of resident room [ROOM NUMBER]. The carpet was observed to have large stains on it.
On 7/30/24 at 9:29 AM, an interview was conducted with Housekeeper (HK) 1. HK 1 stated that the residents' rooms were cleaned every day at the facility.
On 7/30/24 at 10:15 AM, an interview was conducted with HK 2. HK 2 stated that housekeeping used cleaning supplies to clean rooms and that they were provided with all of the necessary supplies to complete their job.
On 7/30/24 at 10:40 AM, a follow up interview was conducted with HK 1. HK 1 stated housekeeping cleaned all the rooms in the 100 hallway daily. HK 1 stated that they vacuumed the carpets and tried to clean the floors. HK 1 stated that it was hard to keep the floors clean.
On 7/30/24 at 10:43 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that housekeeping came everyday to clean. CNA 1 stated the facility wanted the CNAs to attempt to clean up any messes.
On 7/30/24 at 11:11 AM, a follow up interview was conducted with HK 2. HK 2 stated that housekeeping cleaned the bathrooms and took out the trash. HK 2 stated that she thought the large discoloration in resident room [ROOM NUMBER] was from the heater or air conditioner unit.
On 7/30/24 at 11:26 AM, an interview was conducted with the Administrator (ADM). The ADM stated the sprinkler had been turned the wrong way and flooded the carpet of resident room [ROOM NUMBER]. The ADM stated the discoloration had been on the floor for two months. The ADM stated that the carpet was not a super high priority because it was just sprinkler water. The ADM stated that the discoloration looked bad, but did not smell. The ADM stated that the television antenna box in resident room [ROOM NUMBER] was hung by maintenance. The ADM stated he did not think it would fall down off the hook and he thought it looked secure.
On 7/30/24 at 11:35 AM, an observation was made of the ADM asking HK 2 to clean the floors on the 100 hallway because they were sticky.
On 7/31/24 at 7:33 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the hanging antenna box was a safety hazard and should never been hung like that. The DON stated that a resident could knock it off the hook and get hurt.
Based on observation and interview, the facility did not provide a safe, clean, comfortable, and homelike environment. Specifically, there were several brown carpet stains found in multiple residents' rooms, there was a television antenna hanging from the ceiling of a resident room, there were damaged blinds in a resident's room, and a resident had dirty wheelchair tires from being pushed through a brown substance found on the floor of the facility.
Findings Included:
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
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that for 3 of 30 sample residents, the facility did not approp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that for 3 of 30 sample residents, the facility did not appropriately document the basis for the transfer or the discharge summary. In addition, appropriate documentation was not completed in order to ensure a safe and effective transition of care. Resident identifiers: 25, 47, and 298.
Findings include:
1. Resident 25 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses which included sepsis, acute respiratory failure, type 2 diabetes mellitus, vascular dementia, pneumonia, pressure ulcer of left heal, metabolic encephalopathy, hypertension, and atrial fibrillation.
Resident 25's medical record was reviewed from 7/28/24 through 8/14/24.
A Health Status Note dated 12/28/23 at 10:33 PM indicated, Res [resident] lungs assessed this shift, resident c/o [complained of] pain with inhalation, lower lobes junky to auscultation, wheezing heard from chest, resident unable to maintain 02 [oxygen] sats [saturation] above 90 w/o [without] use of oxygen concentrator 02 91% 3L [liters]/min [minute]. MD [medical doctor] notified, Order given, routine CXR [chest xray] to r/o [rule out] pneumonia. [Company name redacted] notified; X-ray technician will be out to facility in the morning 12/29/23, to perform diagnostic request. Order has been written, unable to print, copy saved under documents for day shift to print. Will pass on to upcoming shift nurse to forward results to MD.
An Administration Note dated 12/29/23 at 8:40 AM indicated, sent to hosp [hospital].
On 08/7/24 at 1:42 PM, an interview was conducted with the Director of Nursing (DON). The DON stated when she came in on 12/29/23 at 6:00 AM, resident 25 was ashen and struggling to breathe. The DON stated he was sent to the hospital at 7:30 AM. The DON stated she should have done a progress note for his change of condition and transfer, but she did not have time.
There was no documentation provided in the medical record that indicated the basis for the hospital transfer.
2. Resident 298 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, dementia, essential hypertension, acute kidney failure, and anxiety disorder.
Resident 298's medical record was reviewed on 8/7/24.
An admission Minimum Data Set assessment dated [DATE], documented that resident 298 had a Brief Interview for Mental Status (BIMS) score of 13. A BIMS score of 13 to 15 would indicate intact cognition.
On 5/20/24 at 11:00 PM, an encounter documented Date of Service: 05/21/2024 Visit Type: Acute Transition of Care: No transition occurred. Progress Note . Chief Complaint / Nature of Presenting Problem: Right hip pain History Of Present Illness: [Resident 298] is a [AGE] year-old long-term care resident here at [name redacted]. Per the nurses report he has had a couple of falls over the weekend. He was evaluated yesterday but denied any significant pain. It is unclear if he had another fall since yesterday's evaluation but currently he has complaints of right hip pain. He has been unable to stand. Most of his pain is localized to the anterior and lateral right hip. General: Elderly male in mild distress. Does appear confused which is his baseline Musculoskeletal: Patient does have tenderness to palpation over the right hip laterally anteriorly. He does have pain with internal and external rotation of the right hip. This localizes anteriorly. Acute right hip pain Patient's right hip pain appears to be acute and it is unclear whether this is related to a fall over the weekend or a new fall today. Given his acute right hip pain and evaluation today I do recommend x-rays of the right hip stat [immediately]. These were ordered today. Plan to follow-up after x-rays. Fall On fall precautions. The Medical Director (MD) signed the note on 5/21/24 at 11:17 AM.
On 5/21/24 at 11:40 AM, a Health Status Note documented Note Text: NEW ORDER: Pt [patient] is not bearing any wt [weight] on rt [right] leg has a lg [large] skin tear on rt elbow. md notified ordered a xray it has been ordered and they stated it wil [sic[ be done today. pt had a shr [shower] today.
On 5/21/24, the Diagnostics report documented . Right hip, 2 views Comparison: None. Findings: There is an acute complete femoral neck fracture with partial displacement compatible with a Garden Classification III fracture. IMPRESSION: 1. Garden classification III acute femoral neck fracture. The diagnostics report was signed by the diagnostics radiologist on 5/21/24 at 6:23 PM.
On 5/22/24 at 2:51 AM, a Health Status Note documented Note Text: Follow up on res [resident] x-ray: Impressions noted; There is an acute complete femoral neck Fx [fracture] with partial displacement compatible with a Garden class III. Mild degree of osteopenia. Moderate osteoarthritis. X-ray results sent to MD, response pending. WCTM [will continue to monitor].
On 5/22/24 at 5:30 AM, a Health Status Note documented Note Text: Staff reported res, has been up all night did not sleep a wink, trying to wiggle his way out of bed. Staff has continuously throughout shift had to re center res into bed and remind resident that he, could not walk d/t [due to] broken femur. will pass on to upcoming shift nurse for monitoring and follow-up.
On 5/22/24 at 6:54 AM, an Orders - General Note from electronic Record documented Note Text: MD notified of results of Xray and new order for resident to be sent to ER [emergency room] for eval/tx [evaluation and treatment]. Preparing paperwork.
[Note: The facility transferred resident 298 to the hospital emergently due to a change in condition. The facility did not provide the hospital with the required information including the practitioners name responsible for the care of resident 298, the resident representative information, Advanced Directives, comprehensive care plan goals, and all other information necessary to meet resident 298's needs.]
On 8/5/24 at 2:10 PM, a telephone interview was conducted with RN 5. RN 5 stated that there is no printer at the nurses station, and its embarrassing when people come in. We have to pull each piece of the MAR (medication administration record) and go copy it, but the copy machine did not provide a legible copy. RN 5 stated that the MARs that were printed and in the paper chart were not updated, so she would have to reconcile the medication list prior to sending a resident to the hospital, and this delayed the time the residents were seen at the hospital. RN 5 stated that the Director of Nursing (DON) had been bringing this and other issues to the attention of the management staff, but they don't care.
On 7/29/24 at 10:47 AM, an interview was conducted with DON. The DON stated that things had been much better but she needed support in her program. The DON stated she had asked for the programs for the weekly and quarterly charting. The DON stated if a resident went out at night the staff could not send the required documents because the staff did not have access to a printer.
On 7/31/24 at 3:46 PM, an interview was again conducted with the DON. The DON stated that the night shift nurses do not have access to a printer, only a fax machine in the back office. The DON stated that the night shift nurses are unable to print medication lists out and that on more than one occasion the emergency room has called asking for a copy of the resident's medication list. The DON stated that this has personally happened to her, and that she had to send the original paper orders to the hospital.
On 8/11/24 at 10:37 AM, an interview was conducted with the Business Officer Manager (BOM). The BOM stated if staff needed access to the printer there was a whole process. The BOM stated when staff need something the staff were to call the Administrator and the Administrator would tell the staff where the keys were located. The BOM stated that staff could just make a copy on the fax machine in the medication room and resident facesheets were in the paper medical record. The BOM stated that staff had access to the front office. The BOM stated if the staff had an emergent need they were to call the Administrator and the Administrator had a code for a lock box that had the keys to everything. The BOM stated the lock box also had spare keys to the medication cart. The BOM stated if the key box was accessed the Administrator would come in the next time and change the code.
On 8/11/24 at 10:42 AM, a follow up interview was conducted with the DON. The DON stated that when the BOM mentioned the lock box a few minutes prior, that was the first time she had ever heard about a lock box with keys. The DON stated there was a fax machine in the medication room but it did not print. The DON stated if staff had to send a resident out with a Medication Administration Record the staff could not print one and that was frustrating.
3. Resident 47 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, edema, hyperlipidemia, major depressive disorder, pain in right hip, spinal stenosis, hypertension, low back pain, history of malignant neoplasm of prostate, and and genetic related intellectual disability.
Resident 47's medical record was reviewed on 7/31/24.
Resident 47's medical record that the resident discharged from the facility on 5/15/24. No discharge summary or basis for the discharge could be located in resident 47's medical record.
On 7/31/24 at 3:25 PM, an interview was conducted with the Director of Nursing. (DON). The DON stated that
the Administrator and Social Services Worker worker had a handy [NAME] discharge summary they would provide to the nurse and the nurse would complete the appropriate paperwork. The DON stated that this process has been sporadic since January of 2024. The DON stated that there was a discharge summary that could be completed in the electronic health record that could have been filled out as well.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident 7 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included unsp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident 7 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included unspecified dementia, schizoaffective disorder, paroxysmal atrial fibrillation, obsessive-compulsive disorder, essential hypertension, adult failure to thrive, encephalopathy, and mild cognitive impairment.
On 7/28/24 at 12:28 PM, an observation was made of resident 7 in his room. It was noted that the resident was using an oxygen concentrator and was receiving 3 liters per minute of oxygen via a nasal cannula.
On 7/28/24, resident 7's medical record was reviewed. The following physician order was noted with an order date of 5/22/23, O2 to keep SPO2 [oxygen saturation] greater than 90%.
A review of resident 7's care plan did not document resident 7's oxygen use, goals, or interventions.
6. Resident 24 was admitted to the facility on [DATE] with diagnoses which included, dementia, type 2 diabetes mellitus, chronic viral Hepatitis C, essential hypertension, hyperlipidemia, vertigo, major depressive disorder, osteoarthritis, and inflammatory disease of prostate.
On 7/28/24 at 1:32 PM, an observation was made of resident 24 in his room. It was noted that the resident used an oxygen concentrator. The oxygen tubing was not dated.
On 7/28/24, resident 24's medical record was reviewed. The following physician order was noted with a start date of 1/17/23, O2 @ [at] 2L [liters] via NC [nasal cannula] @ NOC [nocturnal] to keep sats [saturations] > [greater] than 90% every day and night shift.
A care plan Focus addressing oxygen therapy initiated on 1/17/23, documented, The resident has oxygen therapy. Interventions included:
a. Encourage or assist with ambulation as indicated.
b. Monitor for s/sx of respiratory distress and report to MD PRN: Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis, Cough, Pleuritic pain, Accessory muscle usage, Skin color.
On 7/31/24 at 3:39 PM, an interview was conducted with the DON. The DON stated that care plans should be revised if there was a change in the resident's condition, a new diagnosis, or quarterly. The DON stated all the nurses should be making care plans and implementing them. The DON stated that sometimes she thought she was a one horse show and could not work on care plans and work on the floor all of the time. The DON stated that she had talked with the Administrator this past month about nursing staff not doing a lot of things that were required of them.
Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, for 6 out of 30 sampled residents, care plans were not created when there was a specified need and therefore were not reflective of the services required for the residents to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Resident identifiers: 7, 17, 24, 26, 32, and 35.
Findings included:
1. Resident 32 was admitted to the facility on [DATE] with diagnoses which included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD) with acute exacerbation, fluid overload, hypertension, and hyperglycemia.
Resident 32's medical record was reviewed from 7/28/24 through 8/14/24.
The admission Minimum Data Set (MDS) assessment Section V: Care Area Assessment (CAA) Summary dated 3/19/24, indicated the following CAA Triggers: 2. Cognitive Loss/ Dementia; 5. Functional Abilities (Self-Care and Mobility); 6. Urinary Incontinence and Indwelling Catheter; 12. Nutritional Status; 15. Dental Care; 16. Pressure Ulcer/ Injury; and 19. Pain.
The Initial Care Plan dated 3/19/24, indicated Problems: #3: Visual Function/ Altered Visual Function Impaired; #5 Activities of daily living (ADL) Ability Decrease ADL ability related to (r/t): COPD Assistance needed with: ADLs; #11: Falls Potential for fall r/t: COPD; #14: Dehydration/ Fluid Maintenance; and #15: Dental Care no teeth.
The Care Plan indicated a Focus of Terminal care (hospice) Weight loss unavoidable Date Initiated: 04/12/2024 and Resident has the potential for social isolation. He say [sic] his O2 [oxygen] drops when he is to [sic] active. He says he has interest on group activities but has refused all invitations. He prefers in room activities. Date Initiated: 07/20/2024.
There were no care plans developed for resident 32's visual function, ADL abilities, potential falls, dehydration, dental care, oxygen treatment or hospice.
On 7/30/24 at 11:42 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated the care plan should be in the resident's chart. The ADON reviewed the current care plan during the interview and stated she saw a care plan was started but was never completed. The ADON stated the care plan should be completed already.
On 7/31/24 at 12:16 PM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 32's comprehensive care plan should have been completed and should have also included oxygen therapy. No additional information was provided.
2. Resident 35 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included artherosclerotic heart disease, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, gout, memory deficit following cerebral infarction, repeated falls, type 2 diabetes mellitus with diabetic polyneuropathy, cerebral infarction, dysphagia, Charcot's Arthropathy, and acquired absence of other right toe.
On 7/28/24 at 1:05 PM, an observation and interview were conducted with resident 35. Resident 35 was observed sitting in his wheelchair in the dining room, he wore a white sock on his left foot with no brace. Resident 35's left foot appeared severely impaired and was rotated medially. Resident 35 stated he did wear a brace on his ankle, sometimes. Resident 35 stated that he did not currently receive physical or occupational therapy, nor did anyone do range of motion exercises with him for his left foot.
On 7/29/24 at 11:03 AM, an observation of resident 35 was conducted. Resident 35 was in a manual wheelchair and self-propelled himself with the use of his right arm and foot around the nurse's station. Resident 35 wore a white sock on his left foot with no brace and his left hand and wrist had a contracture.
Resident 35's medical record was reviewed from 7/28/24 through 8/14/24.
The admission MDS assessment Section V: CAA Summary with an Assessment Reference Date/Target Date of 3/5/24, indicated the following CAA Triggers: 2. Cognitive Loss/ Dementia; 4. Communication; 5. Functional Abilities (Self-Care and Mobility); 6. Urinary Incontinence and Indwelling Catheter; 9. Behavioral Symptoms; 12. Nutritional Status; 16. Pressure Ulcer/ Injury; and 19. Pain.
The care plan was reviewed and indicated a Focus of:
a. The resident has limited physical mobility r/t hemiplegia, absence of some toes on right foot Date Initiated: 08/05/2021. It indicated the Goals: The resident will demonstrate the appropriate use of motorized wheelchair through the review date. Date Initiated: 08/05/2021 Target Date: 06/05/2024; and The resident will maintain current level of mobility (one person assist limited/extensive) through review date. Date Initiated: 08/05/2021 Target Date: 06/05/2024. It indicated the Interventions/tasks: LOCOMOTION: The resident is able to: operate motorized wheelchair independently Date Initiated: 08/05/2021.
b. The resident had a cerebral vascular accident (CVA/Stroke) affecting left side Date Initiated: 08/05/2021. It indicated the Goals: The resident will be free from s/sx [signs/symptoms] of complications of CVA (DVT [deep vein thrombosis], contractures, aspiration pneumonia, dehydration) through review date. Date Initiated: 08/05/2021 Target Date: 06/05/2024. The resident will be able to communicate needs verbally through the review date. Date Initiated 08/05/2021 Target Date: 06/05/2024. It indicated the Interventions/tasks: Monitor/document mobility status. If resident is presenting with problems or paralysis, obtain order for Physical therapy and Occupational therapy to evaluate and treat. Date Initiated: 08/05/2021; Monitor/document/report PRN [as needed] for neurological deficits: level of consciousness, visual function changes, aphasia, dizziness, weakness, restlessness. Date Initiated: 08/05/2021.
c. The resident has hemiplegia r/t CVA Date Initiated: 08/05/2021. It indicated the Goals: The resident will remain free of complications or discomfort related to hemiplegia through review date. Date Initiated: 08/05/2021. The resident will maintain optimal status and quality of life within limitations imposed by Hemiplegia through review date. Date Initiated: 08/05/2021 Target Date: 06/05/2024. It indicated the Interventions/tasks: Discuss with resident/resident and family any concerns, fears, issues regarding diagnosis or treatments. Date Initiated: 08/05/2021; Educate resident to anticipate needs for safety to affected hemiplegia side during transfers. Date Initiated: 06/27/2022; Give medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated:08/05/2021; Pain management as needed. See MD [Medical Doctor] orders. Provide alternative comfort measures PRN. Date Initiated: 08/05/2021; PT [physical therapy], OT [occupational therapy], ST [speech therapy] evaluate and treat as ordered. Date Initiated: 08/05/2021.
A Clinical Summary dated 6/12/24 at 8:00 AM, indicated resident 35 was seen by an outside orthotic clinic for his ankle foot orthosis (AFO). It further indicated, Device History . posterior leaf spring AFO. Start Date: 2021. End Date: current/present. Comments: This AFO is a generic off the shelf design that of which doesn [sic] not cater to his serve externally rotated ankle foot complex. Increased risk for adverse skin shear with continued use. Custom AFO pursuit necessary in assurance of patient safety/skeletal informational stabilization. It further indicated, Comments: Minor adjustments/repairs pursued as described today. I informed the tending facility staff to pursue daily prolonged stretching of his ankle foot complex in avoiding deformational varus tendency, concern with fixated external rotational deformation at the ankle complex should this not be put in place at his care facility. Written recommendations provided to facility staff present today. All adjustments requested by [Resident name redacted] pursued today were found proper. Follow up as needed. It should be noted that this document was not found in the medical record and was provided after it was requested by the State Survey Agency. The fax server date on this document was 7/30/24 at 4:31 PM from the clinic.
The quarterly MDS assessment Section GG Functional Abilities and Goals dated 6/13/24, indicated, Functional Limitation in Range of Motion to the Lower extremity (hip, knee, ankle, foot with Impairment to one side. It further indicated resident 35 used a wheelchair.
An Encounter Progress Note dated 7/4//24 at 11:00 PM, indicated, [Resident name redacted] is a [AGE] year-old male who is a long-term resident at [Facility name redacted]. He has a history of a cerebral infarction resulting in left-sided weakness, diabetes, obstructive sleep apnea as well as Charcot's arthropathy. When is at the nurses station today patient came to me to discuss his left foot pain and malformation. Patient states that years ago he hurt his foot and it never healed back to normal position properly. The foot is turned inward and a brace is in place at this time. Patient states that he is able to hold the foot or the toes back and push them down but with very poor range of motion. He stated that he needs to have the foot casted to help him get the foot back into normal position. The brace does not appear to be keeping the footin [sic] a normal anatomical alignment position. I am going to refer the patient to an orthopedic specialist to works on her feet and ankles. I informed patient that I would write the referral and patient was very grateful. Patient was sitting in his wheelchair when I left him by the nurses station.
A Progress note dated 7/17/24 at 1:57 PM indicated, Pt [patient] refusing to wear LLE [left lower extremity] brace. Pt educated on importance of wearing brace and verbalized understanding. Pt still refusing to wear brace.
The care plan did not include person-centered or measurable interventions regarding his left-sided weakness and AFO use.
On 7/29/24 at 3:51 PM, an interview was conducted with the DON. The DON stated there was no Restorative Nursing Assistant program and that nursing did not do passive range of motion for residents. The DON stated occupational or physical therapy should provide those services if a resident had that ordered.
On 7/30/24 at 11:42 AM, an interview was conducted with the ADON. The ADON stated resident 35 had an AFO that he used to wear every day but had been refusing to wear it since his last appointment several weeks ago with the outside orthotic clinic. The ADON stated if that clinic sent any notes back it would be filed in the chart. The ADON stated the resident was not on physical therapy treatments at that time. The ADON stated that she and the DON were responsible for completing the care plans and that the ADON was responsible for completing the quarterly reviews and updates. The ADON stated she and the DON worked on the floor and had to work on the care plans when they had time.
On 7/30/24 at 2:01 PM, an interview was conducted with the Occupational Therapist (OT). The OT stated resident 35 was last seen by OT on 8/23/24, for his hand. The OT stated he did know that resident 35 had an AFO for his foot and that the fit rubbed and bothered him. The OT stated he still had trouble with his AFO.
3. Resident 17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including severe sepsis without septic shock, pneumonitis due to inhalation of food and vomit, malignant neoplasm of esophagus, acute respiratory failure unspecified whether with hypoxia or hypercapnia, asthma uncomplicated, asthma with (acute) exacerbation, gastrointestinal hemorrhage, other acute kidney failure, chronic pulmonary embolism, atherosclerosis of other arteries, schizoaffective disorder depressive type, vascular dementia, type 2 diabetes mellitus without complications, and essential hypertension.
Resident 17's medical record was reviewed from 7/28/24 through 8/14/24.
Resident 17's care plan was reviewed. A focus area dated 1/17/23, revealed, The resident has oxygen therapy. The goal for this focus area was documented as, The resident will have no s/sx of poor oxygen absorption through the review date. The interventions for this goal were documented as, Monitor of s/sx of respiratory distress and report to MD PRN: Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis, Cough, Pleuritic pain, Accessory muscle usage, Skin color. There was no guidance in the resident's care plan regarding the changing or cleaning of nasal cannula tubing or oxygen concentrator humidifiers.
4. Resident 26 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizoaffective disorder depressive type, dementia, cannabis abuse, nicotine dependence, and asthma.
Resident 26's medical record was reviewed from 7/28/24 through 8/14/24.
Resident 26's care plan was reviewed. A focus area dated 8/3/23 revealed, The resident has oxygen therapy r/t respiratory illness. The goal for this focus area was documented as, The resident will have no s/x of poor oxygen absorption through the review date. The interventions for this goal were documented as, Monitor for s/sx of respiratory distress to MD PRN: Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis, Cough, Pleuritic pain, Accessory muscle usage, Skin color. There was no guidance in the resident's care plan regarding the changing or cleaning of nasal cannula tubing or oxygen concentrator humidifiers.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which include, paranoid schizophren...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which include, paranoid schizophrenia, chronic obstructive pulmonary disease, chronic viral Hepatitis C, major depressive disorder, suicidal ideations, gastro-esophageal reflux disease, essential hypertension, hypothyroidism, chronic pain, type 2 diabetes mellitus, post traumatic stress disorder, low back pain, and hypo-osmolality and hyponatremia.
Resident 3's medical record was reviewed on 7/28/24.
A MDS assessment dated [DATE], section GG Functional Abilities, documented:
a. Oral hygiene: substantial/maximum assistance
b. Toileting hygiene: substantial/maximum assistance
c. Shower/bathe self: substantial/maximum assistance
d. Upper body dressing: substantial/maximum assistance
e. Lower body dressing: substantial/maximum assistance
f. Putting on/taking off footwear: substantial/maximum assistance
g. Personal hygiene: substantial/maximum assistance
h. Chair/bed to chair transfer: dependent
i. Toilet transfer: dependent
j. Tub/shower transfer: dependent
A care plan Focus addressing self-care initiated on 2/23/16, documented, The resident has an ADL self-care performance deficit r/t weakness. The interventions included:
a. BATHING/SHOWERING: Check nail length and trim and clean on bath days and as necessary. Report any changes to the nurse. Date initiated 2/25/13.
b. ORAL CARE: The resident has upper/lower dentures, The resident requires oral inspection Report changes to the nurse. Date initiated 2/25/13.
c. TOILET USE: The resident requires assist of 1 staff for toileting and incontinence care at night, independent during the day. Date initiated 2/10/16.
A care plan Focus addressing falls initiated on 8/3/21, documented, The resident has had an actual fall and history of falls r/t difficulty walking, muscle weakness. The interventions included:
a. Monitor/document/report PRN x 72 hours to MD for s/sx: Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. Date initiated 8/3/21.
b. Staff will assist resident with all transfers. Date initiated 8/3/21.
On 7/29/24 at 8:30 AM, an interview was conducted with resident 3. Resident 3 stated that she could not get out of bed without extensive assistance from facility staff due to a stroke that she had which left her with weakness on the left side of her body. Resident 3 stated that she was unable to walk or use her left hand or arm. Resident 3 stated that she preferred to stay in bed because she was afraid of falling due to her weakness and inability to move her legs well.
On 7/29/24 at 8:35 AM, an observation was made of resident 3's left hand which showed a contracture.
On 6/14/24, a quarterly MDS assessment revealed that resident 3 had no impairment with range of motion for both upper and lower extremities.
On 7/29/24 at 3:09 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that resident 3 always stayed in bed and had to be hoyer lifted anytime she needed to get out of bed.
On 7/29/24 at 3:43 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated resident 3 liked to stay in bed. RN 1 stated that resident 3 could not position herself and did not have use of lower legs. RN 1 stated that resident 3 had to be lifted with the hoyer lift. RN 1 stated that resident 3 had bilateral shoulder weakness, and both wrists and hands had arthritis. RN 1 stated that resident 3 had a contracture with her left hand.
On 7/31/24 at 7:13 AM, an interview was conducted with the DON. The DON stated that resident 3 had physical therapy for increased strengthening. The DON stated that resident 3 had a contracture in her left hand and this had caused a decrease in range of motion.
6. Resident 298 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included unspecified dementia, essential hypertension, benign prostatic hyperplasia without lower urinary tract symptoms, acute kidney failure, weakness, and unspecified anxiety disorder.
Resident 298's medical record was reviewed on 8/7/24.
A care plan Focus addressing nutrition initiated on 4/12/24, documented, New resident with a potential nutrition defects r/t: advanced age, dementia. Interventions included:
a. Diet order: regular, regular, thins
b. Supplements/snacks as ordered
A review of resident 298's electronic medical record documented the following weights for resident 298:
a. 165.2 pounds on 3/28/24
b. 163.6 pounds on 3/31/24
c. 166.8 pounds on 4/7/24
d. 199.8 pounds on 4/8/24
e. 168.6 pounds on 5/10/24
f. 167.0 pounds on 5/27/24
g. 156.6 pounds on 6/2/24
h. 140.3 pounds on 7/11/24
From 6/2/24 to 7/11/24, resident 298 had a 10.41% loss of weight. It was to be noted, no revisions to the care plan were made to address the weight loss.
On 7/31/24 at 3:39 PM, an interview was conducted with the DON. The DON stated that care plans for residents should be revised if the resident had a change in condition, a new diagnosis, or quarterly MDS assessment. The DON stated she tried to update the care plans as much as she could, but did not have enough time to revise care plans.
On 8/7/24 at 1:42 PM, an interview was conducted via text messaging with the Registered Dietitian (RD). The RD texted that resident 298 had a fortified diet ordered and health shakes to help with his weight loss. The RD texted that the facility had weekly weight lists and weekly meetings to discuss residents that had weight loss.
Based on observation, interview, and record review, the facility failed to ensure the interdisciplinary team reviewed and revised the comprehensive care plan after each assessment, including both the comprehensive and quarterly review assessments. Specifically, or 6 out of 30 sampled residents, care plans were not updated after a change in the resident's condition or in response to implemented interventions. Resident identifiers: 3, 17, 26, 32, 35, and 298.
Findings included:
1. Resident 32 was admitted to the facility on [DATE] with diagnoses which included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD) with acute exacerbation, fluid overload, hypertension, and hyperglycemia.
On 7/28/24 at 10:14 AM, an interview was conducted with resident 32. Resident 32 stated he had pain in his legs, feet, and arm. Resident 32 stated he was on pain medication, but they were administered late.
Resident 32's medical record was reviewed from 7/28/24 through 8/14/24.
A Physician's Telephone Orders dated 5/27/24 at 2:00 PM, indicated, gabapentin 100mg [milligrams] BID [twice a day] for neuropathy.
A Physician's Telephone Orders dated 7/11/24 at 12:00 PM, indicated, Increase morphine to 1 ml [milliliter] Q1hr [every 1 hour] PRN [as needed].
A Physician's Telephone Orders dated 7/15/24 at 9:30 AM, indicated, Schedule morphine 1 ml QHS [hour of sleep] with night medication. Keep PRN morphine active.
A Physician's Telephone Orders dated 7/15/24 at 12:00 PM, indicated, Lorazepam 2mg / ml 0.50 ml every hours [sic] as needed for anxiety/sob [shortness of breath]/pain x [for] 2 weeks.
The Medication Administration Record (MAR) dated May 2024 indicated resident 32 reported his pain level: 12 times at a level 3, nine times at a level 4, 21 times at a level 5, 13 times at a level 6, and two times at a level 7.
The MAR dated June 2024 indicated resident 32 reported his pain level: one time at a level 3, two times at a level 4, 36 times at a level 5, one time at a level 6, and three times at a level 7.
The MAR dated July 2024 indicated resident 32 reported his pain level: 14 times at a level 3, two times at a level 4, 26 times at a level 5, two times at a level 6, and two times at a level 7.
The admission Minimum Data Set (MDS) Section V: Care Area Assessment (CAA) Summary dated 3/19/24, indicated the following CAA Triggers: 2. Cognitive Loss/ Dementia; 5. Functional Abilities (Self-Care and Mobility); 6. Urinary Incontinence and Indwelling Catheter; 12. Nutritional Status; 15. Dental Care; 16. Pressure Ulcer/ Injury; and 19. Pain.
The Initial Care Plan dated 3/19/24, indicated Problems: #3: Visual Function/ Altered Visual Function Impaired; #5 Activities of daily living (ADL) Ability Decrease ADL ability related to (r/t): COPD Assistance needed with: ADLs; #11: Falls Potential for fall r/t: COPD; #14: Dehydration/ Fluid Maintenance; and #15: Dental Care no teeth.
The Care Plan indicated a Focus of Terminal care (hospice) Weight loss unavoidable Date Initiated: 04/12/2024 and Resident has the potential for social isolation. He say [sic] his O2 [oxygen] drops when he is to [sic] active. He says he has interest on group activities but has refused all invitations. He prefers in room activities. Date Initiated: 07/20/2024.
No care plans were developed or revised for resident 32's pain or hospice care.
On 7/30/24 at 11:42 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated she made sure the quarterly reviews of the care plans were completed. The ADON stated she worked on the floor and would work on the care plans when she had time.
On 7/31/24 at 12:16 PM, an interview was conducted with the Director of Nursing (DON). No further documentation was provided.
2. Resident 35 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included artherosclerotic heart disease, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, gout, memory deficit following cerebral infarction, repeated falls, type 2 diabetes mellitus with diabetic polyneuropathy, cerebral infarction, dysphagia, Charcot's Arthropathy, and acquired absence of other right toe.
On 7/28/24 at 1:05 PM, an observation and interview were conducted with resident 35. Resident 35 was observed sitting in his wheelchair in the dining room, he wore a white sock on his left foot with no brace. Resident 35's left foot appeared severely impaired and was rotated medially. Resident 35 stated he did wear a brace on his ankle, sometimes. Resident 35 stated that he did not currently receive physical or occupational therapy, nor did anyone do range of motion exercises with him for his left foot.
On 7/29/24 at 11:03 AM, an observation of resident 35 was conducted. Resident 35 was in a manual wheelchair and self-propelled himself with the use of his right arm and foot around the nurse's station. Resident 35 wore a white sock on his left foot with no brace and his left hand and wrist had a slight contracture.
Resident 35's medical record was reviewed from 7/28/24 through 8/14/24.
The admission MDS assessment Section V: CAA Summary with an Assessment Reference Date/Target Date of 3/5/24, indicated the following CAA Triggers: 2. Cognitive Loss/ Dementia; 4. Communication; 5. Functional Abilities (Self-Care and Mobility); 6. Urinary Incontinence and Indwelling Catheter; 9. Behavioral Symptoms; 12. Nutritional Status; 16. Pressure Ulcer/ Injury; and 19. Pain.
The care plan was reviewed and indicated a Focus of:
a. The resident has limited physical mobility r/t hemiplegia, absence of some toes on right foot Date Initiated: 08/05/2021. It indicated the Goals: The resident will demonstrate the appropriate use of motorized wheelchair through the review date. Date Initiated: 08/05/2021 Target Date: 06/05/2024; and The resident will maintain current level of mobility (one person assist limited/extensive) through review date. Date Initiated: 08/05/2021 Target Date: 06/05/2024. It indicated the Interventions/tasks: LOCOMOTION: The resident is able to: operate motorized wheelchair independently Date Initiated: 08/05/2021. It should be noted that this focus area had not been revised since it was initiated on 8/5/21.
b. The resident had a cerebral vascular accident (CVA/Stroke) affecting left side Date Initiated: 08/05/2021. It indicated the Goals: The resident will be free from s/sx [signs/symptoms] of complications of CVA (DVT [deep vein thrombosis], contractures, aspiration pneumonia, dehydration) through review date. Date Initiated: 08/05/2021 Target Date: 06/05/2024. The resident will be able to communicate needs verbally through the review date. Date Initiated 08/05/2021 Target Date: 06/05/2024. It indicated the Interventions/tasks: Monitor/document mobility status. If resident is presenting with problems or paralysis, obtain order for Physical therapy and Occupational therapy to evaluate and treat. Date Initiated: 08/05/2021; Monitor/document/report PRN for neurological deficits: level of consciousness, visual function changes, aphasia, dizziness, weakness, restlessness. Date Initiated: 08/05/2021. It should be noted that this focus area had not been revised since it was initiated on 8/5/21.
c. The resident has hemiplegia r/t CVA Date Initiated: 08/05/2021. It indicated the Goals: The resident will remain free of complications or discomfort related to hemiplegia through review date. Date Initiated: 08/05/2021. The resident will maintain optimal status and quality of life within limitations imposed by Hemiplegia through review date. Date Initiated: 08/05/2021 Target Date: 06/05/2024. It indicated the Interventions/tasks: Discuss with resident/resident and family any concerns, fears, issues regarding diagnosis or treatments. Date Initiated: 08/05/2021; Educate resident to anticipate needs for safety to affected hemiplegia side during transfers. Date Initiated: 06/27/2022; Give medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated:08/05/2021; Pain management as needed. See MD [Medical Doctor] orders. Provide alternative comfort measures PRN. Date Initiated: 08/05/2021; PT [physical therapy], OT [occupational therapy], ST [speech therapy] evaluate and treat as ordered. Date Initiated: 08/05/2021. It should be noted that this focus area had not been revised since 6/27/22.
A Clinical Summary dated 6/12/24 at 8:00 AM, indicated resident 35 was seen by an outside orthotic clinic for his ankle foot orthosis (AFO). It further indicated, Device History . Start Date: 2021. End Date: current/present. Comments: This AFO is a generic off the shelf design that of which doesn [sic] not cater to his serve externally rotated ankle foot complex. Increased risk for adverse skin shear with continued use. Custom AFO pursuit necessary in assurance of patient safety/skeletal informational stabilization. It further indicated, Comments: Minor adjustments/repairs pursued as described today. I informed the tending facility staff to pursue daily prolonged stretching of his ankle foot complex in avoiding deformational varus tendency, concern with fixated external rotational deformation at the ankle complex should this not be put in place at his care facility. Written recommendations provided to facility staff present today. All adjustments requested by [Resident name redacted] pursued today were found proper. Follow up as needed. It should be noted that this document was not found in the medical record and was provided after it was requested by the State Survey Agency. The fax server date on this document was 7/30/24 at 4:31 PM from the clinic.
The quarterly MDS assessment Section GG Functional Abilities and Goals dated 6/13/24, indicated, Functional Limitation in Range of Motion to the Lower extremity (hip, knee, ankle, foot with Impairment to one side. It further indicated resident 35 used a wheelchair.
An Encounter Progress Note dated 7/4//24 at 11:00 PM, indicated, [Resident name redacted] is a [AGE] year-old male who is a long-term resident at [Facility name redacted]. He has a history of a cerebral infarction resulting in left-sided weakness, diabetes, obstructive sleep apnea as well as Charcot's arthropathy. When is at the nurses station today patient came to me to discuss his left foot pain and malformation. Patient states that years ago he hurt his foot and it never healed back to normal position properly. The foot is turned inward and a brace is in place at this time. Patient states that he is able to hold the foot or the toes back and push them down but with very poor range of motion. He stated that he needs to have the foot casted to help him get the foot back into normal position. The brace does not appear to be keeping the footin [sic] a normal anatomical alignment position. I am going to refer the patient to an orthopedic specialist to works on her feet and ankles. I informed patient that I would write the referral and patient was very grateful. Patient was sitting in his wheelchair when I left him by the nurses station.
A Progress note dated 7/17/24 at 1:57 PM, indicated, Pt [patient] refusing to wear LLE [left lower extremity] brace. Pt educated on importance of wearing brace and verbalized understanding. Pt still refusing to wear brace.
On 7/29/24 at 3:51 PM, an interview was conducted with the DON. The DON stated there was no Restorative Nursing Assistant program and that nursing did not do passive range of motion for residents. The DON stated occupational or physical therapy should provide those services if a resident had that ordered.
On 7/30/24 at 11:42 AM, an interview was conducted with the ADON. The ADON stated resident 35 had an AFO that he used to wear every day but had been refusing to wear it since his last appointment several weeks ago with the outside orthotic clinic. The ADON stated if that clinic sent any notes back it would be filed in the chart. The ADON stated the resident was not on physical therapy treatments at that time.
On 7/30/24 at 2:01 PM, an interview was conducted with the Occupational Therapist (OT). The OT stated resident 35 was last seen by OT on 8/23/24, for his hand. The OT stated he did know that resident 35 had an AFO for his foot and that the fit rubbed and bothered him. The OT stated he still had trouble with his AFO.
3. Resident 17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including severe sepsis without septic shock, pneumonitis due to inhalation of food and vomit, malignant neoplasm of esophagus, acute respiratory failure unspecified whether with hypoxia or hypercapnia, asthma uncomplicated, asthma with (acute) exacerbation, gastrointestinal hemorrhage, other acute kidney failure, chronic pulmonary embolism, atherosclerosis of other arteries, schizoaffective disorder depressive type, vascular dementia, type 2 diabetes mellitus without complications, and essential hypertension.
Resident 17's medical record was reviewed from 7/28/24 through 8/14/24.
Resident 17's care plan was reviewed. A focus area dated 1/17/23, revealed, The resident has oxygen therapy. The goal for this focus area was documented as, The resident will have no s/sx of poor oxygen absorption through the review date. The interventions for this goal were documented as, Monitor of s/sx of respiratory distress and report to MD PRN: Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis, Cough, Pleuritic pain, Accessory muscle usage, Skin color. It should be noticed that the last time this focus area was revised was on 1/17/23.
4. Resident 26 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizoaffective disorder depressive type, dementia, cannabis abuse, nicotine dependence, and asthma.
Resident 26's medical record was reviewed from 7/28/24 through 8/14/24.
Resident 26's care plan was reviewed. A focus area dated 8/3/23 revealed, The resident has oxygen therapy r/t respiratory illness. The goal for this focus area was documented as, The resident will have no s/x of poor oxygen absorption through the review date. The interventions for this goal were documented as, Ensure resident is wearing his N/C [nasal cannula] at all times and SPO2 [oxygen saturations] checked QS [every shift] and Monitor for s/sx of respiratory distress to MD PRN: Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis, Cough, Pleuritic pain, Accessory muscle usage, Skin color. It should be noted that the last time this focus area was revised was on 9/12/22.
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
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident 7 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included deme...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident 7 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included dementia, schizoaffective disorder, paroxysmal atrial fibrillation, obsessive-compulsive disorder, essential hypertension, adult failure to thrive, encephalopathy, and mild cognitive impairment.
On 7/28/24 at 12:28 PM, an observation was made of resident 7 in his room. It was noted that the resident was using an oxygen concentrator and was receiving 3 liters per minute of oxygen via a nasal cannula. The oxygen tubing was not dated.
On 7/28/24, resident 7's medical record was reviewed. The following physician order was noted with an order date of 5/22/23, O2 to keep SPO2 greater than 90%.
There were no orders for resident 7's oxygen tubing and nasal cannula to be changed.
On 7/29/24, resident 7's TAR was reviewed for the months of May 2023 through July 2024. There was no documentation of oxygen tubing or nasal cannula changes recorded.
5. Resident 24 was admitted to the facility on [DATE] with diagnoses which included, dementia, type 2 diabetes mellitus, chronic viral Hepatitis C, essential hypertension, hyperlipidemia, vertigo, major depressive disorder, osteoarthritis, and inflammatory disease of prostate.
On 7/28/24 at 1:32 PM, an observation was made of resident 24 in his room. It was noted that the resident used an oxygen concentrator. The oxygen tubing was not dated.
On 7/28/24, resident 24's medical record was reviewed. The following physician order was noted with a start date of 1/17/23, O2 @ 2L via NC @ NOC to keep sats > than 90% every day and night shift.
There were no orders for resident 24's oxygen tubing and nasal cannula to be changed.
On 7/29/24, resident 24's TAR was reviewed for the months of January 2023 to July 2024. There was no documentation of oxygen tubing or nasal cannula changes recorded.
On 7/29/24 at 11:52 AM, an interview was conducted with CNA 2. CNA 2 stated that CNAs reported to the floor nurse about oxygen supplies. CNA 2 stated she was unsure how often the nasal cannulas and oxygen tubing were changed.
On 7/30/24 at 8:01 AM, an interview was conducted with RN 1. RN 1 stated that the graveyard shift usually changed out the oxygen supplies. RN 1 stated that the nasal cannulas and oxygen tubing should be changed at least monthly. RN 1 stated that there should be an order in the MAR that showed when it needed to be changed.
On 7/31/24 at 7:21 AM, an interview was conducted with the DON. The DON stated that the night nurses changed the oxygen supplies once a month on Sundays. The DON stated that it should be charted in the MAR. The DON stated that she had asked the nurses to place tape with the date on it so people knew that it had been changed.
The DON was unable to locate in the medical records of residents 7 and 24 where the order for the oxygen supplies to be changed was located or where this was documented that it had been changed.
3. Resident 32 was admitted to the facility on [DATE] with diagnoses which included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease with acute exacerbation, fluid overload, hypertension, and hyperglycemia.
On 7/28/24 at 10:18 AM, an observation was made of resident 32 in his room. Resident 32 was awake, in bed, and wore a nasal cannula connected to an oxygen concentrator running at 8 liters per minute.
On 7/29/24 at 10:18 AM, an observation was made of resident 32. Resident 32 was in his bed and wore a nasal cannula that was connected to an oxygen concentrator.
Resident 32's medical record was reviewed from 7/28/24 through 8/14/24.
A physician's order dated 3/19/24 at 6:00 PM, indicated, Continuous oxygen per moustache cannula at 6-8L every day and night shift.
It should be noted that resident 32's care plan did not address oxygen therapy.
On 7/29/24 at 11:57 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated resident 32 wore a nasal cannula and received 6 to 15 liters of oxygen. RN 1 stated she did not know what a moustache cannula was and looked it up online during the interview. RN 1 stated a moustache cannula was for high concentration oxygen.
On 7/29/24 at 12:12 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated resident 32 wore a nasal cannula.
On 7/30/24 at 1:53 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated resident 32 wore a nasal cannula and a moustache cannula at times. The ADON stated the moustache cannula was from a hospital order and that the order should have been clarified with hospice.
On 7/31/24 at 12:16 PM, an interview was conducted with the Director of Nursing (DON). The DON stated if resident 32 wore a moustache cannula he could get more oxygen and it would be more effective than a nasal cannula. The DON stated he wore a nasal cannula by error or that it could have been because his insurance would not pay for it, but the nurse should have notified the physician and got an order for it. The DON stated resident 32's oxygen therapy should have been in his care plan.
Based on observation, interview, and record review, the facility did not ensure that a resident who needed respiratory care was provided such care care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for 5 out of 30 sampled residents, the facility did not have orders for multiple residents' nasal cannulas, oxygen concentrator humidifier or oxygen concentrator to be changed nor was there any documentation that they were being changed, and a resident with an order for a mustache cannula instead received a standard nasal cannula. Resident identifiers: 7, 17, 24, 26, and 32.
Findings Included:
1. Resident 17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including severe sepsis without septic shock, pneumonitis due to inhalation of food and vomit, malignant neoplasm of esophagus, acute respiratory failure unspecified whether with hypoxia or hypercapnia, asthma uncomplicated, asthma with (acute) exacerbation, gastrointestinal hemorrhage, other acute kidney failure, chronic pulmonary embolism, atherosclerosis of other arteries, schizoaffective disorder depressive type, vascular dementia, type 2 diabetes mellitus without complications, and essential hypertension.
On 7/28/24 at 1:24 PM, an initial observation was made of resident 17. Resident 17 was laying in bed and noted to be using an oxygen concentrator. There were no dates on the nasal cannula tubing or the humidifier. Upon interview, resident 17 was unable to tell me when or how often staff change the tubing or the humidifier for the concentrator.
Resident 17's medical record was reviewed from 7/28/24 through 8/14/24.
Resident 17's physician orders were reviewed. There were no orders for resident 17's oxygen concentrator tubing or oxygen concentrator humidifier to be changed. The only oxygen related order was an order dated 8/18/23, that stated, O2 [oxygen] @ [at] 3L [liters] via nc [nasal cannula] @ NOC [night shift] to keep sats [saturations] > [greater than] 90% every day and night shift.
Resident 17's Medication Administration Record (MAR) and Treatment Administration Record (TAR) were reviewed for the month of July 2024. There was no documentation on the MAR or TAR showing that resident 17's oxygen concentrator tubing or oxygen concentrator humidifier had been changed.
Resident 17's care plan was reviewed. A focus area dated 1/17/23, revealed, The resident has oxygen therapy. The goal for this focus area was documented as, The resident will have no s/sx [signs and symptoms] of poor oxygen absorption through the review date. The interventions for this goal were documented as, Monitor of s/sx of respiratory distress and report to MD [Medical Doctor] PRN [as needed]: Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis, Cough, Pleuritic pain, Accessory muscle usage, Skin color. There was no guidance in the resident's care plan regarding the changing or cleaning of nasal cannula tubing or oxygen concentrator humidifiers.
2. Resident 26 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including schizoaffective disorder depressive type, dementia, cannabis abuse, nicotine dependence, and asthma.
On 7/28/24 at 11:02 AM, an initial observation was made of resident 26. Resident 26 was noted to have an oxygen concentrator in his room. There were no dates on the nasal cannula tubing or the humidifier. Upon interview, resident 26 stated that he did not know how often staff changed the tubing or the humidifier. Resident 26 stated that staff change the tubing and humidifier as needed. It should be noted that while the oxygen concentrator was running, resident 26 was not wearing his nasal cannula.
Resident 26's medical record was reviewed from 7/28/24 through 8/14/24.
Resident 26's physician orders were reviewed. There were no orders for resident 26's oxygen concentrator tubing or oxygen concentrator humidifier to be changed. The only oxygen related order was an order dated 1/17/23, that stated, O2 @ 2L via nc @ NOC to keep sats > 90% every day and night shift for hypoxia. Wean as tolerated.
Resident 26's MAR and TAR were reviewed for the months of March 2024 through August 2024. There was no documentation on the MAR or TAR showing that resident 26's oxygen concentrator tubing or oxygen concentrator humidifier had been changed.
Resident 26's care plan was reviewed. A focus area dated 8/3/23, revealed, The resident has oxygen therapy r/t [related to] respiratory illness. The goal for this focus area was documented as, The resident will have no s/sx of poor oxygen absorption through the review date. The interventions for this goal were documented as, Ensure resident is wearing his N/C at all times and SPO2 [oxygen saturations] checked QS [every shift] and Monitor for s/sx of respiratory distress to MD PRN: Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis, Cough, Pleuritic pain, Accessory muscle usage, Skin color. There was no guidance in the resident's care plan regarding the changing or cleaning of nasal cannula tubing or oxygen concentrator humidifiers.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0712
(Tag F0712)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that 5 of ^^ sample residents were seen by the physician at le...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that 5 of ^^ sample residents were seen by the physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. Resident identifiers: 7, 24, 28, 29, and 44.
Findings include:
1. Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dementia, schizoaffective disorder, paroxysmal atrial fibrillation, obsessive-compulsive disorder, essential hypertension, mild cognitive impairment of uncertain or unknown etiology, adult failure to thrive, and encephalopathy.
A review of resident 7's medical record of physician visits revealed that the last facility MD [medical doctor] visit was 2/27/24, indicating that the resident had not been seen by the physician in approximately 5.5 months.
2. Resident 24 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia, type 2 diabetes mellitus, chronic viral Hepatitis C, essential hypertension, hyperlipidemia, major depressive disorder, and inflammatory disease of the prostate.
A review of resident 24's medical record of physician visits revealed that the last facility MD visit was 2/27/24, indicating that the resident had not been seen by the physician in approximately 5.5 months.
3. Resident 28 was admitted to the facility on [DATE] with diagnoses which included, unspecified dementia, generalized anxiety disorder, schizoaffective disorder, and unspecified severe protein-calorie malnutrition.
A review of resident 28's medical record of physician visits revealed the last facility MD visit was 9/9/23, indicating that the resident had not been seen by the physician in approximately 11 months.
4. Resident 29 was admitted to the facility on [DATE] with diagnoses which included, dysarthria and anarthria, gastro-esophageal reflux disease without esophagitis, dysphagia, unruptured cerebral aneurysm, major depressive disorder, chronic kidney disease, anemia in chronic kidney disease, type 1 diabetes mellitus, cognitive communication deficit, generalize muscle weakness, and history of falling.
A review of resident 29's medical record of physician visits revealed that she had not been seen by the facility MD since being admitted to the facility.
5. Resident 44 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, type 2 diabetes mellitus, unspecified dementia, anxiety disorder, benign prostatic hyperplasia without lower urinary tract symptoms, dysphagia, hyperlipidemia, major depressive disorder, unstable angina, and unspecified anemia.
A review of resident 44's medical record of physician visits revealed the only facility MD visit was 6/5/24.
On 8/12/24 at 12:09 PM, an interview was conducted with the Director of Nursing [DON]. The DON stated that facility providers discussed with the nursing staff in regards to what residents needed to be seen or were in need of recertification visits. The DON stated that the facility MD needed to see residents every 60 days.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not provide pharmaceutical services that included the accurate acquiring,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not provide pharmaceutical services that included the accurate acquiring, receiving, dispensing, and administering of all drugs and biological's to meet the needs of each resident. Specifically, for 4 out of 30 sampled residents, licensed nursing staff were not signing out controlled substances and reconciling at the time of administration. Resident identifiers: 1, 3, 4, and 38.
Findings included:
1. Resident 38 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, dementia with agitation, essential hypertension, and neurocognitive disorder with Lewy bodies.
Resident 38's medical record was reviewed on 8/12/24.
The August 2024 Medication Administration Record (MAR) was reviewed on 8/12/24 at 12:21 PM. Resident 38's ARISE medications had not been administered. (Note: According to the medication pass times provided by the facility the ARISE medications were to be administered between 7:00 AM to 11:00 AM.) The ARISE medications included the following:
a. amlodipine besylate 5 milligram (mg) tablet one time a day related to essential hypertension.
b. citalopram hydrobromide 20 mg tablet one time a day for depression.
c. lisinopril 40 mg tablet one time a day related to essential hypertension.
d. olanzapine 5 mg tablet one time a day for anxiety.
e. spironolactone 25 mg tablet one time a day for blood pressure.
f. Senna 8.6 mg tablet two times a day for bowel care.
g. hydrocodone-acetaminophen 5-325 mg tablet three times a day for pain.
h. lorazepam 1 mg tablet three times a day for agitation give after meal.
The August 2024 Electronic MAR Administration Details was reviewed. On 8/12/24 at 12:32 PM, resident 38 had received the ARISE and NOON dose of hydrocodone-acetaminophen and lorazepam. (Note: According to the medication pass times provided by the facility the NOON medications were to be administered between 11:00 AM and 2:00 PM.)
The Controlled Drug Record was reviewed. The hydrocodone-acetaminophen and lorazepam had not been signed out as being administered to resident 38.
On 8/12/24 at 2:09 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that the Business Officer Manager spoke with her and told her to come tell the State Survey Agency (SSA) Lead Licensor that she had documented the hydrocodone-acetaminophen and lorazepam at the same time on the MAR. RN 1 stated that she had given resident 38 her morning medications but did not document them until 12:31 PM.
On 8/12/24 at 2:24 PM, a follow up interview was conducted with RN 1. RN 1 stated that she was not sure why she did not sign out resident 38's medications at the time of administration. RN 1 stated that she thought she was just wound up with everything going on. RN 1 stated there were other residents that received their medications and she had not signed them out that morning. The SSA Lead Licensor asked RN 1 what the process was for administering medications. RN 1 stated she knew that she was to chart as she went but sometimes she did not. RN 1 stated she thought it was faster and cutting corners. RN 1 stated she was not sure what do you want me to say.
2. Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, paranoid schizophrenia, chronic viral hepatitis C, major depressive disorder, type 2 diabetes mellitus without complications, psychoactive substance dependence, psychosis, post-traumatic stress disorder, attention-deficit hyperactivity disorder, chronic pain, essential hypertension, suicidal ideations, and low back pain.
Resident 3's medical record was reviewed on 8/12/24.
The August 2024 MAR was reviewed. The ARISE dose of clonazepam 0.5 mg tablet, the ARISE and NOON dose of gabapentin 600 mg tablet, and the ARISE and NOON dose of Oxycodone 10 mg tablet had been signed out as being administered to resident 3.
The Controlled Drug Record was reviewed. The medications had not been signed out as being administered to resident 3.
3. Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, acute myocardial infarction, acute respiratory failure with hypoxia, age-related cognitive decline, type 2 diabetes mellitus, non-pressure chronic ulcer of foot, rheumatoid arthritis, acquired deformity of lower leg, muscle wasting and atrophy, dysphagia, and difficulty in walking.
Resident 1's medical record was reviewed on 8/12/24.
The August 2024 MAR was reviewed. The ARISE dose of lorazepam 0.5 mg tablet had been signed out as being administered to resident 1.
The Controlled Drug Record was reviewed. The medication had not been signed out as being administered to resident 1.
4. Resident 4 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Huntington's disease, psychotic disorder with delusions, mood disorder due to known physiological condition, bipolar II disorder, conversion disorder with seizures or convulsions, migraine, chronic pain, essential hypertension, and gastro-esophageal reflux disease.
Resident's medical record was reviewed on 8/12/24.
The August 2024 MAR was reviewed. The ARISE dose of pregabalin 200 mg capsule, the NOON dose of pregabalin 100 mg capsule, the ARISE dose of Morphine Sulfate extended release 15 mg tablet, the ARISE dose of modafinil 200 mg tablet, the ARISE dose of Oxycodone 10 mg tablet, and the NOON dose of clonazepam 1 mg tablet had been signed out as being administered to resident 4.
The Controlled Drug Record was reviewed. The medications had not been signed out as being administered to resident 4.
On 8/12/24 at 2:47 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the nursing staff should be signing out medications at the time they were administered. The DON stated that sometimes they may be signed out within the hour.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident 298 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dement...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident 298 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dementia, essential hypertension, benign prostatic hyperplasia without lower urinary symptoms, acute kidney failure, weakness, and unspecified anxiety disorder.
Resident 298's medical record was reviewed 8/7/24.
A review of resident 298's physician orders in the electronic medical record revealed the following orders:
a. Warfarin Sodium Oral Tablet 2 mg, Give 2 mg by mouth one time a day for Anticoagulation Deep Vein Thrombosis (DVT). Start date 6/22/24.
b. Warfarin Sodium Oral Tablet 2 mg, Give 1.5 tablet by mouth one time a day for Anticoagulation DVT until 7/1/24 at 11:59 PM. Start date 6/26/24. End date 7/1/24.
c. Coumadin Oral Tablet (Warfarin Sodium), Give 3 mg by mouth one time a day for DVT. Start date 6/27/24.
d. Coumadin Oral Tablet 1 mg, Give 1 tablet by mouth one time a day for DVT give with 2 mg to equal 3 mg. Start date 6/27/24.
e. Coumadin Oral Tablet 4 mg, Give 4 mg by mouth one time a day for DVT. Start date: 7/2/24.
f. Coumadin Oral Tablet 4 mg, Give 3 mg by mouth by one time a day every Tuesday (Tues), Wednesday (Wed), Friday (Fri), Saturday (Sat), and Sunday (Sun) for DVT until 7/7/24 at 11:59 PM. Start date 7/2/24.
g. Coumadin Oral Tablet, Give 3 mg by mouth one time a day every Tuesday, Wednesday, Friday, Saturday, and Sunday for DVT until 7/8/24 at 11:59 PM. Recheck prothrombin time (PT)/ international normalized ratio (INR) on 7/8/24. Start date 7/3/24.
h. Coumadin Oral Tablet 4 mg, Give 1 tablet by mouth one time a day for DVT until 7/8/24 at 11:59 PM. Start date 7/3/24.
i. Coumadin Oral Tablet 4 mg, Give 1 tablet by mouth one time a day every Monday and Thursday for DVT until 7/8/24 at 11:59 PM. Start date 7/4/24.
j. Coumadin Oral Tablet 4 mg, Give 1 tablet by mouth one time a day every Monday and Thursday for DVT until 7/4/24 at 11:59 PM. Start date 7/4/24.
On 7/1/24 at 11:48 PM, a health status note documented, PT 18.9 INR 1.63 MD [Medical Doctor] notified: New Order received: Give 4mg on Monday 07/01/24; give 4mg on Thursday 07/04/24. Give 3mg all other days (Tues 07/02, Wed 07/03, Fri 07/05, Sat 07/06, and Sun 07/07/2024 Re-check PT/INR on 07/08/2024. All orders completed under orders and labs; PT/INR tracker completed; order sent to pharmacy.
On 7/3/24 at 12:56 AM, a health status note documented, Res [resident] received 4mg coumadin x2 [sic] this shift. MD was notified on what if anything to monitor for and hold on tomorrow evenings PM dose? (07/03/24) Response from MD is pending. WCTM [will continue to monitor] Med [medication] error completed and placed on DON desk.
On 8/8/24 at 1:58 PM, an interview was conducted with the DON. The DON stated that staff always had access to the DON, ADON, the Administrator, and the doctors if an error had been made. The DON stated there was always a way to get a hold of them by calling or text message. The DON stated that text messaging was better because she did not always see that she had missed a call. The DON stated that a change of condition due to an error the staff were to text message first and then call if no response. The DON stated that staff were to use their judgement and send the resident out if necessary. The DON stated she would say if it was a dire emergency the staff should call the MD if they had not heard back from text message in 15 to 30 minutes. The DON stated there were some nurses who thought that they had to get an order before they could do anything. The DON stated there were forms that were filled out and brought back to DON office.
Based on observation, interview, and record review, the facility did not ensure that residents were free of any significant medication errors. Specifically, for 4 out of 30 sampled residents, one resident had multiple missed doses of two medications, a second resident was not administered pregabalin a time sensitive medication at the scheduled times as ordered by the physician, a third resident received a double dose of their pain and anxiety medications, and a fourth resident received a double dose of warfarin. Resident identifiers: 4, 32, 38, and 298.
Findings include:
1. Resident 32 was admitted to the facility on [DATE] with diagnoses which included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD) with acute exacerbation, fluid overload, hypertension, and hyperglycemia.
On 7/29/24 at 10:11 AM, an observation and interview were conducted with resident 32. Resident 32 was awake, in bed, and wore a nasal cannula connected to an oxygen concentrator running at 8 liters per minute. Resident 32 stated one of his respiratory medications, air duo had been empty and he had not received that medication since Friday.
Resident 32's medical record was reviewed from 7/28/24 through 8/14/24.
A physician's order dated 3/19/24 at 7:00 PM, indicated, Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated 232-14 MCG/ACT [micrograms/actuation] (Fluticasone-Salmeterol) 2 puff inhale orally two times a day for COPD.
The July 2024 Medication Administration Record (MAR) indicated a 9 for the hour of sleep (HS) doses on 7/27/24, 7/28/24, and the Arise dose on 7/29/24, for the medication, Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated 232-14 MCG/ACT (Fluticasone-Salmeterol) 2 puff inhale orally two times a day for COPD.
On 7/29/24 at 11:57 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated resident 32 was on hospice and they were in charge of his medications. RN 1 stated, All of his breathing stuff is on them. RN 1 held a medication box which was labeled, Fluticasone Propionate and Salmeterol HFA [hydrofluoroalkane] Inhalation 115 mcg/21 mcg. RN 1 stated hospice sent the wrong dose and that even when they have the correct medication, it only lasted 15 days. RN 1 stated she called the hospice nurse today because resident 32 was very mad that the medication was not available. RN 1 stated, He can't breathe. RN 1 stated that the hospice company was available on the weekends and had a backup on-call person if nobody answered. RN 1 reviewed resident 32's MAR and stated when there was a 9 on the document, that indicated the medication was not given.
A physician's order dated 5/27/24, indicated, Gabapentin 100mg [milligrams] PO (by mouth) BID (twice a day) for neuropathy.
The MAR dated May 2024 was reviewed. There was no Gabapentin order listed or administration documented.
The MAR dated June 2024 indicated, Gabapentin Oral Tablet (Gabapentin) Give 100 mg orally two times a day for neuropathy -Start Date- 06/08/2024 1600 [4:00 PM]. It further indicated the medication was administered for the first time on 6/9/24, PM.
On 7/30/24 at 1:53 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated a telephone order should be put in immediately and then faxed to the pharmacy. The ADON stated the pharmacy could deliver it late at night. The ADON reviewed the order in the chart and stated that it was written by the hospice Family Nurse Practitioner. The ADON stated she was not sure why the order did not get put in sooner.
2. Resident 38 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, dementia with agitation, essential hypertension, and neurocognitive disorder with Lewy bodies.
On 8/12/14 at 11:45 AM, an observation was conducted. The Administrator was observed pushing resident 38 in the wheel chair into the assisted dining room for the lunch meal service. Resident 38 was observed yelling no repeatedly. Certified Nursing Assistant (CNA) 1 was observed to assist resident 38 with dining. Resident 38 was observed to be agitated, mumbling, crying, and spit out her dentures. The Business Office Manager (BOM) was observed to walk to the nurses station and asked RN 1 if resident 38 had any anxiety medication. The BOM told RN 1 that she better medicate resident 38 or resident 38 would not eat and would be back in her room.
Resident 38's medical record was reviewed on 8/12/24.
The August 2024 MAR was reviewed on 8/12/24 at 12:21 PM. Resident 38's ARISE medications had not been administered. (Note: According to the medication pass times provided by the facility the ARISE medications were to be administered between 7:00 AM to 11:00 AM.) The ARISE medications included the following:
a. amlodipine besylate 5 mg tablet one time a day related to essential hypertension.
b. citalopram hydrobromide 20 mg tablet one time a day for depression.
c. lisinopril 40 mg tablet one time a day related to essential hypertension.
d. olanzapine 5 mg tablet one time a day for anxiety.
e. spironolactone 25 mg tablet one time a day for blood pressure.
f. Senna 8.6 mg tablet two times a day for bowel care.
g. hydrocodone-acetaminophen 5-325 mg tablet three times a day for pain.
h. lorazepam 1 mg tablet three times a day for agitation give after meal.
The August 2024 Electronic MAR Administration Details was reviewed. On 8/12/24 at 12:32 PM, resident 38 had received the ARISE and NOON dose of hydrocodone-acetaminophen and lorazepam.
The Controlled Drug Record was reviewed. The hydrocodone-acetaminophen and lorazepam had not been signed out as being administered to resident 38.
On 8/12/24 at 1:26 PM, an interview was conducted with RN 1. RN 1 stated that resident 38 had a lot of anxiety. RN 1 stated that resident 38's anxiety was usually after the husband left the facility. RN 1 stated that resident 38's husband was not in the facility today and she was not sure what started resident 38's agitation. RN 1 stated that resident 38 wanted to go home. RN 1 stated if resident 38 was agitated she would not eat well. RN 1 stated that resident 38's medications yes and no helped resident 38's agitation. RN 1 stated that some days were better then others. RN 1 stated that she was not aware if the Medical Director had reassessed resident 38's medications for effectiveness.
On 8/12/24 at 1:37 PM, an interview was conducted with CNA 1. CNA 1 stated that resident 38 was not normally like that. CNA 1 stated that someone gave resident 38 a Pepsi earlier today and resident 38 wanted her Pepsi and did not want to eat. CNA 1 stated that resident 38 might not have gotten her medications on time. CNA 1 stated that resident 38 was usually fussy but not like she was today. CNA 1 stated that resident 38 kept stating she wanted the Pepsi. CNA 1 stated that resident 38 usually struggled with eating lunch but she would eat breakfast. CNA 1 stated that after she got resident 38's Pepsi resident 38 did eat her lunch better. CNA 1 stated that resident 38's husband would bring in Pepsi.
On 8/12/24 at 2:09 PM, an interview was conducted with RN 1. RN 1 stated that the BOM spoke with her and told her to come tell the State Survey Agency (SSA) Lead Licensor that she had documented the hydrocodone-acetaminophen and lorazepam medications at the same time. RN 1 stated that she had given resident 38 her morning medications but did not document them until 12:31 PM.
On 8/12/24 at 2:24 PM, a follow up interview was conducted with RN 1. RN 1 stated that she was not sure why she did not sign out resident 38's medications at the time of administration. RN 1 stated that she thought she was just wound up with everything going on. RN 1 stated there were other residents that received their medications and she did not sign them out this morning. The SSA Lead Licensor asked RN 1 what the process was for administering medications. RN 1 stated she knew that she was to chart as she went but sometimes she did not. RN stated she thought it was faster and cutting corners. RN 1 stated she was not sure what do you want me to say.
On 8/12/24 at 2:47 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the nursing staff should be signing out medications at the time they were administered. The DON stated that sometimes they may be signed within the hour.
3. Resident 4 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Huntington's disease, psychotic disorder with delusions, mood disorder due to known physiological condition, bipolar II disorder, conversion disorder with seizures or convulsions, migraine, chronic pain, essential hypertension, and gastro-esophageal reflux disease.
On 7/29/24 at 7:51 AM, RN 1 was observed to prepare and administer medications to resident 4. RN 1 administered a pregabalin capsule 200 mg with the other morning medications that were prepared.
Resident 4's medical record was reviewed on 7/29/24.
A physician's order dated 5/7/20, documented Pregabalin Capsule 200 MG Give 1 capsule by mouth one time a day for GIVE AT 0600 [6:00 AM] am ONLY (time sensitive).
A physician's order dated 5/9/20, documented Pregabalin Capsule 100 MG Give 1 capsule by mouth one time a day for TIME SENSITIVE NARCOTIC (Give at 1400 [2:00 PM]).
A physician's order dated 5/9/20, documented Pregabalin Capsule 100 MG Give 1 capsule by mouth one time a day for TIME SENSITIVE NARCOTIC (GIVE AT 2100 [9:00 PM] ONLY).
The July 2024 Electronic MAR Administration Details was reviewed. The following administration times were documented for the pregabalin:
a. On 7/1/24 at 7:21 AM, 1:32 PM, and 7/2/24 at 12:57 AM.
b. On 7/2/24 at 6:28 AM, 12:04 PM, and 10:60 PM.
c. On 7/3/24 at 7:38 AM, 12:07 PM, and 7:40 PM.
d. On 7/4/24 at 6:06 AM, 1:17 PM, and 7:33 PM.
e. On 7/5/24 at 8:25 AM, 12:55 PM, and 7:43 PM.
f. On 7/6/24 at 6:30 AM, 12:57 PM, and 7:24 PM.
g. On 7/7/24 at 6:11 AM, 1:00 PM, and 7:39 PM.
h. On 7/8/24 at 9:30 AM, 12:30 PM, and 7:28 PM.
i. On 7/9/24 at 6:39 AM, 1:18 PM, and 7:28 PM.
j. On 7/10/24 at 7:35 AM, 12:02 PM, and 8:32 PM.
k. On 7/11/24 at 6:22 AM, 1:00 PM, and 7:36 PM.
l. On 7/12/24 at 8:17 AM, 12:39 PM, and 9:05 PM.
m. On 7/13/24 at 8:01 AM, 12:02 PM, and 6:31 PM.
n. On 7/14/24 at 6:18 AM, 1:29 PM, and 6:33 PM.
o. On 7/15/24 at 6:08 AM, 1:04 PM, and 7:40 PM.
p. On 7/16/24 at 9:15 AM, 12:15 PM, and 8:16 PM.
q. On 7/17/24 at 7:31 AM, 2:05 PM, and 7:54 PM.
r. On 7/18/24 at 7:39 AM, 1:43 PM, and 7:50 PM.
s. On 7/19/24 at 10:01 AM, 12:37 PM, and 7:30 PM.
t. On 7/20/24 at 6:17 AM, 1:18 PM, and 7:10 PM.
u. On 7/21/24 at 6:39 AM, 1:05 PM, and 7:51 PM.
v. On 7/22/24 at 10:35 AM, 12:15 PM, and 11:13 PM.
w. On 7/23/24 at 6:06 AM, 1:08 PM, and 9:36 PM.
x. On 7/24/24 at 10:50 AM, 2:02 PM, and 9:10 PM.
y. On 7/25/24 at 6:11 AM, 1:22 PM, and 7:17 PM.
z. On 7/26/24 at 9:07 AM, 4:19 PM, and 7:03 PM.
aa. On 7/27/24 at 6:31 AM, 12:57 PM, and 6:17 PM.
bb. On 7/28/24 at 7:06 AM, 1:00 PM, and 7:31 PM.
cc. On 7/29/24 at 8:00 AM and 12:21 PM.
On 7/29/24 at 10:30 AM, an interview was conducted with RN 1. RN 1 stated that resident 4's pregabalin on the MAR documented to administer at ARISE. RN 1 stated that ARISE was a flex time for medication administration but the physician's order documented to give the pregabalin at 6:00 AM. RN 1 stated the physician's order indicated 6:00 AM, because resident 4 received a noon dose of the pregabalin. RN 1 stated that the noon dose of the pregabalin was on a flex time also. RN 1 stated that resident 4 received three doses of pregabalin a day. RN 1 stated the morning dose of pregabalin was 200 mg and the other doses were 100 mg. RN 1 stated the facility had the noon dose of pregabalin coded to give at 1:00 PM, but the physician's order documented to give the pregabalin at 2:00 PM. RN 1 stated that she would give the noon dose of pregabalin closer to 2:00 PM.
On 7/29/24 at 11:13 AM, an interview was conducted with the DON. The DON stated the facility had flex times to administer the medications but the nurse should have given the pregabalin between 6:00 AM and 7:00 AM. The DON stated that pregabalin was a narcotic and the staff liked to watch resident 4 because resident 4 took a lot of narcotics. The DON stated that resident 4 would have another dose of the pregabalin at 2:00 PM, so the staff needed to be conscious about the medication timing.
A facility Memorandum dated 1/22/2013, documented the following Medication Pass Times.
To allow the residents here at [facility name redacted] more autonomy and flexibility we are changing medication pass times. The new times are as follows:
Early AM (5am to 9am)
Arise (7am to 11am)
Noon (11 am to 2 pm)
PM (4pm to 7 pm)
HS (7pm to 10pm)
BID = arise & pm
TID [three times a day] = arise, noon, & pm
QID [four times a day] = arise, noon, pm, & hs.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Laboratory Services
(Tag F0770)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 44 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, type 2 diabetes mellitu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 44 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, type 2 diabetes mellitus, dementia, anxiety disorder, benign prostatic hyperplasia without lower urinary tract symptoms, dysphagia, hyperlipidemia, major depressive disorder, unstable angina, and anemia.
Resident 44's medical record was reviewed on 8/9/24 through 8/13/24.
On 8/9/24 at 4:36 PM, a physician progress note documented, .Pt [patient] is more confused and has increased general weakness, because patient's white blood cell count is elevated I am going to have a urine analysis and a culture and sensitivityperformed [sic] to determine if patient has a urinary tract infection which could be causing the elevated white blood cell count and confusion.
On 8/10/24 at 12:47 PM, a health status note documented, Order noted to obtain UA and C&S if indicated. UA collected this shift6 [sic] at 1115. [11:15 AM] [Lab name redacted] notified for UA pick up.
On 8/10/24 at 2:17 PM, an interview was conducted with LN 5. LN 5 stated that labs were collected by the nurses and then the lab needed to be called to pick up the samples. LN 5 stated that once she placed an order in the computer she would print off a lab slip to accompany the samples.
On 8/10/24 at 2:51 PM, an interview was conducted with LN 3. LN 3 stated that resident 44 had an increase in aggression and this was why a urinalysis was ordered. LN 3 stated that resident 44 had complained of the inability to urinate on 8/9/24, and the doctor wanted a urinalysis done. LN 3 stated he had been able to get a urine sample from resident 44 on 8/10/24. LN 3 stated that if he was unable to get the lab company to come to the facility then the Administrator would drop off the sample when he left for the day.
On 8/13/24 at 9:30 AM , an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that no results for the urinalyses had come back. The ADON stated that since the lab company was used, it took longer for the results to be faxed to the facility. The ADON stated that results would be faxed from the hospital to the fax machine located in the nurse's office.
Based on observation, interview, and record review, the facility did not obtain laboratory (lab) services to meet the needs of the residents. Specifically, for 3 out of 30 sampled residents, residents that had a urinalysis (UA) collected did not have the UA completed in a timely manner. Resident identifiers: 8, 18, and 44.
Findings included:
1. Resident 18 was admitted to the facility on [DATE] with diagnoses which included schizophrenia, other stimulant abuse with stimulant-induced psychotic disorder, and unspecified mycosis.
On 8/10/24 at 2:17 PM, an observation was made of the physician's phone. There was a text message at 2:03 PM, from Licensed Nurse (LN) 3 to the physician which revealed resident 18 had redness to his groin area and had urgency and burning upon urination. LN 3 text messaged resident 18's urine was positive for leukocytes and nitrates. LN 3 asked the Medical Director (MD) if it was okay to have a UA with Culture and Sensitivity (C&S) completed.
On 8/10/24 at 2:52 PM, an interview was conducted with LN 3. LN 3 stated resident 18 had some redness in his groin area. LN 3 stated resident 18 was on Diflucan not long ago. LN 3 stated he asked the MD if resident 18 needed a UA completed. LN 3 stated resident 18 had provided a urine sample and it was ready to be picked up from the laboratory.
Resident 18's medical record was reviewed from 7/28/24 through 8/14/24.
A Health Status Note dated 8/10/24 at 6:01 PM, indicated, Resident completed the oral Diflucan ABX [antibiotics] on 8/9/24. Resident's groin not so red this shift, resident does c/o [complain of] burning upon urination. Order noted to obtain UA-C&S if indicated. I notified [company name redacted] lab for pickup on specimen, I was informed later that [NAME] [sic] will not be able to pickup later in the day, I informed the lab rep [representative] that UA needs picked up today and rep sent reply they will do there [sic] best to pick up the specimen in the med [medication] room specimen fridge.
A physician's order dated 8/10/24, indicated, UA- obtain C&S if indicated.
On 8/12/24 at 1:34 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated he was not sure where urine dip results were supposed to be located. LPN 2 stated if he did a urine dip, he would document the results in the medical chart and notify the physician.
On 8/12/24 at 2:47 PM, an interview was conducted with the Director of Nursing (DON). The DON stated she could not find urine dip results and did not have the results from the urine analysis that was supposed to have been sent out on 8/10/24.
3. Resident 8 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, schizoaffective disorder, chronic kidney disease stage 3, cannabis abuse, essential hypertension, polycystic kidney, type 2 diabetes mellitus without complications, mental disorders, stimulant dependence, and urinary tract infection.
On 8/10/24 at 2:17 PM, an observation was made of the physician's phone. There was a text message at 2:03 PM, from LN 3 to the physician which revealed resident 8 had signs and symptoms of a urinary tract infection (UTI). Resident 8 had urgency and burning upon urination. LN 3 dipped resident 8's urine and was positive for leukocytes and nitrates. LN 3 asked the MD if it was okay to have a UA and C&S completed. LN 3 text messaged that resident 8 had redness in groin and asked if it was okay to start Nystatin powder.
On 8/10/24 at 2:52 PM, an interview was conducted with LN 3. LN 3 stated resident 8 was being monitored for a UTI and was waiting for the physician to respond to the text message. LN 3 stated resident 8's urine was dipped two hours ago and was positive so there was a sample waiting for the laboratory to pick up.
Resident 8's medical record was reviewed on 8/11/24.
On 8/10/24 at 2:16 PM, a Health Status Note documented Note Text: Resident assisted with her shower before lunch. I obtained a UA sample from resident d/t [due to] complaints of burning upon urinations [sic]. Resident has redness in groin area, will see about order for Nystatin powder. Notified NP [Nurse Practitioner].
On 8/10/24 at 6:10 PM, a Health Status Note documented Note Text: Order noted to obtain UA-C&S if indicated. I collected the UA from resident and specimen is in med room specimen fridge. [Name of lab redacted] informed. Will continue to monitor.
On 8/11/24 at 9:11 AM, an interview was conducted with the DON and LN 3. LN 3 stated there had not been any residents with a change of condition in the last 24 hours. The DON stated there had not been any residents with a change of condition in the last 24 hours but three urinalyses were collected. The DON stated the staff could not send the urinalyses out because the staff did not have a printer. The DON stated she was waiting for the Business Officer Manager (BOM) to come to the facility so she could print the orders. The DON stated that staff did not have access to the printer on the weekends. The DON stated that Administration needed to provide staff with a printer so they could print orders. The DON stated that when the NP was getting ready to leave the facility LN 3 needed to see if there were any orders. The DON stated if you know your patient needed a UA and has had a change of condition you need to take care of it and change the change of condition. The DON stated that LN 3 needed to get the labs out. LN 3 stated that he needed the paperwork. The DON stated there was only one order for the urinalyses that were collected. The DON stated when the UA was collected staff were to put in the order, get a copy of the order, and send the order with the UA. The DON stated she was waiting for the BOM to come to the facility so she could print the order and complete the process. The DON stated that the BOM would have to come in every time if Administration did not want staff to have access to the printer. LN 3 stated that he needed to get a hold of the lab company to see what they were doing. LN 3 stated that the lab company messaged the night nurse last night and stated they needed to reschedule the pick up to Monday for the urinalyses. LN 3 and the DON stated that a UA was good in the fridge for 24 hours. The DON stated that staff had been trained on the lab company. The DON stated that she thought the training was in April 2024. LN 3 stated that resident 44's UA was ordered Friday evening and was collected Saturday morning. LN 3 stated that mid Saturday he sent a message to the lab company, dated and time stamped the UA. LN 3 stated that when the UA was time stamped the 24 hour time frame for results started. LN 3 stated that resident 8 and resident 18 fell under the change of condition. LN 3 stated he notified the MD and dipped the urine. LN 3 stated the urine had signs of nitrates and the MD wanted to collect a UA. LN 3 stated the urinalyses were collected on Saturday. LN 3 stated he contacted the lab company and was told the lab company would be to the facility to pick up the urinalyses. LN 3 stated he stayed last night and let the night shift nurse know. LN 3 stated he could run the urinalyses over to the local hospital and the Administrator was going to do that yesterday but the lab company said that they would pick up the urinalyses and the lab company never showed up. LN 3 stated that he could still run the urinalyses over to the local hospital today but he was waiting to print the information. LN 3 stated on the weekends it could be difficult because staff had to clarify things. LN 3 stated the MD came in late on Friday at 3:30 PM, and was at the facility until at least 6:00 PM. LN 3 stated it was hard when you get all these orders and then the weekend was coming. LN 3 stated that he decided to get a UA on resident 8 and resident 18 because they were having the same symptoms as resident 44.
On 8/11/24 at 9:54 AM, the DON asked the Certified Nursing Assistant to take the three urinalyses to the lab at the local hospital.
On 8/11/24 at 10:03 AM, an interview was conducted with LN 3. LN 3 stated that he needed to follow up regarding resident 8's Nystatin powder. LN 3 stated that he sent a message to the MD regarding the urinalyses and the Nystatin powder. LN 3 stated that the night nurse told him that the MD responded but did not say anything about the Nystatin powder. LN 3 stated that the urinalyses were not ordered urgent.
On 8/11/24 at 10:10 AM, the BOM asked LN 3 if the labs from yesterday came back. LN 3 stated that he called the lab company twice and they never came to the facility.
On 8/11/24 at 10:37 AM, an interview was conducted with the BOM. The BOM stated if staff needed access to the printer there was a whole process. The BOM stated when staff need something the staff were to call the Administrator and the Administrator would tell the staff where the keys were located. The BOM stated that staff could just make a copy on the fax machine in the medication room and the resident face sheets were in the paper medical record. The BOM stated that staff had access to the front office. The BOM stated if the staff had an emergent need they were to call the Administrator and the Administrator had a code for a lock box that had the keys to everything. The BOM stated the lock box also had spare keys to the medication cart. The BOM stated if the key box was accessed the Administrator would come in the next time and change the code. The BOM stated when the staff do an order the lab company would come in on Wednesdays. The BOM stated that staff were to write a telephone order which was there official order. The BOM stated that results would come to the fax machine in the medication room or the labs could be accessed through the lab portal on the computer.
On 8/11/24 at 10:42 AM, an interview was conducted with the DON. The DON stated that was the first time she had ever heard about a lock box with keys. The DON stated there was a fax machine in the medication room but it did not print. The DON stated if staff had to send a resident out with a Medication Administration Record the staff could not print one and that was frustrating.
On 8/12/24 at 11:40 AM, an interview was conducted with the DON. The DON stated the urinalyses had not come back yet. The DON stated the lab company told staff to take the labs to the local hospital if the lab company was unable to come pick them up. The DON stated that the local hospital would call the lab company with the results. The DON stated if the lab was critical the local hospital would call the facility, if the lab was not critical the local hospital would fax the lab to the facility. The DON checked the lab portal for the lab company and stated that the urinalyses were not back yet. The State Survey Agency (SSA) Lead Licensor asked the DON if the local hospital lab used the lab company to process their urinalyses because the three urinalyses were taken to the local hospital yesterday. The DON stated that the facility used the lab company for the three urinalyses. The SSA Lead Licensor asked the DON if the three urinalyses were taken to the local hospital yesterday. The DON stated Oh ya I will have to call them.
On 8/12/24 at 2:43 PM, an interview was conducted with the DON. The DON stated that the local hospital had an outside lab company process the three urinalyses which was separate from the lab company that the facility used. The DON stated the urinalyses were in process right now and in the hands of the outside lab company.
On 8/13/24 at 11:52 AM, an interview was conducted with resident 8. Resident 8 stated she was not having burning with urination and the facility had done some tests. Resident 8 was unable to complete the interview. Resident 8 stated she was having a hard time communicating with me.
On 8/14/24 at 7:33 AM, an interview was conducted with the DON. The DON stated that the three urinalyses did not come back yesterday so she would need to follow up with those today.
The three urinalyses results were never provided to the SSA.
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
Administration
(Tag F0835)
Could have caused harm · This affected multiple residents
Based on interview, observation and record review, the facility did not ensure that the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain...
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Based on interview, observation and record review, the facility did not ensure that the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, multiple areas of immediate jeopardy and harm were identified. In addition, multiple areas of non compliance were cited on the previous survey and again during the current recertification survey. Resident identifiers: 46 and 298.
Findings include:
1. Based on interview and record review, the facility did not ensure that 2 of 30 sample residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, ongoing monitoring for changes in condition were not provided after one resident experienced ongoing emesis and abdominal pain, and a second resident had a deep vein thrombosis. The findings for resident 46 were determined to have resulted in immediate jeopardy for resident 46. Resident identifiers: 46 and 298.
[Cross refer to F684]
2. Based on observation, interview, and record review, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents and the resident environment did not remain as free of accident hazards as was possible. Specifically, for 1 out of 30 sampled residents, a resident was not provided adequate supervision and interventions to reduce hazards and risks that resulted in an acute complete femoral neck fracture with partial displacement. Resident identifiers: 298.
[Cross refer to F689]
3. Based on interview and record review, the facility did not ensure for 2 of 30 sample residents that radiology and other diagnostic services were provided to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services. Specifically, residents were not provided with ultrasounds as ordered by the physician. This resulted in a finding of Immediate Jeopardy for resident 46. Resident identifiers: 46 and 298.
[Cross refer to F776]
4. Based on interview and record review, the facility did not ensure that pain management was provided to residents who required such services. Specifically, for 1 out of 30 sampled residents, a resident with an acute complete femoral neck fracture was not provided pain management prior to being discharged to the hospital. Resident identifiers: 298.
[Cross refer to F697]
5. In addition, during the October 2022 recertification survey, the facility was cited F550, F580, F584, F609, F610, F641, F656, F684, F689, F692, F697, F755, F760, F761, F773, F812, F835, F840, F842, F867, F880, F882, and F923 among other areas of non-compliance. These same areas were again identified during the current recertificaiton survey.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0841
(Tag F0841)
Could have caused harm · This affected multiple residents
Based on interview, observation and record review, the facility did not ensure the the medical director was effective in their role of implementing resident care policies and coordinating medical care...
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Based on interview, observation and record review, the facility did not ensure the the medical director was effective in their role of implementing resident care policies and coordinating medical care in the facility. Specifically, multiple areas of immediate jeopardy and harm were identified. In addition, multiple areas of non compliance were cited on the previous survey and again during the current recertification survey. Resident identifiers: 46 and 298.
Findings include:
1. Based on interview and record review, the facility did not ensure that 2 of 30 sample residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, ongoing monitoring for changes in condition were not provided after one resident experienced ongoing emesis and abdominal pain, and a second resident had a deep vein thrombosis. The findings for resident 46 were determined to have resulted in immediate jeopardy for resident 46. Resident identifiers: 46 and 298.
[Cross refer to F684]
2. Based on observation, interview, and record review, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents and the resident environment did not remain as free of accident hazards as was possible. Specifically, for 1 out of 30 sampled residents, a resident was not provided adequate supervision and interventions to reduce hazards and risks that resulted in an acute complete femoral neck fracture with partial displacement. Resident identifiers: 298.
[Cross refer to F689]
3. Based on interview and record review, the facility did not ensure for 2 of 30 sample residents that radiology and other diagnostic services were provided to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services. Specifically, residents were not provided with ultrasounds as ordered by the physician. This resulted in a finding of Immediate Jeopardy for resident 46. Resident identifiers: 46 and 298.
[Cross refer to F776]
4. Based on interview and record review, the facility did not ensure that pain management was provided to residents who required such services. Specifically, for 1 out of 30 sampled residents, a resident with an acute complete femoral neck fracture was not provided pain management prior to being discharged to the hospital. Resident identifiers: 298.
[Cross refer to F697]
5. In addition, during the October 2022 recertification survey, the facility was cited F550, F580, F584, F609, F610, F641, F656, F684, F689, F692, F697, F755, F760, F761, F773, F812, F835, F840, F842, F867, F880, F882, and F923 among other areas of non-compliance. These same areas were again identified during the current recertificaiton survey.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 7 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which include unspe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 7 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which include unspecified dementia, schizoaffective disorder, paroxysmal atrial fibrillation, obsessive-compulsive disorder, essential hypertension, adult failure to thrive, encephalopathy, and mild cognitive impairment.
Resident 7's medical record was reviewed 7/28/24
An appointment referral note for resident 35 was located in resident 7's paper medical chart.
3. Resident 24 was admitted to the facility on [DATE] with diagnoses which included, unspecified dementia, type 2 diabetes mellitus, chronic viral Hepatitis C, essential hypertension, hyperlipidemia, vertigo, major depressive disorder, osteoarthritis, and inflammatory disease of prostate.
Resident 24's medical record was reviewed on 7/28/24.
An order for occupational therapy for a different resident dated 11/21/22, was located inside resident 24's paper medical chart.
On 7/29/24 at 11:01 AM, an interview was conducted with the Business Office Manager (BOM). The BOM stated that the facility did not really have a person for medical records. The BOM stated the Receptionist or any extra Certified Nursing Assistant would help file medical records in the resident paper medical record if they had time. The BOM stated that once the paperwork went through the signature process the DON would get the paperwork together, bring the paperwork to the Receptionist, and the Receptionist would file the paperwork in the resident paper medical record when there was time.
4. On 8/9/24 at 11:02 PM, an observation was made in the office of the DON of three stacks of papers approximately 12 to 15 inches each and bound by rubber bands and stacked on top of boxed items in the corner of the room. The papers were observed to have resident protected heath information and personally identifiable information. The DON office door was open and was not being occupied or monitored.
Based on observation, interview, and record review, the facility did not maintain records on each resident that were complete, accurately documented, and readily accessible. Specifically, for 6 out of 30 sampled residents, progress notes, an appointment referral, and Occupational Therapy orders were located in the wrong resident medical records. In addition, resident medical records were unsecured in the Director of Nursing (DON) office. Resident identifiers: 1, 3, 7, 24, 35, and 148.
Findings included:
1. Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, acute myocardial infarction, acute respiratory failure with hypoxia, age-related cognitive decline, type 2 diabetes mellitus, non-pressure chronic ulcer of foot, rheumatoid arthritis, acquired deformity of lower leg, muscle wasting and atrophy, dysphagia, and difficulty in walking.
On 7/29/24, resident 1's paper medical record was reviewed. Progress Notes for resident 3 and resident 148 were located in resident 1's paper medical record.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0843
(Tag F0843)
Could have caused harm · This affected multiple residents
Based on interview, the facility did not have in effect a written transfer agreement with one or more hospitals approved for participation under the Medicare and Medicaid programs. Specifically, the f...
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Based on interview, the facility did not have in effect a written transfer agreement with one or more hospitals approved for participation under the Medicare and Medicaid programs. Specifically, the facility never provided the State Survey Agency (SSA) their hospital transfer agreement.
Findings included:
On 8/7/24 at 1:03 PM, the hospital transfer agreement was requested from the Administrator.
On 8/7/24 at 1:25 PM, an interview was conducted with the Administrator. The Administrator stated that he was having trouble finding the hospital transfer agreement.
On 8/12/24 at 9:53 AM, an interview was conducted with the Administrator. The Administrator stated that the hospital transfer agreement that he had was outdated. The Administrator stated that he reached out to the two local hospitals to get the hospital transfer agreement updated. The Administrator stated that one of the hospitals he contacted was by email only. The Administrator stated that he would provide the SSA the hospital transfer agreement when he received it.
A hospital transfer agreement was never provided to the SSA.
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
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected multiple residents
Based on interview, the facility did not establish an infection prevention and control program (IPCP) that included, at a minimum, an antibiotic stewardship program that included antibiotic use protoc...
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Based on interview, the facility did not establish an infection prevention and control program (IPCP) that included, at a minimum, an antibiotic stewardship program that included antibiotic use protocols and a system to monitor the antibiotic use. Specifically, the facility infection control tracking and trending was not done and the facility had not established an antibiotic stewardship program.
Findings included:
On 7/31/24 at 7:23 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that she could not locate her infection control binder, but would look for the binder and bring it to the State surveyor. The DON stated that she was not currently tracking or trending infections in the facility. The DON stated that she did not have the policy for antibiotic stewardship. The DON stated to prevent infections from being spread, all staff should be hand sanitizing in between contact with residents and then washing their hands after they entered a resident's room.
On 8/14/24 at 12:00 PM, it should be noted that the infection control binder was never brought to the State surveyor.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0923
(Tag F0923)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility did not have adequate outside ventilation. Specifically, the facility was found...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility did not have adequate outside ventilation. Specifically, the facility was found to have numerous odors throughout the survey.
Findings included:
On 7/28/24 at 10:05 AM, an observation was made of the 100 hall locked unit. There was a strong urine odor near rooms [ROOM NUMBERS].
On 7/28/24 at 10:22 AM, an observation was made of the 300 hall at the facility. There was noted to be a strong urine odor through out the hallway.
On 7/28/24 at 10:43 AM, an observation was made of the 200 hall at the facility. there was noted to be a strong urine odor around rooms [ROOM NUMBERS].
On 7/28/24 at 12:18 PM, an observation was made of the 300 hall at the facility. There was noted to be a strong urine odor near the entrance to room [ROOM NUMBER].
On 7/28/24 at 12:28 PM, an observation was made of the 100 hall locked unit. There was a strong urine odor near room [ROOM NUMBER].
On 7/29/24 at 7:36 AM, an observation was made of the 100 hall locked unit. There was a strong urine odor when entering the hallway.
On 7/29/24 at 10:40 AM, an observation was made of the 200 hall at the facility. There was noted to be a strong odor of urine near the entrances to rooms 204, 205, 212, and 213.
On 7/29/24 at 10:46 AM, an observation was made of the 200 hall at the facility. There was noted to be a strong urine odor with the strongest smell around rooms [ROOM NUMBERS].
On 7/29/24 at 11:50 AM, an observation was made of the solarium room on the 400 hall of the facility. There were noted to be odors of urine and moisture. It should be noted that there was a koi fish pond located in this room.
On 7/29/24 at 1:11 PM, an observation was made of the 100 hall locked unit. There was a strong urine odor near room [ROOM NUMBER].
On 7/29/24 at 1:40 PM, an observation was made of the 200 hall at the facility. There was noted to be a strong urine odor with the strongest odors around rooms 204 through 207.
On 7/29/24 at 3:34 PM, an observation was made of the 100 hall locked unit. There was a strong urine odor near room [ROOM NUMBER].
On 7/30/24 at 7:36 AM, an observation was made of the 100 hall locked unit. There was a strong urine odor near room [ROOM NUMBER].
On 7/30/24 at 8:00 AM, an observation was made of the 200 hall at the facility. There was a strong urine odor on the 200 hallway near rooms [ROOM NUMBERS].
On 7/30/24 at 9:16 AM, an additional observation was made of the 200 hall at the facility. There was noted to be a strong odor of urine near rooms [ROOM NUMBERS].
On 7/30/24 at 9:29 AM, an interview was conducted with Housekeeper (HK) 1. HK 1 stated that the residents' rooms were cleaned everyday at the facility. HK 1 stated that room [ROOM NUMBER] was dirty and smelled really bad.
On 7/30/24 at 10:15 AM, an interview was conducted with HK 2. HK 2 stated that housekeeping used cleaning supplies to clean the rooms and remove odors.
On 7/30/24 at 10:42 AM, an observation was made of the 100 hall locked unit. There was a strong urine odor near room [ROOM NUMBER].
On 7/30/24 at 2:34 PM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated that she sprayed herself with perfume after changing a resident's soiled brief because the smell overwhelmed her.
On 8/10/24 at 1:30 PM until 2:51 PM, an observation was made of the 200 hall at the facility. There was noted to be a strong urine odor throughout the hallway.
On 8/10/24 at 1:43 PM, an observation was made of the 100 hall locked unit. There was a strong urine odor near room [ROOM NUMBER].
On 8/10/24 at 2:00 PM, an observation was made of the 300 hall at the facility. There was a strong urine odor in the 300 hallway near room [ROOM NUMBER].
On 8/11/24 at 8:55 AM, an observation was made of the central nurses station at the facility. There was noted to be a strong urine odor.
On 8/11/24 at 10:04 AM, an observation was made of the 200 hall at the facility. There was noted to be a strong urine odor in the hallway near the entrance to room [ROOM NUMBER].
On 8/12/24 at 10:22 AM, an observation was made of the 300 hall at the facility. There was noted to be a strong urine odor throughout the hallway.
On 8/13/24 at 8:10 AM, an observation was made of the main lobby. There was noted to be a strong odor of urine.
On 8/13/24 at 11:35 AM, an observation was made of a strong urine odor in the solarium.
On 8/14/24 at 7:36 AM, an observation was made of the 200 hall at the facility. There was noted to be a strong urine odor throughout the hallway.
On 8/14/24 at 11:30 AM, an observation was made of the 100 hall locked unit. There was a strong urine odor when entering the 100 hallway.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to designate a registered nurse to serve as the Director of Nursing (DON) on a full-time basis. Specifically, the DON did not work 40 hours a ...
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Based on interview and record review, the facility failed to designate a registered nurse to serve as the Director of Nursing (DON) on a full-time basis. Specifically, the DON did not work 40 hours a week.
Findings included:
On 7/31/24 at 7:20 AM, an interview was conducted with the DON. The DON stated she worked 12 hours on Mondays, Wednesdays, and Fridays. The DON stated she was assigned to resident care on her shifts.
On 7/31/24 at 2:54 PM, an interview was conducted with the Administrator (ADM). The ADM stated the DON worked a 12 hour shift on Mondays, Tuesdays, and Wednesdays.
The Nurse's July 2024 schedule indicated, DON Registered Nurse (RN) was scheduled as follows: D [day shift] Monday, July 1; D Wednesday, July 3; N [night shift] Sunday, July 7; D Monday, July 8; 0.5 [half shift] Tuesday, July 9; D Thursday, July 11; * [not available] Friday, July 12; * Saturday, July 13; * Sunday, July 14; D Monday, July 15; D Tuesday, July 16; D Wednesday, July 17; D Friday, July 19; D Monday, July 22; D Wednesday, July 24; D Friday, July 26; D Monday, July 29; and D Wednesday, July 31.
On 8/5/24 at 2:10 PM, a telephone interview was conducted with RN 5. RN 5 stated that she would like to see the DON work full time. RN 5 stated that the DON was always scheduled to work the floor when she was on shift, and that a DON and a shift nurse are two different things. RN 5 stated that she did not communicate with the current DON unless it was the DON who had worked with a specific resident.
On 8/7/24 at 9:55 AM, an interview was conducted with the DON. The DON stated that a D on the nurse's schedule indicated the staff member worked the day shift, an N indicated the staff member worked the night shift, a 0.5 on the nurse's schedule indicated the staff was available for part of a shift to pass medications or work half of the day, and an asterisk on the nurse's schedule meant the staff member was not available to work.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the ...
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Based on observation, interview, and record review, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the low temperature dish washing machine did not reach a minimum temperature of 120 degrees Fahrenheit, a whole ham was stored above premade peanut butter and jelly sandwiches, bagged fruit, and strawberry dessert cups in the walk in refrigerator, there were onions stored on the floor of the walk in refrigerator, yogurt cups were not stored on ice on a snack cart located in a hallway, and meals were stored uncovered at the central nurse's station.
Findings included:
On 7/28/24 at 8:52 AM, an initial observation was made of the facility kitchen. The dish machine was noted to be a low temperature dish machine. The dish machine temperature log for the month of July 2024 was reviewed. It was noted that none of the logged temperatures were at or above 120 degrees Fahrenheit.
On 7/30/24 at 11:49 AM, an observation was made of the kitchen walk in refrigerator. There was noted to be a box of Buffetmaster ham and water product stored on the top shelf of the walk in refrigerator. The Buffetmaster was stored above pre-made peanut butter and jelly sandwiches, strawberry dessert cups, and bagged fruit. There was also noted to be a bag of onions stored on the floor of the walk in refrigerator.
On 7/30/24 at 2:02 PM, the Dietary Manager (DM) ran the dish machine for a cycle while the surveyor was present. The dish machine did not reach higher than 100 degrees Fahrenheit during the wash or rinse cycle. It should be noted that the dish machine had been running for several cycles prior to being observed.
On 8/7/24 at 8:17 AM, an observation was made of the central nurse's station. There were noted to be three uncovered breakfast meal trays sitting on the counter of the station.
On 7/30/24 at 1:52 PM, an interview was conducted with the DM. The DM stated that the dish machine should reach 140 degrees Fahrenheit. The DM stated that meat should not be stored above other foods in the walk-in refrigerator.
On 8/9/24 at 8:00 PM, an observation was made of a service cart in the hallway across from the dining area. The cart had pre-made sandwiches, two yogurt cups, snacks, and a pitcher of ice water on the top shelf. The second shelf of the cart had a cooler that contained ice. The yogurt cups were not stored on ice to keep them cool. The sandwiches appeared to be mostly peanut butter and jelly. Some sandwiches had resident names on them. A Mighty Shake was observed to be in a container on the nurses medication cart. There was no ice to keep the shake cool.
On 8/9/24 at 9:25 PM, an observation was made of Certified Nursing Assistant (CNA) 4 who exited the secure unit to obtain snacks for some of the residents on the unit. He obtained several sandwiches and snack items and returned to the secure unit.
On 8/10/24 at 2:15 AM, an observation was made of the service cart in the hallway across from the dining area. The two yogurts were still sitting on the cart and had not been chilled, and the Mighty Shake remained on the nurse cart in the container with no ice to chill the shake.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. On 7/31/24 at 7:23 AM, an interview was conducted with the DON. The DON stated that she could not locate her infection contro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. On 7/31/24 at 7:23 AM, an interview was conducted with the DON. The DON stated that she could not locate her infection control binder, but would look for the binder and bring it to the State surveyor. The DON stated that she was not currently tracking or trending infections in the facility. The DON stated that she did not have the policy for antibiotic stewardship. The DON stated to prevent infections from being spread, all staff should be hand sanitizing in between contact with residents and then washing their hands after they entered a resident's room.
On 8/14/24 at 12:00 PM, it should be noted that the infection control binder was never brought to the State surveyor.
3. On 7/31/24 at 12:16 PM, an interview was conducted with the DON. The DON stated the respiratory equipment was stored in her office's bathroom. The DON stated she used the bathroom facilities in which the respiratory equipment was stored. The DON further stated the medical equipment should not be stored in the bathroom. A subsequent observation was made of the DON's bathroom where there was one sink; one toilet; a metal rack with shelves; and eight large boxes, which contained medical supplies, were stacked on the floor. Boxes of suction canister lids, oxygen tubing, and oxygen extension tubing; oxygen supplies; and various medical equipment were observed on the shelves.
On 7/31/24 at 3:06 PM, an interview was conducted with the Administrator (ADM). The ADM stated he was aware of distilled water and solutions and other medical supplies were stored in the DON's bathroom. The ADM stated he was not aware that the toilet was being used and only thought staff were using the sink to wash their hands.
On 7/31/24 at 3:26 PM, an interview was conducted with RN 1. RN 1 stated she, and other staff, used the toilet in the DON's office. RN 1 stated, Anything that has to do with respiratory equipment was stored in the DON's bathroom.
4. On 7/28/24 at 11:49 AM, an observation was made of the Dietary Aide (DA) 2 during the mealtime lunch service. At 11:51 AM, DA 2 was observed to touch rolls with the same gloves and not perform hand hygiene. At 11:52 AM, DA 2 was observed to touch the middle of a plate with the same gloves and not perform hand hygiene or change gloves. At 11:57 AM, DA 2 was observed to touch the middle of a disposable foam plate with the same gloves and not perform hand hygiene.
On 7/28/24 at 12:14 PM, an observation was made of CNA 4 during the mealtime lunch service. CNA 4 was noted to wipe his forehead with a gloved hand. CNA 4 was not observed to change his gloves or wash his hands after touching his forehead.
On 7/29/24 at 7:40 AM, an observation was made of DA 1 and CNA 1 during the mealtime breakfast service. At 7:42 AM, DA 1 was observed serving the first resident and not changing gloves or performing hand hygiene. At 7:43 AM, CNA 1 was observed serving a plate of food to a resident and did not perform hand hygiene after serving the resident and touching the table. At 7:44 AM, DA 1 was observed to touch the middle of a plate with the same gloves and not perform hand hygiene. At 7:44 AM, CNA 1 was observed to serve a resident and not perform hand hygiene after touching the table. At 7:45 AM, DA 1 was observed wearing the same gloves and touched the middle of a plate and a banana. At 7:49 AM, DA 1 was observed to wear the same gloves throughout breakfast service and did not perform hand hygiene.
On 7/30/24 at 12:00 PM, an observation was made of the mealtime lunch service for residents who ate in the dining room. At 12:03 PM, CNA 3 was observed to serve a resident. After serving the resident their meal, CNA 3 did not wash or sanitize her hands. At 12:04 PM, CNA 3 was observed to serve a meal to another resident. After serving this additional resident their meal, CNA 3 did not wash or sanitize her hands. At 12:15 PM, staff finished serving meals to all of the residents in the dining room. Dietary Aide (DA) 1 was observed to return to the kitchen to grab additional food to serve to residents in their rooms. DA 1 was observed to not change her gloves or wash her hands after re-entering the kitchen from the dining room.
On 7/30/24 at 12:19 PM, an observation was made of the mealtime lunch service for residents who ate in their room. At 12:19 PM, CNA 3 was observed helping the resident in room [ROOM NUMBER] get set up to eat her meal. After assisting the resident in room [ROOM NUMBER], CNA 3 left the room, grabbed another meal tray, and took the meal tray into the resident in room [ROOM NUMBER]. CNA 3 did not wash or sanitize her hands during this series of events. At 12:20 PM, CNA 3 took a meal into room [ROOM NUMBER] and then took a meal into room [ROOM NUMBER] immediately after. CNA 3 did not wash or sanitize her hands between serving the two rooms. At 12:26 PM, CNA 3 took a meal into room [ROOM NUMBER] and then took a meal into room [ROOM NUMBER] immediately after. CNA 3 did not wash or sanitize her hands between serving the two rooms. At 12:32 PM, DA 1 was observed to place the paper meal ticket for the resident in room [ROOM NUMBER] directly into the plate of food being served. At 12:36 PM, CNA 3 was observed to enter room [ROOM NUMBER] with a plate of food. The resident in room [ROOM NUMBER] was asleep and CNA 3 left the meal at the bedside. CNA 3 covered the plate with another disposable plate, but the second plate did not fully cover the meal, leaving it open to air. At 12:38 PM, CNA 3 took a meal into room [ROOM NUMBER] without sanitizing or washing her hands prior. CNA 3 was observed to come out of room [ROOM NUMBER], grab a bread roll, and then take the roll back into room [ROOM NUMBER] without washing or sanitizing her hands. CNA 3 then took a packet of barbeque sauce to the resident in room [ROOM NUMBER] without washing or sanitizing her hands.
On 8/7/24 at 8:17 AM, an observation was made of the central nurse's station. There were noted to be three uncovered breakfast meal trays sitting on the counter of the station.
Based on observation, interview, and record review, the facility did not establish an infection prevention and control program (IPCP) designed to provide a safe, sanitary, and comfortable environment. In addition, the facility did not establish an infection prevention and control program system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases. Specifically, for 2 out of 30 sampled residents, a nurse dropped a pill on the medication cart, picked up the pill with bare hands, and administered the medication to a resident. In addition, hand hygiene was not performed when the Certified Nursing Assistants (CNA) were passing resident meal trays, medical supplies were stored in a bathroom that was in use by staff, there was no tracking and trending for the IPCP, staff were not using the appropriate personal protective equipment (PPE) for residents on Enhanced Barrier Precautions (EBP), and the licensed nurse cross contaminated during a wound care dressing change. Resident identifier: 1 and 33.
Findings included:
1. Resident 33 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, schizoaffective disorder, dementia, alcohol dependence, essential hypertension, and metabolic syndrome.
On 7/29/24 at 8:17 AM, Registered Nurse (RN) 1 was observed to prepare and administer medications to resident 33. RN 1 was observed to open the pre filled medication pouches and poured the pills into a medication cup. A pill was observed to fall onto the medication cart. RN 1 was observed to pick up the pill with bare hands, put the pill in the medication cup with the other prepared medications, and RN 1 was observed to administer the medications to resident 33. RN 1 stated that she did not know what to do when a pill was dropped on the medication cart.
On 7/29/24 at 11:53 AM, an interview was conducted with the Director of Nursing (DON). The DON stated when a medication was dropped on a surface the staff were to throw that medication away, take that medication from another packet, flag the packet, and let the pharmacy know so they could reorder that specific medication. The DON stated that every surface was considered contaminated.
2. Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, acute myocardial infarction, acute respiratory failure with hypoxia, age-related cognitive decline, type 2 diabetes mellitus, non-pressure chronic ulcer of foot, rheumatoid arthritis, acquired deformity of lower leg, muscle wasting and atrophy, dysphagia, and difficulty in walking.
On 8/13/24 at 10:52 AM, an observation of resident 1's wound care was conducted with the Assistant Director of Nursing (ADON). The ADON was observed to don clean gloves. The ADON cleansed resident 1's right foot with wound cleanser. The ADON without doffing the contaminated gloves preceded to apply skin prep to the outside of the wound, applied silver collagen gel to the bandage, and applied the bandage to resident 1's right foot. The ADON was observed to use the same set of gloves throughout the wound care and hand hygiene was not performed. The ADON stated that she was unsure when to use the EBP precautions because the EBP were a new thing the facility was doing and the facility did not have the PPE carts yet.
Resident 1's room was observed to have an ENHANCED BARRIER PRECAUTIONS stop sign on the outside of the door. The sign documented EVERYONE MUST: Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound Care: any skin opening requiring a dressing.
On 8/13/24 at 11:24 AM, an interview was conducted with CNA 3. CNA 3 stated that she kind of had been trained on EBP. CNA 3 stated that she knew what the sign was but there were no carts available with PPE. CNA 3 stated that she would just put gloves on. CNA 3 stated that the facility did not communicate with her and she did not know why the residents were on precautions. CNA 3 stated that she knew where the gloves and masks were but she did not know where the gowns were stored. CNA 3 stated she thought the gowns were in the locked CNA closet but she did not have a key to the closet.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected most or all residents
Based on interview, the facility did not ensure that the designated Infection Preventionist (IP) who was responsible for the facility's infection prevention and control program had completed specializ...
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Based on interview, the facility did not ensure that the designated Infection Preventionist (IP) who was responsible for the facility's infection prevention and control program had completed specialized training in infection prevention and control. Specifically, the Director of Nursing (DON) who was the designated IP had not completed the specialized training in infection prevention and control.
Findings included:
On 7/29/24 at 10:47 AM, an interview was conducted with the DON. The DON stated that she was the designated IP for the facility and she had completed the specialized training for the IP certification. The DON stated she took the training and was supposed to take the test. The DON stated she had until November 2024 to take the test. The DON stated she thought she did the training in May 2024. The DON stated regarding infection control she had been so busy. The DON stated she learned about the enhanced barrier precautions, multidrug resistant organisms, and how she could do charts. The DON stated she was still working on those things to get them in place. The DON stated they sent her a form to see where she was at with the infection control and to see what strategies she was using. The DON stated she thought they was the State. The DON stated she did not have the programs in place in the computer for infection control. The DON stated she did not have it all in order to function as a health care facility.
The DON was unable to provide documentation that she had attended or completed specialized training in infection prevention and control.
On 7/31/24 at 3:15 PM, a follow up interview was conducted with the DON. The DON stated that she had been informed during the previous survey in October 2022 that she needed to obtain her IP certification. The DON stated that she did not start the training until January of 2024, but had since completed the training. The DON stated she had not yet taken the test to become a certified IP. When asked why the DON waited from October 2022 until January 2024 to start her IP certification training, the DON stated, probably because I had other things going on.
Oct 2022
49 deficiencies
4 IJ (3 affecting multiple)
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 9 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, paranoid schizophr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 9 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, paranoid schizophrenia, cognitive communication deficit, type 2 diabetes mellitus, low back pain, essential hypertension, epilepsy, and hyperlipidemia.
A review of resident 9's electronic medical record was conducted.
Resident 9's MDS from 7/10/22 reported that physical behavioral symptoms directed towards others was not exhibited.
Resident 9's care plan updated on 7/31/22 did not have a focus area related to physical aggression towards other residents.
A form titled Behavioral Care Plan from 5/13/22 was found in resident 9's paper chart. The documented stated that the problem was Aggressive Behavior with Physically combative with resident, Verbally aggressive with resident, and Anxiety circled on the document. The interventions circled on the document included, Medication as ordered, Redirect and reorient as needed/able, Documentation (incident reports if indicated), Report injuries to Administration within 24 hours, Set firm limits and o (sic) not allow behavior that is abusive to others. The following interventions were handwritten in; Redirect resident when beh. (behavior) occurs, De-esclate (sic) and calm situation, Educate appropriate response to anger, Redirect resident, Remove/separate residents, Notify [mental health provider information redacted]/LCSW (Licensed Clinical Social Worker)/case mgnt (management), Increase monitoring, Sent to ER (emergency room) for eval (evaluation), [mental health provider], LCSW in to see resident.
A review of medical records and incident reports revealed three physical altercations involving resident 9. The following were reviewed:
a. Resident 14 was initially admitted to the facility on [DATE] and again on 10/13/22 with diagnoses which include metabolic encephalopathy, Wernicke's encephalopathy, cellulitis, osteoarthritis, dementia, psychosis, chronic pain, and insomnia.
A review of an Initial Entity Report which was submitted to the State Survey Agency on 5/23/22 at 7:14 PM revealed that on 5/17/22 at 9:30 PM, [Resident 14] was sitting on the couch in the hallway. [Resident 9] walked by and he said that [resident 14] called him a name so he punched him in the eye. The actions taken was reported as Residents were separated. Increased monitoring.
It should be noted that the Initial Entity Report was not submitted for 5 days.
The summary of investigation, which was dated 5/23/22, stated, Resident to resident altercation. Aggressor: [Resident 9] . It was later in the evening at 21:30 [9:30 PM] and [resident 9] was coming back in from smoking. He says that [resident 14] called him a bad name, so he hit him in the face .[Resident 14] was sitting on the couch in the hallway and when [resident 9] came back in from smoking, they exchanged some words. [Resident 9] hit him in the face resulting in a black eye. Staff intervened, assessed client, and residents were separated to their own rooms. There were no further interactions that night .Nurses have spoken with [Resident 9] -he is not allowed to hit other people even when he gets frustrated. He understands that he needs to speak to the nurse when he is frustrated .
There were no progress notes in resident 14's medical record related to the incident on 5/17/22. However, on 5/18/22, a progress note revealed that resident 14 had a bruised eye.
A progress note from resident 14's medical record dated 5/18/22 at 5:18 PM written by the Director of Nursing (DON) stated, Resident has a small redness/purple area to r [right] eye. Does not remember what happened. I asked if he fell and he reports he does not know.
There were no progress notes in resident 9's medical record related to the incident on 5/17/22.
b. Resident 39 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which include atherosclerotic heart disease, peripheral vascular disease, vascular dementia, history of falling, unsteadiness on feet, essential hypertension, type 2 diabetes mellitus, schizoaffective disorder, post-traumatic stress disorder, and insomnia.
Resident 15 was admitted to the facility on [DATE] with diagnoses which include hearing loss, chronic kidney disease, essential hypertension, insomnia, hyperparathyroidism, anxiety disorder, and Alzheimer's disease.
A review of an Initial Entity Report which was submitted to the State Survey Agency on 5/25/22 at 6:29 PM revealed that, on 5/23/22 at 11:30 AM, there was a physical altercation between resident 9, resident 39, and resident 15. The report stated, All 3 clients live on the secure dementia unit. [Resident 15] was laying down sleeping on the couch. [Resident 9] and [Resident 39] came up to her to sit there also. [Resident 39] pulled [Resident 15]'s leg to have her sit up. [Resident 15] kicked [resident 39] with the foot she was pulling on. This mad[e] [resident 9] angry and he kicked [resident 15]. Then [Resident 39] climbed on the couch to hit [resident 15]. [Resident 15] got up and left.
It should be noted that the Initial Entity Report was not submitted until two days after the incident.
A summary of the investigation, written by the Administrator, dated 6/3/22 stated, Resident to Resident to Resident Altercation. [Resident 15] (a lady that is hard of hearing) was lying on the couch in the hallway sleeping. When [Resident 39] and [Resident 9] came up to her and wanted to sit on the couch. [Resident 39] started pulling on [resident 15]'s foot, which startled [resident 15] and she kicked [resident 39] to make her release the foot. This made [resident 9] angry that [resident 15] kicked his friend. [Resident 9] tried to kick [resident 15], which made his slipper come off. [Resident 39] then climbed on the couch at [resident 15]'s feet to slap her in the face. [Resident 15] got up and left. Nurse checked everyone involved for any injuries. No injuries were found. Residents were all separated to different areas. [Resident 9] had a prior issue.Licensed Clinical Social Worker has been working with him. They are reviewing his case in med (medication) management meeting .
It should be noted that the investigation was submitted four days after the incident.
Resident 9's progress notes were reviewed.
On 5/25/22 at 12:05 PM a Social Services Note stated, LCSW from [Provider name redacted] came in to visit with client. She talked to him about appropriate interactions. He said he wants more ice water.
On 5/25/22 at 4:02 PM a Heath Status Note stated, Resident tolerated new med order Zyprexa and no increased aggression noted, this will be 3rd day on Zyprexa. Resident has some controlling issues which have not improved at this time. Will continue to monitor behaviors to see if Zyprexa will help him manage his aggression for his safety as well as others.
Resident 39 and resident 15 did not have any progress notes in their Electronic Medical Records regarding the incident on 5/23/22.
c. On 10/15/22 at 9:26 PM, the facility reported to the State Survey Agency that on 10/15/22 at 5:40 PM, resident 9 and resident 15 got into a verbal altercation that led to resident 15 hitting resident 9 on the shoulder, and resident 9 striking resident 15 on the face. The residents were separated and assessed. The residents did not have any injuries.
The summary of the investigation was submitted on 10/20/22 to the State Survey Agency revealed, Both were in the hallway on (sic) when a CNA passed out and hit the floor. [Resident 15] was yelling for help and getting residents out of the aides way. She speaks loudly because of her hearing loss. [Resident 9] started yelling back at [resident 15]. [Resident 15] hit him in the shoulder. [Resident 9] hit [resident 15] back in the face. The nurse came, helped the aide to get up. Everyone dispersed and separated and went their separate ways. Nurse assessed both residents to signs of any injury. Families for both residents were notified of altercation. MD also notified.
On 10/17/22 at 11:13 AM, an interview with CNA 1 was conducted. CNA 1 stated she knew that resident 9 was verbally aggressive. CNA 1 stated that she did not know of any time resident 9 was physically aggressive with another resident.
On 10/13/22 at 11:56 AM, an interview with Licensed Practical Nurse (LPN) 1 was conducted. LPN 1 stated that he was aware of resident 9 being verbally aggressive towards staff and residents. LPN 1 stated he did not know if resident 9 has been physically aggressive towards other residents.
On 10/18/22 at 12:15 PM, an interview with RN 3 was conducted. RN 3 stated that the only physical altercation involving resident 9 that she was aware of was the incident on 10/15/22 when resident 9 and resident 15 hit each other. RN 3 stated that when physical altercations occur, their intervention was to pass on the information to the next shift to help keep the residents separated.
On 10/24/22 at 4:56 PM, an interview with resident 9 was conducted. Resident 9 recalled the incident on 10/15/22. Resident 9 stated that a CNA got dizzy and sat on the floor. Resident 9 stated resident 15 was in the way of someone trying to help the CNA up. Resident 9 asked resident 15 to move and resident 15 hit resident 9 on hit back and his shoulder. Resident 9 stated that he hit resident 15 back on the head. Resident 9 stated that he did not hurt resident 15, and that hitting her was more of a reaction from being hit.
The facility Policy and Procedure for Prohibiting Abuse with no date revealed the following:
Facility policy: It is the policy of this facility to prohibit any abuse of its residents regardless of source. This facility seeks to promote the well-being of its residents by providing a safe and supportive environment. Every resident had the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion.
Definition of abuse
Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This also includes the deprivation by an individual including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being.
Verbal abuse: .
Sexual abuse: Including but not limited to sexual harassment, sexual coercion or sexual assault.
Physical abuse: Hitting, slapping, pinching, kicking, or controlling through corporal
punishment.
Screening of potential residents
All potential residents will be screened to determine if there is a prior pattern of abusive behavior including but not limited to sexual or physical aggression.
If the facility determines that it can adequately meet needs of a potential resident who has an abusive history without negatively impacting its current residents, prior to admission the interdisciplinary team with the involvement of appropriate professionals will develop a care plan with behavioral approaches designed to prevent the potential resident from engaging in any abusive behavior.
Prevention of abuse
This facility seeks to prevent abuse from staff by careful screening prior to hire.
Initial orientation for new hires and continuing education for staff will occur at least twice a year will include topics such as identification and reporting of abuse, dealing with stressful situations and managing behavioral challenges.
Inservice includes training on restriction on policy prohibiting photography/recordings of clients and their personal living space.
Residents with challenging behaviors will be reviewed periodically at the interdisciplinary team meetings and the mood/behavior/psychotropic meeting. Referrals will be made to appropriate professionals when the facility deems it necessary.
Residents will be educated at least twice a year at Resident council meetings of their right to be free from abuse.
Posters regarding reporting of abuse will be prominently displayed.
The facility will periodically analyze the physical environment and evaluate staffing to ensure sufficient numbers of adequately trained staff, monitor staff for potentially
inappropriate behaviors and evaluate the care planning process to ensure adequate
monitoring of resident at risk for potential behavioral challenges.
Facility will conduct periodic evaluations of the environment and staffing patterns to ensure that the needs of the residents are being met and that staff has adequate
knowledge to meet their care needs.
Identification of perpetrators and potential victims
At least one in-service per year will train staff to identify potential signs and symptoms of abuse including behavior changes and injuries of unknown origin.
Each new resident will undergo a risk assessment completed by nursing and/or social services in order to determine if the resident is at high risk for mood, behavior or
psychosocial problems.
If a resident is determined to be at risk, the interdisciplinary team will initiate
appropriate monitoring and behavioral approaches using the care plan process.
Protection of high risk residents
Following an allegation of abuse, the facility will immediately implement increased
monitoring of any residents deemed to be at risk for further abuse. If the alleged perpetrator is a resident, the interdisciplinary team will convene as soon as feasible to review current plan of care and make any necessary revisions in order to ensure the safety of others.
Based on observations, interviews and record review, it was determined for 8 of 33 sampled residents, that the facility failed to protect the resident's right to be free from physical abuse and sexual abuse by other residents. Specifically, one resident with severe cognitive impairment was sexually abused by a resident that was congitively intact. This identified deficient practice was found to have occurred at the Immediate Jeopardy (IJ) Level. Additionally, incidents of physical abuse between residents and a bruise with an unknown origin were identified at a potiential for harm level. Resident identifiers: 7, 9, 14, 15, 26, 31, 36 and 39.
Findings include:
On 10/17/22 at 4:30 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to prevent various forms of abuse. Notice of the IJ was given verbally to the facility Administrator (ADM).
On 11/10/22 at 11:56 AM, the facility Consultant Group provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 11/10/22 at 12:00 PM:
1. Resident #26 was placed on a neighborhood that has only male residents and placed on 1:1 supervision on 10/17/22 and remains on 1:1. The community is looking at alternative placement for resident #26. The Medical Director will review medications for resident #26. Resident #31no longer resides in the community; therefore, no individualized plan of correction is indicated. Resident #31 discharged to another community on 11/4/2022. Resident #26 was assessed on 11/1/22 for capacity to consent to sexual intimacy by the LCSW (Licensed Clinical Social Worker).
2. Residents residing in the memory care neighborhood were assessed for signs and symptoms of abuse by an LCSW on 11/1/22. For residents who are unable to be interviewed due to dementia, observation tools are being completed to identify any changes in mood or behavior that may be indicative of signs of past abuse.
3. The community has hired a Nursing Home Administrator (NHA) and an Administrator in Training (AIT). The new NHA will be responsible to investigate and report any allegation of abuse. The community also has contracted with a RN (Registered Nurse) nurse manager to assist with implementation of clinical/behavioral policies and procedures and survey corrective actions. This RN will be on site in the community on 11/9/2022. This RN will be on site minimally for three days a week.
The community will initiate Guardian Angel rounds. The IDT (Interdisciplinary Team) team will be responsible to meet with their assigned residents weekly to ensure care needs are met and that they feel safe in their
environment and are free of any type of abuse. Residents who are non interviewable will continue to be assessed for any changes from baseline and reported to NHA or designee for additional review and follow up.
Education was initiated on 11/1/2022 regarding the community abuse policy including reporting allegations of abuse to the abuse prevention coordinator, reporting allegations of abuse to the proper authorities, and conducting thorough investigations. Thorough investigations to include immediate protection of the residents, interviewing the alleged victim, alleged assailant, any witnesses, other residents who could potentially be affected by the alleged violation, family/visitors if there are any who may have pertinent information, conducting an assessment of the alleged victim, conducting observations of cares if pertinent, conducting searches if necessary, and implementing pertinent interventions to attempt to prevent recurrence.
Progress notes to be reviewed (M-F) by the DON(Director of Nursing)/designee daily to ensure that any allegations of abuse are being reported per community expectations to management and to the appropriate
authorities, and that allegations of abuse are thoroughly investigated. Identified concerns to be addressed immediately and investigations initiated. Additionally, the community has initiated daily morning huddles (M-F) (Monday through Friday) to discuss any changes in resident behaviors, any type of risk management concerns. The IDT team as well as nursing staff and dietary manager will participate in this morning huddle.
NHA/designee will be responsible for contacting the appropriate authorities for allegations of abuse. Each allegation will be discussed verbally with the consultants and the consultants will have access to the report to ensure they are submitted timely to the health department.
The Temporary Managers will provide the community with a new daily standup meeting agenda. This agenda will include an abuse reporting log to track and trend all reported allegations for the month. The community also initiated afternoon stand down meetings (Monday through Friday) to ensure follow up items from the morning meeting were completed.
NHA/designee to complete review of three (3) abuse allegations a week for three (3) months to
ensure that the investigation was thorough, that there were interventions implemented to correct
the alleged violations, and that there was protection of the alleged victim while the investigation
was ongoing.
4. The NHA/designee will report findings from the audits to the QAPI (Quality Assurance Performance Improvement) Committee monthly for three (3) months. The QAPI committee will identify any trends and take corrective action as needed.
5. Please accept this abatement plan of corrective action - effective 11/10/2022 at 12PM.
On 11/14/22, after the completion of the survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 11/10/22.
Immediate Jeopardy:
1. Resident 31 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, unspecified dementia with behavioral disturbance, and depression.
Resident 31's medical record was reviewed.
An annual Minimum Data Set (MDS) dated [DATE] revealed resident 31 did not have a Brief Interview for Mental Status (BIMS) because she rarely/never understood. The MDS further revealed resident 31 had short and long term memory problems. The MDS revealed her cognitive skills for daily decision making were severely impaired. The MDS revealed resident 31 required extensive one person assistance with dressing.
Resident 31's care plan dated 3/27/17 revealed The resident has a behavior problem of wearing multiple layers of clothing and resisting to change or remove the clothing. The goal with a target date of 5/27/22 was The resident will have fewer episodes of wearing multiple layers of clothing weekly, by review date. Interventions included Assist the resident to develop more appropriate methods of coping and interacting. Encourage the resident to express feelings appropriately; Explain all procedures to the resident before starting and allow the resident 5-10 (minutes) to adjust to changes; If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Praise any indication of The resident's progress/improvement in behavior.
Another care plan for resident 31 dated 8/25/16 revealed, The resident has a behavior problem of wearing multiple layers of clothing and resisting to change or remove the clothing The goal with a target date of 5/27/22 revealed, The resident will have fewer episodes of wearing multiple layers of clothing weekly, by review date. Interventions were Assist the resident to develop more appropriate methods of coping and interacting; Encourage the resident to express feelings appropriately; Explain all procedures to the resident before starting and allow the resident 5-10 (minutes) to adjust to changes; If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Praise any indication of The resident's progress/improvement in behavior.
Resident 26 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, diabetes mellitus, and hypertension.
Resident 26's medical record was reviewed.
Resident 26's quarterly MDS dated [DATE] revealed a BIMS score of 5 which indicated severe cognitive impairment. The MDS further revealed resident 26 walked in corridor, walked in room, locomotion on the unit and locomotion off the unit required supervision and setup help only.
Resident 26's care plan 8/3/21 revealed The resident has a behavior problem r/t (related to) Schizophrenia. The goal was The resident will have no evidence/decrease of behavior problems by review date. Interventions developed were Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by; If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes.
On 8/29/21, resident 26 was found in a room with resident 31 by a surveyor during a recertification survey. Resident 26 had his penis exposed while standing directly in front of resident 31. Resident 31 had her back to the wall. This incident was cited as part of the annual recertification survey.
There were no progress notes in resident 26's or resident 31's medical record regarding the incident on 8/29/21.
A nursing progress note dated 9/4/21 at 10:41 PM revealed, resident 26 was observed touching staff and other residents without consent.
On 9/17/21, the facility reported to the state survey agency that resident 31 had been found naked with resident 26 in a room in the locked unit.
A nursing progress note by Licensed Practical Nurse (LPN) 1 in resident 31's medical record revealed on 9/17/21 at 3:24 PM, Resident was found in room [ROOM NUMBER] on the bed naked with another resident (male). CNA informed me and RN and we directed male resident back to his room and resident was assessed by RN and CNA then re-dressed while I informed the Administrator at 0645 (6:45 AM), which he addressed the occurrence to proper authorities. Resident was transported to [local hospital] ER (emergency room) to be assessed. Resident returned with order for doxycyline 100 mg one PO (by mouth) BID (twice daily) x 7 days.Incident report completed.
A nursing progress note by the DON dated 9/17/21 revealed that a physician's order was received to transfer resident 26 to the emergency room for possible transfer to a mental health facility. At 4:21 PM, resident 26 was transported to a local emergency room (ER) for mental health evaluation.
A nursing progress note by LPN 1 in resident 26's medical record revealed on 9/17/21 at 2:59 PM, Resident was found by CNA in room [ROOM NUMBER] with another resident (Female) naked on the bed at 0645 (6:45 AM). CNA informed Me (Nurse) and Charge nurse and we directed resident to his room and informed him to stay in his room until one of us (Nursing staff) comes back. RN and CNA assessed the female resident and re-dressed her and remained with her. I Phoned Facility Administrator at time of incident and informed him of the incident. Administrator stated he will advise and report to proper authorities, I informed Administrator both individuals were separated and one on one staff until further notice.
A nursing progress note dated 9/18/21 at 10:04 PM revealed, resident 26 was moved to a room outside of the locked unit. The note further revealed resident 26 frequently wandered into the rooms of female resident and was sexually inappropriate with residents and staff. Staff were to continue to monitor resident 26.
A nursing progress note dated 9/25/21 at 11:06 PM revealed resident 26 had been sexually inappropriate with the female staff.
Resident 26's Medication Administration Record indicated that staff were to monitor resident 26 for sexually inappropriate behaviors as of 9/25/21. Resident 26 was also started on Risperdol as of 9/26/21.
A physician's progress note for resident 31 dated 10/18/21 at 12:54 PM, .On 9/17 she was found naked with a male resident on top of her. She was transported to the ER where evaluation did not reveal signs of physical trauma.
A nursing progress note dated 12/4/21 at 10:18 PM revealed resident 26 was occasionally sexually inappropriate.
A nursing progress note dated 1/2/22 at 1:29 AM revealed resident 26 had allegedly not harmed anyone.
A nursing progress note dated 7/10/22 at 2:18 AM revealed resident 26 was discovered missing about 7:30 PM. Staff checked every room and the outside around the entire building. Police, Administrator and physician were notified.
A nursing progress note dated 7/10/22 at 1:22 PM revealed police returned resident 26 at approximately 10:30 AM and a physician's order was obtained to change room to memory lane, despite his history of sexually abusing resident 31, who still resided on the memory care unit. The progress note indicated that resident 26 was happy to see his old roommate.
Resident 26's monthly nurses assessments for the months of September 2021, October 2021, November 2021, December 2021, January 2022, April 2022, June 2022, and July 2022 documented that resident 26 had sexual behaviors but did not indicate what the behaviors were. [It should be noted that the monthly assessments for February 2022, March 2022, May 2022, August 2022, and September 2022 were not able to be located in resident 26's medical record.]
A nursing medication administration note dated 8/28/22 at 1:32 PM, revealed resident 26 was seen by other resident pulling a female resident into his bathroom. he noticed he was caught and let her go.
An entity report dated 8/29/22 revealed that on 8/26/22 resident 31 and resident 26 lived on the secured unit in the nursing facility. Resident 31 was often found pacing. She wanders in and out of any room and often climbed into bed when she is tired. She also immediately takes off her brief when they are wet. It is believed that she climbed into his bed. He often sleeps with just a T-shirt or naked. While CNAs were doing rounds they found them both in bed with no briefs on. The RN did checks and found no evidence of any encounter. Residents were sent to their own rooms. [Resident 26] is a client of [local mental health company] the provider is looking at adjusting medications and increased visits from case manager and LCSW.
Resident 26 and 31's nursing progress notes were reviewed and there were no notes in either of the residents medical records regarding this event.
Review of resident 26's care plan indicated that no interventions had been put into place to prevent further incidents with resident 31 after the incident on 8/26/22.
A nursing progress note regarding resident 26 dated 9/4/22 at 12:16 AM revealed, has been doing about the same. We have to watch him so he doesn't coax one of the ladies into his room.
On 10/1/22, resident 26 was documented as demonstrating inappropriate behavior, such as making inappropriate comments to this nurse. Resident says 'I need you tonight' 'I love women and trying to kiss on the hand. Resident was reminded of appropriate communication and that these comments are unacceptable. Resident verbalized understanding 'okay okay '.
Review of resident 26's September and October 2022 TAR indicated that staff had not been consistently documenting resident 26's sexual behaviors.
An incident/accident report dated 10/5/22 at 2:15 PM, revealed resident 31 was walking through the hallway without her clothes on, CNA found resident's clothes in closet of room # 104 ? at 2:15 PM. No injuries. [It should be noted the 104 was written over another room number that was unreadable.] The additional comments and/or steps taken to prevent reoccurrence were clothes to be ordered; to remind staff that designated CNA needs to be on the unit at ALL TIMES; and ensure staff on unit. The incident report was not signed by the Medical Director or Administrator until 10/17/22 when it was reviewed.
A nursing progress note dated 10/5/22 at 3:48 PM by LPN 1 revealed, Resident (31) walking down hall on memory unit without her clothes on and other residents saw her naked. CNA's assisted resident to cloth (sic) her. CNA found resident's clothes in closet of room [ROOM NUMBER]. Resident's granddaughter witnessed the incident, and she is CNA here today this shift. I counseled the designated CNA working on memory unit and wrote action taken form and DON present during this write up. Copy of write up given to Admin '[name removed]'. NP (Nurse Practitioner) informed as well as family.
On 10/12/22, both residents were observed to residing on the memory care unit that was the locked unit of the facility. Resident 26[TRUNCATED]
CRITICAL
(K)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Report Alleged Abuse
(Tag F0609)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident 9 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, paranoid schizophr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident 9 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, paranoid schizophrenia, cognitive communication deficit, type 2 diabetes mellitus, low back pain, essential hypertension, epilepsy, and hyperlipidemia.
A review of resident 9's electronic medical record was conducted.
Resident 9's MDS from 7/10/22 reported that physical behavioral symptoms directed towards others was not exhibited.
Resident 9's care plan updated on 7/31/22 did not have a focus area related to physical aggression towards other residents.
A form titled Behavioral Care Plan from 5/13/22 was found in resident 9's paper chart. The documented stated that the problem was Aggressive Behavior with Physically combative with resident, Verbally aggressive with resident, and Anxiety circled on the document. The interventions circled on the document included, Medication as ordered, Redirect and reorient as needed/able, Documentation (incident reports if indicated), Report injuries to Administration within 24 hours, Set firm limits and o (sic) not allow behavior that is abusive to others. The following interventions were handwritten in; Redirect resident when beh. (behavior) occurs, De-esclate (sic) and calm situation, Educate appropriate response to anger, Redirect resident, Remove/separate residents, Notify [mental health provider information redacted]/LCSW (Licensed Clinical Social Worker)/case mgnt (management), Increase monitoring, Sent to ER (emergency room) for eval (evaluation), [mental health provider], LCSW in to see resident.
A review of medical records and incident reports revealed three physical altercations involving resident 9. The following were reviewed:
a. Resident 14 was initially admitted to the facility on [DATE] and again on 10/13/22 with diagnoses which include metabolic encephalopathy, Wernicke's encephalopathy, cellulitis, osteoarthritis, dementia, psychosis, chronic pain, and insomnia.
A review of an Initial Entity Report which was submitted to the State Survey Agency on 5/23/22 at 7:14 PM revealed that on 5/17/22 at 9:30 PM, [Resident 14] was sitting on the couch in the hallway. [Resident 9] walked by and he said that [resident 14] called him a name so he punched him in the eye. The actions taken was reported as Residents were separated. Increased monitoring.
It should be noted that the Initial Entity Report was not submitted for 5 days.
The summary of investigation, which was dated 5/23/22, stated, Resident to resident altercation. Aggressor: [Resident 9] . It was later in the evening at 21:30 [9:30 PM] and [resident 9] was coming back in from smoking. He says that [resident 14] called him a bad name, so he hit him in the face .[Resident 14] was sitting on the couch in the hallway and when [resident 9] came back in from smoking, they exchanged some words. [Resident 9] hit him in the face resulting in a black eye. Staff intervened, assessed client, and residents were separated to their own rooms. There were no further interactions that night .Nurses have spoken with [Resident 9] -he is not allowed to hit other people even when he gets frustrated. He understands that he needs to speak to the nurse when he is frustrated .
There were no progress notes in resident 14's medical record related to the incident on 5/17/22. However, on 5/18/22, a progress note revealed that resident 14 had a bruised eye.
A progress note from resident 14's medical record dated 5/18/22 at 5:18 PM written by the Director of Nursing (DON) stated, Resident has a small redness/purple area to r [right] eye. Does not remember what happened. I asked if he fell and he reports he does not know.
There were no progress notes in resident 9's medical record related to the incident on 5/17/22.
b. Resident 39 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which include atherosclerotic heart disease, peripheral vascular disease, vascular dementia, history of falling, unsteadiness on feet, essential hypertension, type 2 diabetes mellitus, schizoaffective disorder, post-traumatic stress disorder, and insomnia.
Resident 15 was admitted to the facility on [DATE] with diagnoses which include hearing loss, chronic kidney disease, essential hypertension, insomnia, hyperparathyroidism, anxiety disorder, and Alzheimer's disease.
A review of an Initial Entity Report which was submitted to the State Survey Agency on 5/25/22 at 6:29 PM revealed that, on 5/23/22 at 11:30 AM, there was a physical altercation between resident 9, resident 39, and resident 15. The report stated, All 3 clients live on the secure dementia unit. [Resident 15] was laying down sleeping on the couch. [Resident 9] and [Resident 39] came up to her to sit there also. [Resident 39] pulled [Resident 15]'s leg to have her sit up. [Resident 15] kicked [resident 39] with the foot she was pulling on. This mad[e] [resident 9] angry and he kicked [resident 15]. Then [Resident 39] climbed on the couch to hit [resident 15]. [Resident 15] got up and left.
It should be noted that the Initial Entity Report was not submitted until two days after the incident.
A summary of the investigation, written by the Administrator, dated 6/3/22 stated, Resident to Resident to Resident Altercation. [Resident 15] (a lady that is hard of hearing) was lying on the couch in the hallway sleeping. When [Resident 39] and [Resident 9] came up to her and wanted to sit on the couch. [Resident 39] started pulling on [resident 15]'s foot, which startled [resident 15] and she kicked [resident 39] to make her release the foot. This made [resident 9] angry that [resident 15] kicked his friend. [Resident 9] tried to kick [resident 15], which made his slipper come off. [Resident 39] then climbed on the couch at [resident 15]'s feet to slap her in the face. [Resident 15] got up and left. Nurse checked everyone involved for any injuries. No injuries were found. Residents were all separated to different areas. [Resident 9] had a prior issue.Licensed Clinical Social Worker has been working with him. They are reviewing his case in med (medication) management meeting .
It should be noted that the investigation was submitted four days after the incident.
Resident 9's progress notes were reviewed.
On 5/25/22 at 12:05 PM a Social Services Note stated, LCSW from [Provider name redacted] came in to visit with client. She talked to him about appropriate interactions. He said he wants more ice water.
On 5/25/22 at 4:02 PM a Heath Status Note stated, Resident tolerated new med order Zyprexa and no increased aggression noted, this will be 3rd day on Zyprexa. Resident has some controlling issues which have not improved at this time. Will continue to monitor behaviors to see if Zyprexa will help him manage his aggression for his safety as well as others.
Resident 39 and resident 15 did not have any progress notes in their Electronic Medical Records regarding the incident on 5/23/22.
c. On 10/15/22 at 9:26 PM, the facility reported to the State Survey Agency that on 10/15/22 at 5:40 PM, resident 9 and resident 15 got into a verbal altercation that led to resident 15 hitting resident 9 on the shoulder, and resident 9 striking resident 15 on the face. The residents were separated and assessed. The residents did not have any injuries.
The summary of the investigation was submitted on 10/20/22 to the State Survey Agency revealed, Both were in the hallway on (sic) when a CNA passed out and hit the floor. [Resident 15] was yelling for help and getting residents out of the aides way. She speaks loudly because of her hearing loss. [Resident 9] started yelling back at [resident 15]. [Resident 15] hit him in the shoulder. [Resident 9] hit [resident 15] back in the face. The nurse came, helped the aide to get up. Everyone dispersed and separated and went their separate ways. Nurse assessed both residents to signs of any injury. Families for both residents were notified of altercation. MD also notified.
On 10/17/22 at 11:13 AM, an interview with CNA 1 was conducted. CNA 1 stated she knew that resident 9 was verbally aggressive. CNA 1 stated that she did not know of any time resident 9 was physically aggressive with another resident.
On 10/13/22 at 11:56 AM, an interview with Licensed Practical Nurse (LPN) 1 was conducted. LPN 1 stated that he was aware of resident 9 being verbally aggressive towards staff and residents. LPN 1 stated he did not know if resident 9 has been physically aggressive towards other residents.
On 10/18/22 at 12:15 PM, an interview with RN 3 was conducted. RN 3 stated that the only physical altercation involving resident 9 that she was aware of was the incident on 10/15/22 when resident 9 and resident 15 hit each other. RN 3 stated that when physical altercations occur, their intervention was to pass on the information to the next shift to help keep the residents separated.
On 10/24/22 at 4:56 PM, an interview with resident 9 was conducted. Resident 9 recalled the incident on 10/15/22. Resident 9 stated that a CNA got dizzy and sat on the floor. Resident 9 stated resident 15 was in the way of someone trying to help the CNA up. Resident 9 asked resident 15 to move and resident 15 hit resident 9 on hit back and his shoulder. Resident 9 stated that he hit resident 15 back on the head. Resident 9 stated that he did not hurt resident 15, and that hitting her was more of a reaction from being hit.
The facility Policy and Procedure for Prohibiting Abuse with no date revealed the following:
Facility policy: It is the policy of this facility to prohibit any abuse of its residents regardless of source. This facility seeks to promote the well-being of its residents by providing a safe and supportive environment. Every resident had the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion.
Reporting procedures pursuant to Utah Code Annotated 62A-3-302
'Any person, including, but not limited to, a social worker, physician, psychologist, nurse,
teacher, or employee of a private or public facility serving adults, who has reason to believe that any disabled or elder adult has been the subject of abuse, emotional or psychological abuse, neglect or exploitation shall immediately notify the nearest police, law enforcement agency or local office of Adult Protective Services within the division.'
'Anyone who makes that report in good faith is immune from civil liability in connection with the report.'
'When the initial report involves a resident of a long-term care facility . the local long-term care ombudsman shall immediately be notified.'
'A person who is required to report suspected abuse, emotional or psychological abuse, neglect or exploitation of a disable or elder adult . and who willfully fails to do so is guilty of a class B misdemeanor.'
Investigation and reporting procedures
1. Any person, who suspects that abuse, neglect, or misappropriation of property may
have occurred, will immediately report the alleged violation to his facility administration and/or advocacy agencies.
2. The administration will immediately notify Adult Protective Services or local law
enforcement authority and the local long-term care ombudsman. Injuries of unknown
origin, significant incidents between residents, abuse, and misappropriation of
resident ' s property must be immediately reported (during normal business hours) to
the State Survey and Certification Agency at [PHONE NUMBER], or using the online reporting process at health.utah.gov/hflcra/
3. The administration will initiate the investigation process by interviewing all staff and
residents having any knowledge of the allegation immediately.
4. The director of nursing will ensure notification of responsible parties and physician of
the alleged incident.
5. The administration will complete the investigation within the next five days and will
document all interviews include the date, time and content of the interview.
6. Following an allegation, the facility will implement increased supervision and monitoring of residents as needed to ensure that all residents are safe from any
further abuse.
7. If the complaint alleges abuse by staff that staff member will be either suspended
until the investigation has been completed or assigned to a work area where there is
no contact with residents.
8. After investigation is complete, the administration will document a summary of its
findings as to whether the alleged abuse was verified and report its findings to the
agencies which were notified at the beginning of the investigation. If the nature of the
incident required that Survey and Certification was initially notified, the results of the
investigation must be faxed to that agency at [PHONE NUMBER] attention of [name of State Survey Agency staff member], R.N.
Protection of high risk residents
Following an allegation of abuse, the facility will immediately implement increased
monitoring of any residents deemed to be at risk for further abuse. If the alleged perpetrator is a resident, the interdisciplinary team will convene as soon as feasible to review current plan of care and make any necessary revisions in order to ensure the safety of others.
Reporting of findings/Response
The facility will report the results of its findings within five working days to the required state Agencies as above as well as to the resident ' s physician and the resident or his/her legal representative. If it is determined that abuse may have occurred, the facility quality Assurance Committee will review the findings and determine if any changes in facility policies and procedures are required to prevent further potential for abuse.
Based on observation, interview and record review it was determined, for 8 of 33 sampled residents, that in response to an allegation of abuse the facility did not report immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse. In addition, the facility did not report the results of the investigation within 5 working days of the incident and if the alleged violation was verified appropriate corrective action was taken. Specifically, the facility did not report within 2 hours when a resident was found with another resident without clothing, the resident was found without clothing, and the same resident was found being touched in the genitals by another resident. Additional, the facility did not report when two residents, who were unable to consent, were found having oral sex. This was found to have occurred at an immediate jeopardy level. In addition, a bruise was discovered on a resident and it was not reported. In addition, there was physical abuse between residents that was not reported. Resident identifiers: 9, 13, 14, 15, 26, 31, 36 and 39.
Findings include:
On 10/26/22 at 9:30 AM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to prevent various forms of abuse. Notice of the IJ was given verbally to the facility Administrator (ADM).
On 11/9/22 at 8:32 AM, the facility Consultant Group provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 11/9/22 at 10:00 AM:
1. Resident #26 was placed on a unit that has only male residents and placed on 1:1 supervision on 10/17/22 and remains on 1:1. Resident #31 no longer resides in the community; therefore, no individualized plan of correction is indicated. Resident #31 discharged to another community on 11/4/2022. An investigation was initiated on 11/1/22 for the alleged incident between Resident #36 and #13. Resident #26, #31, #36 and #13 were assessed by the LCSW (Licensed Clinical Social Worker) for capacity to consent to sexual intimacy on 11/1/22.
2. Residents residing in the facility were assessed for signs and symptoms of abuse by an LCSW on 11/1/22. For residents who are unable to be interviewed due to dementia,
observation tools are being completed to identify any changes in mood or behavior that may be indicative of signs of past abuse.
3. Education was initiated on 11/1/22 by the consultants regarding the community abuse policy including reporting allegations of abuse to the abuse prevention coordinator, reporting allegations of abuse to the proper authorities, and conducting thorough investigations. Signs were posted throughout the facility on how to contact the Abuse Coordinator. The NHA/designee will be responsible for contacting the appropriate authorities for allegations of abuse. Each allegation will be discussed verbally with the consultants and the consultants will have access to the report to ensure that reports are submitted timely to the health department. Progress notes to be reviewed (M-F) by the DON/designee daily to ensure that any allegations of abuse are being reported per community expectations to management and to the appropriate authorities, and that allegations of abuse are thoroughly investigated. Identified concerns to be addressed immediately and investigations initiated. The Temporary Managers will provide the community with a new daily standup meeting agenda. This agenda will include an abuse reporting log to track and trend all reported allegations for the month. The community also initiated afternoon stand down meetings (Monday through Friday) to ensure follow up items from the morning meeting were completed.
4. The NHA/designee will report findings from the audits to the QAPI Committee monthly for three (3) months. The QAPI committee will identify any trends and take corrective action as needed.
5. Please accept this abatement plan of corrective action - effective 11/10/2022 at 12PM.
On 11/14/22, after the completion of the survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 11/10/22.
Immediate Jeopardy
1. Resident 31 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, unspecified dementia with behavioral disturbance, and depression.
Resident 31's medical record was reviewed.
An annual Minimum Data Set (MDS) dated [DATE] revealed resident 31 did not have a Brief Interview for Mental Status (BIMS) because she rarely/never understood. The MDS further revealed resident 31 had short and long term memory problems. The MDS revealed her cognitive skills for daily decision making was severely impaired. The MDS revealed resident 31 required extensive one person assistance with dressing.
Resident 31's care plan dated 3/27/17 revealed The resident has a behavior problem of
wearing multiple layers of clothing and resisting to change or remove the clothing. The goal with a target date of 5/27/22 was The resident will have fewer episodes of wearing multiple layers of clothing weekly, by review date. Interventions included Assist the resident to develop more appropriate methods of coping and interacting. Encourage the resident to express feelings appropriately; Explain all procedures to the resident before starting and allow the resident 5-10 to adjust to changes; If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Praise any indication of The resident's progress/improvement in behavior.
Another care plan for resident 31 dated 8/25/16 revealed, The resident has a behavior problem of wearing multiple layers of clothing and resisting to change or remove the clothing The goal with a target date of 5/27/22 revealed, The resident will have fewer
episodes of wearing multiple layers of clothing weekly, by review date. Interventions were Assist the resident to develop more appropriate methods of coping and interacting; Encourage the resident to express feelings appropriately; Explain all procedures to the resident before starting and allow the resident 5-10 to adjust to changes; If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Praise any indication of The resident's progress/improvement in behavior.
Resident 26 was admitted to the facility on [DATE] with diagnoses that included
schizophrenia, diabetes mellitus, and hypertension.
Resident 26's medical record was reviewed.
Resident 26's quarterly MDS dated [DATE] revealed a BIMS score of 5 which indicated severe cognitive impairment. The MDS further revealed resident 26 walked in corridor, walked in room, locomotion on the unit and locomotion off the unit required supervision and setup help only.
Resident 26's care plan 8/3/21 revealed The resident has a behavior problem r/t (related to) Schizophrenia. The goal was The resident will have no evidence/decrease of behavior problems by review date. Interventions developed were Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by; If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes.
On 8/29/21, resident 26 was found in a room with resident 31 by a surveyor during a recertification survey. Resident 26 had his penis exposed while standing directly in front of resident 31. Resident 31 had her back to the wall. This incident was cited as part of the annual recertification survey.
There were no progress notes in resident 26's or resident 31's medical record regarding the incident on 8/29/21.
A nursing progress note dated 9/4/21 at 10:41 PM revealed, resident 26 was observed touching staff and other residents without consent.
On 9/17/21 at 2:57 PM, the facility reported to the State Survey Agency that resident 31 had been found naked with resident 26 in a room in the memory care unit at 7:15 AM. It should be noted this allegation was reported over 8 hours after the incident occurred.
A nursing progress note by Licensed Practical Nurse (LPN) 1 in resident 31's medical record revealed on 9/17/21 at 3:24 PM, Resident was found in room [ROOM NUMBER] on the bed naked with another resident (male). CNA informed me and RN and we directed male resident back to his room and resident was assessed by RN and CNA then re-dressed while I informed the Administrator at 0645 (6:45 AM), which he addressed the occurrence to proper authorities. Resident was transported to [local hospital] ER (emergency room) to be assessed. Resident returned with order for doxycyline 100 mg one PO (by mouth) BID (twice daily) x 7 days.Incident report completed.
A nursing progress note by the DON dated 9/17/21 revealed that a physician's order was received to transfer resident 26 to the emergency room for possible transfer to a mental health facility. At 4:21 PM, resident was transported to emergency room (ER) for mental health evaluation.
A nursing progress note by LPN 1 in resident 26's medical record revealed on 9/17/21 at 2:59 PM, Resident was found by CNA in room [ROOM NUMBER] with another resident (Female) naked on the bed at 0645 (6:45 AM). CNA informed Me (Nurse) and Charge nurse and we directed resident to his room and informed him to stay in his room until one of us (Nursing staff) comes back. RN and CNA assessed the female resident and re-dressed her and remained with her. I Phoned Facility Administrator at time of incident and informed him of the incident. Administrator stated he will advise and report to proper authorities, I informed Administrator both individuals were separated and one on one staff until further notice.
A nursing progress note dated 9/18/21 at 10:04 PM revealed, resident 26 was moved to a room outside of the locked unit. The note further revealed resident 26 frequently wandered into the rooms of female resident and was sexually inappropriate with residents and staff. Staff were to continue to monitor resident 26.
A nursing progress note dated 9/25/21 at 11:06 PM revealed resident 26 had been sexually inappropriate with the female staff.
Resident 26's Medication Administration Record indicated that staff were to monitor resident 26 for sexually inappropriate behaviors as of 9/25/21. Resident 26 was also started on Risperdol as of 9/26/21.
A physician's progress note for resident 31 dated 10/18/21 at 12:54 PM, .On 9/17 she was found naked with a male resident on top of her. She was transported to the ER where evaluation did not reveal signs of physical trauma.
A nursing progress note dated 12/4/21 at 10:18 PM revealed resident 26 was occasionally sexually inappropriate.
A nursing progress note dated 1/2/22 at 1:29 AM revealed resident 26 had not harmed anyone.
A nursing progress note dated 7/10/22 at 2:18 AM revealed resident 26 was discovered missing about 7:30 PM. Staff checked every room and the outside around the entire building. Police, Administrator and physician were notified.
A nursing progress note dated 7/10/22 at 1:22 PM revealed police returned resident 26 at approximately 10:30 AM and a physician's order was obtained to change room to memory lane, despite his history of sexually abusing resident 31, who still resided on the memory care unit. The progress note indicated that resident 26 was happy to see his old roommate.
The facility reported resident 26's elopement on 7/11/22 at 7:41 AM. The facility reported resident 26 eloped at 12:14 AM on 7/10/22. It should be noted the elopement was not reported to the State Agency for over 31 hours.
Resident 26's monthly nurses assessments for the months of September 2021, October 2021, November 2021, December 2021, January 2022, April 2022, June 2022, and July 2022 documented that resident 26 had sexual behaviors but did not indicate what the behaviors were. [It should be noted that the monthly assessments for February 2022, March 2022, May 2022, August 2022, and September 2022 were not able to be located in resident 26's medical record.]
A nursing medication administration note dated 8/28/22 at 1:32 PM, revealed resident 26 was seen by other resident pulling a female resident into his bathroom. he noticed he was caught and let her go.
An entity report dated 8/29/22 revealed that on 8/26/22 resident 31 and resident 26 lived on the secured unit in the nursing facility. Resident 31 was often found pacing. She wanders in and out of any room and often climbed into bed when she is tired. She also immediately takes off her brief when they are wet. It is believed that she climbed into his bed. He often sleeps with just a T-shirt or naked. While CNAs were doing rounds they found them both in bed with no briefs on. The RN did checks and found no evidence of any encounter. Residents were sent to their own rooms. [Resident 26] is a client of [local mental health company] the provider is looking at adjusting medications and increased visits from case manager and LCSW.
Resident 26 and 31's nursing progress notes were reviewed and there were no notes in either of the residents medical records regarding this event.
A nursing progress note regarding resident 26 dated 9/4/22 at 12:16 AM revealed, has been doing about the same. We have to watch him so he doesn't coax one of the ladies into his room.
On 10/1/22, resident 26 was documented as demonstrating inappropriate behavior, such as making inappropriate comments to this nurse. Resident says 'I need you tonight' 'I love women and trying to kiss on the hand. Resident was reminded of appropriate communication and that these comments are unacceptable. Resident verbalized understanding 'okay okay '.
Review of resident 26's September and October 2022 Treatment Administration Record (TAR) indicated that staff had not been consistently documenting resident 26's sexual behaviors.
Review of resident 26's care plan indicated that no interventions had been put into place to prevent further incidents with resident 31 after the incident on 8/26/22.
An incident/accident report dated 10/5/22 at 2:15 PM, revealed resident 31 was walking through the hallway without her clothes on, CNA found resident's clothes in closet of room # 104 ? at 2:15 PM. No injuries. [It should be noted the 104 was written over another room number that was unreadable.] The additional comments and/or steps taken to prevent reoccurrence were clothes to be ordered; to remind staff that designated CNA needs to be on the unit at ALL TIMES; and ensure staff on unit. The incident report was not signed by the Medical Director or Administrator on 10/17/22 when it was reviewed.
A nursing progress note dated 10/5/22 at 3:48 PM by LPN 1 revealed, Resident walking down hall on memory unit without her clothes on and other residents saw her naked. CNA's assisted resident to cloth her. CNA found resident's clothes in closet of room [ROOM NUMBER]. Resident's granddaughter witnessed the incident, and she is CNA here today this shift. I counseled the designated CNA working on memory unit and wrote action taken form and DON present during this write up. Copy of write up given to Admin '[name removed]'. NP informed as well as family.
On 10/12/22, both residents were observed to resided on the memory care unit that was the locked unit of the facility. Resident 26 resided in room [ROOM NUMBER] and resident 31 resided in room [ROOM NUMBER].
On 10/12/22 an observation was made of resident 31. At 2:59 PM, resident 31 was observed to wander into the door way of room [ROOM NUMBER] and was redirected by staff. At 3:03 PM, resident 31 was wandering into room [ROOM NUMBER]. At 3:08 PM, resident 31 wandered into room [ROOM NUMBER].
On 10/11/22 at 4:10 AM, an observation was made of RN 1, CNA 6 and CNA 7 at the nurses station. The memory care unit was unattended until 4:22 AM when CNA 6 was observed to enter the unit. At 4:43 AM, CNA 6 was observed to exit the memory care unit. At 5:48 AM, CNA 6 entered the memory care unit. Resident 36 was observed to be ambulating up and down the hallway during that time. [It should be noted the memory care unit was unattended for 1 hour and 5 minutes.]
On 10/22/22 at 10:40 PM, an observation was made of CNA 6, CNA 7 and RN 5 at the nurses station. The memory care unit was unattended until 10:51 PM. Resident 36 was observed wandering the hallway. At 11:19 PM, CNA 6 was observed to leave the memory care unit. At 11:25 PM, CNA 6 was observed to return to the memory care unit. At 11:56 PM, CNA 6 and CNA 7 were observed to leave the memory care unit. At 11:57 PM, RN 5 entered the memory care unit. On 10/23/22 at 12:04 AM, RN 5 was observed to leave the memory care unit and open the door to the magnet. RN 5 was observed to wheel the charts in front of the open door. Resident 36 was observed wandering the hallway. RN 5 was observed to sit behind the charts near the open door. At 12:35 AM, CNA 6 and CNA 7 were observed to enter the memory care unit. At 12:37 AM, resident 31 was observed wandering the hallway without pants, wearing only a sweatshirt and brief. Resident 36 and resident 7 were observed in the hallway.
On 10/12/22 at 10:17 AM, an interview was conducted with CNA 2, who was also resident 31's family member. Resident 31's family member stated on 10/[TRUNCATED]
CRITICAL
(K)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Investigate Abuse
(Tag F0610)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident 9 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, paranoid schizophr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident 9 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, paranoid schizophrenia, cognitive communication deficit, type 2 diabetes mellitus, low back pain, essential hypertension, epilepsy, and hyperlipidemia.
A review of resident 9's electronic medical record was conducted.
Resident 9's MDS from 7/10/22 reported that physical behavioral symptoms directed towards others was not exhibited.
Resident 9's care plan updated on 7/31/22 did not have a focus area related to physical aggression towards other residents.
A form titled Behavioral Care Plan from 5/13/22 was found in resident 9's paper chart. The documented stated that the problem was Aggressive Behavior with Physically combative with resident, Verbally aggressive with resident, and Anxiety circled on the document. The interventions circled on the document included, Medication as ordered, Redirect and reorient as needed/able, Documentation (incident reports if indicated), Report injuries to Administration within 24 hours, Set firm limits and o (sic) not allow behavior that is abusive to others. The following interventions were handwritten in; Redirect resident when beh. (behavior) occurs, De-esclate (sic) and calm situation, Educate appropriate response to anger, Redirect resident, Remove/separate residents, Notify [mental health provider information redacted]/LCSW (Licensed Clinical Social Worker)/case mgnt (management), Increase monitoring, Sent to ER (emergency room) for eval (evaluation), [mental health provider], LCSW in to see resident.
A review of medical records and incident reports revealed three physical altercations involving resident 9. The following were reviewed:
a. Resident 14 was initially admitted to the facility on [DATE] and again on 10/13/22 with diagnoses which include metabolic encephalopathy, Wernicke's encephalopathy, cellulitis, osteoarthritis, dementia, psychosis, chronic pain, and insomnia.
A review of an Initial Entity Report which was submitted to the State Survey Agency on 5/23/22 at 7:14 PM revealed that on 5/17/22 at 9:30 PM, [Resident 14] was sitting on the couch in the hallway. [Resident 9] walked by and he said that [resident 14] called him a name so he punched him in the eye. The actions taken was reported as Residents were separated. Increased monitoring.
It should be noted that the Initial Entity Report was not submitted for 5 days.
The summary of investigation, which was dated 5/23/22, stated, Resident to resident altercation. Aggressor: [Resident 9] . It was later in the evening at 21:30 [9:30 PM] and [resident 9] was coming back in from smoking. He says that [resident 14] called him a bad name, so he hit him in the face .[Resident 14] was sitting on the couch in the hallway and when [resident 9] came back in from smoking, they exchanged some words. [Resident 9] hit him in the face resulting in a black eye. Staff intervened, assessed client, and residents were separated to their own rooms. There were no further interactions that night .Nurses have spoken with [Resident 9] -he is not allowed to hit other people even when he gets frustrated. He understands that he needs to speak to the nurse when he is frustrated .
There was no additional investigation into the incident.
There were no progress notes in resident 14's medical record related to the incident on 5/17/22. However, on 5/18/22, a progress note revealed that resident 14 had a bruised eye.
A progress note from resident 14's medical record dated 5/18/22 at 5:18 PM written by the DON stated, Resident has a small redness/purple area to r [right] eye. Does not remember what happened. I asked if he fell and he reports he does not know.
There were no progress notes in resident 9's medical record related to the incident on 5/17/22.
b. Resident 39 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which include atherosclerotic heart disease, peripheral vascular disease, vascular dementia, history of falling, unsteadiness on feet, essential hypertension, type 2 diabetes mellitus, schizoaffective disorder, post-traumatic stress disorder, and insomnia.
Resident 15 was admitted to the facility on [DATE] with diagnoses which include hearing loss, chronic kidney disease, essential hypertension, insomnia, hyperparathyroidism, anxiety disorder, and Alzheimer's disease.
A review of an Initial Entity Report which was submitted to the State Survey Agency on 5/25/22 at 6:29 PM revealed that, on 5/23/22 at 11:30 AM, there was a physical altercation between resident 9, resident 39, and resident 15. The report stated, All 3 clients live on the secure dementia unit. [Resident 15] was laying down sleeping on the couch. [Resident 9] and [Resident 39] came up to her to sit there also. [Resident 39] pulled [Resident 15]'s leg to have her sit up. [Resident 15] kicked [resident 39] with the foot she was pulling on. This mad[e] [resident 9] angry and he kicked [resident 15]. Then [Resident 39] climbed on the couch to hit [resident 15]. [Resident 15] got up and left.
It should be noted that the Initial Entity Report was not submitted until two days after the incident.
There was no additional investigation into the incident.
A summary of the investigation, written by the Administrator, dated 6/3/22 stated, Resident to Resident to Resident Altercation. [Resident 15] (a lady that is hard of hearing) was lying on the couch in the hallway sleeping. When [Resident 39] and [Resident 9] came up to her and wanted to sit on the couch. [Resident 39] started pulling on [resident 15]'s foot, which startled [resident 15] and she kicked [resident 39] to make her release the foot. This made [resident 9] angry that [resident 15] kicked his friend. [Resident 9] tried to kick [resident 15], which made his slipper come off. [Resident 39] then climbed on the couch at [resident 15]'s feet to slap her in the face. [Resident 15] got up and left. Nurse checked everyone involved for any injuries. No injuries were found. Residents were all separated to different areas. [Resident 9] had a prior issue.Licensed Clinical Social Worker has been working with him. They are reviewing his case in med (medication) management meeting .
It should be noted that the investigation was submitted four days after the incident.
There was no additional investigation into the incident.
Resident 9's progress notes were reviewed.
On 5/25/22 at 12:05 PM a Social Services Note stated, LCSW from [Provider name redacted] came in to visit with client. She talked to him about appropriate interactions. He said he wants more ice water.
On 5/25/22 at 4:02 PM a Heath Status Note stated, Resident tolerated new med order Zyprexa and no increased aggression noted, this will be 3rd day on Zyprexa. Resident has some controlling issues which have not improved at this time. Will continue to monitor behaviors to see if Zyprexa will help him manage his aggression for his safety as well as others.
Resident 39 and resident 15 did not have any progress notes in their Electronic Medical Records regarding the incident on 5/23/22.
c. On 10/15/22 at 9:26 PM, the facility reported to the State Survey Agency that on 10/15/22 at 5:40 PM, resident 9 and resident 15 got into a verbal altercation that led to resident 15 hitting resident 9 on the shoulder, and resident 9 striking resident 15 on the face. The residents were separated and assessed. The residents did not have any injuries.
The summary of the investigation was submitted on 10/20/22 to the State Survey Agency revealed, Both were in the hallway on (sic) when a CNA passed out and hit the floor. [Resident 15] was yelling for help and getting residents out of the aides way. She speaks loudly because of her hearing loss. [Resident 9] started yelling back at [resident 15]. [Resident 15] hit him in the shoulder. [Resident 9] hit [resident 15] back in the face. The nurse came, helped the aide to get up. Everyone dispersed and separated and went their separate ways. Nurse assessed both residents to signs of any injury. Families for both residents were notified of altercation. MD also notified.
There was no additional investigation into the incident.
On 10/17/22 at 11:13 AM, an interview with CNA 1 was conducted. CNA 1 stated she knew that resident 9 was verbally aggressive. CNA 1 stated that she did not know of any time resident 9 was physically aggressive with another resident.
On 10/13/22 at 11:56 AM, an interview with LPN 1 was conducted. LPN 1 stated that he was aware of resident 9 being verbally aggressive towards staff and residents. LPN 1 stated he did not know if resident 9 has been physically aggressive towards other residents.
On 10/18/22 at 12:15 PM, an interview with RN 3 was conducted. RN 3 stated that the only physical altercation involving resident 9 that she was aware of was the incident on 10/15/22 when resident 9 and resident 15 hit each other. RN 3 stated that when physical altercations occur, their intervention was to pass on the information to the next shift to help keep the residents separated.
On 10/24/22 at 4:56 PM, an interview with resident 9 was conducted. Resident 9 recalled the incident on 10/15/22. Resident 9 stated that a CNA got dizzy and sat on the floor. Resident 9 stated resident 15 was in the way of someone trying to help the CNA up. Resident 9 asked resident 15 to move and resident 15 hit resident 9 on hit back and his shoulder. Resident 9 stated that he hit resident 15 back on the head. Resident 9 stated that he did not hurt resident 15, and that hitting her was more of a reaction from being hit.
The facility Policy and Procedure for Prohibiting Abuse with no date revealed the following:
Facility policy: It is the policy of this facility to prohibit any abuse of its residents regardless of source. This facility seeks to promote the well-being of its residents by providing a safe and supportive environment. Every resident had the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion.
Reporting procedures pursuant to Utah Code Annotated 62A-3-302
'Any person, including, but not limited to, a social worker, physician, psychologist, nurse,
teacher, or employee of a private or public facility serving adults, who has reason to believe that any disabled or elder adult has been the subject of abuse, emotional or psychological abuse, neglect or exploitation shall immediately notify the nearest police, law enforcement agency or local office of Adult Protective Services within the division.'
'Anyone who makes that report in good faith is immune from civil liability in connection with the report.'
'When the initial report involves a resident of a long-term care facility . the local long-term care ombudsman shall immediately be notified.'
'A person who is required to report suspected abuse, emotional or psychological abuse, neglect or exploitation of a disable or elder adult . and who willfully fails to do so is guilty of a class B misdemeanor.'
Investigation and reporting procedures
1. Any person, who suspects that abuse, neglect, or misappropriation of property may
have occurred, will immediately report the alleged violation to his facility administration and/or advocacy agencies.
2. The administration will immediately notify Adult Protective Services or local law
enforcement authority and the local long-term care ombudsman. Injuries of unknown
origin, significant incidents between residents, abuse, and misappropriation of
resident ' s property must be immediately reported (during normal business hours) to
the State Survey and Certification Agency at [PHONE NUMBER], or using the online reporting process at health.utah.gov/hflcra/
3. The administration will initiate the investigation process by interviewing all staff and
residents having any knowledge of the allegation immediately.
4. The director of nursing will ensure notification of responsible parties and physician of
the alleged incident.
5. The administration will complete the investigation within the next five days and will
document all interviews include the date, time and content of the interview.
6. Following an allegation, the facility will implement increased supervision and monitoring of residents as needed to ensure that all residents are safe from any
further abuse.
7. If the complaint alleges abuse by staff that staff member will be either suspended
until the investigation has been completed or assigned to a work area where there is
no contact with residents.
8. After investigation is complete, the administration will document a summary of its
findings as to whether the alleged abuse was verified and report its findings to the
agencies which were notified at the beginning of the investigation. If the nature of the
incident required that Survey and Certification was initially notified, the results of the
investigation must be faxed to that agency at [PHONE NUMBER] attention of [name of State Survey Agency staff member], R.N.
Protection of high risk residents
Following an allegation of abuse, the facility will immediately implement increased
monitoring of any residents deemed to be at risk for further abuse. If the alleged perpetrator is a resident, the interdisciplinary team will convene as soon as feasible to review current plan of care and make any necessary revisions in order to ensure the safety of others.
Reporting of findings/Response
The facility will report the results of its findings within five working days to the required state Agencies as above as well as to the resident ' s physician and the resident or his/her legal representative. If it is determined that abuse may have occurred, the facility quality Assurance Committee will review the findings and determine if any changes in facility policies and procedures are required to prevent further potential for abuse.
Based on observation, interview and record review it was determined, for 8 of 33 sampled residents, that in response to allegation of abuse, the facility did not have evidence that all all leeged violation were thoroughly investigated and reported to the State Survey Agency within 5 days of the incident, and if the alleged violations were verified appropriate corrective action was taken. Specifically, there were no thorough investigations when a severly impared cognitive resident was sexually abused by a resident that was cognitively intact and when two residents were not assessed for ablitiy to consent, engaged in oral sex. These example were cited at an Immediate Jeopary level. In addition, the facility did not thoroughly investigate when a resident eloped from the facility, a resident had a bruise of unknown source and residents had a physical altercation. These examples were cited at a potiential for harm. Resident identifiers: 9, 13, 14, 15, 26, 31, 36 and 39.
Findings include:
On 10/26/22 at 9:30 AM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to prevent various forms of abuse. Notice of the IJ was given verbally to the facility Administrator (ADM).
On 11/9/22 at 8:32 AM, the facility Consultant Group provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 11/9/22 at 10:00 AM:
1.Resident #26 was placed on a unit that has only male residents and placed on 1:1 supervision on 10/17/22 and remains on 1:1. Resident #31 no longer resides in the community; therefore, no individualized plan of correction is indicated. Resident #31 discharged to another community on 11/4/2022. An investigation was initiated on 11/1/22 for the alleged incident between Resident #36 and #13. Neither resident recall the incident. Resident #26, #31, #36 and #13 were assessed for capacity to consent to sexual intimacy by the LCSW.
2. Residents residing in the facility were assessed for signs and symptoms of abuse by an LCSW on 11/1/22. For residents who are unable to be interviewed due to dementia,
observation tools are being completed to identify any changes in mood or behavior that may be indicative of signs of past abuse.
3. Education was initiated on 11/1/22 by the consultants regarding the community abuse policy including reporting allegations of abuse to the abuse prevention coordinator, reporting allegations of abuse to the proper authorities, and conducting thorough investigations.
Thorough investigations to include immediate protection of the residents, interviewing the alleged victim, alleged assailant, any witnesses, other residents who could potentially be affected by the alleged violation, family/visitors if there are any who may have pertinent information, conducting an assessment of the alleged victim, conducting observations of cares if pertinent, conducting searches if necessary, and implementing pertinent interventions to attempt to prevent recurrence.
NHA/designee will be responsible for contacting the appropriate authorities for allegations of abuse. Each allegation will be discussed verbally with the Temporary Managers and the Temporary Managers will have access to the report to ensure that reports are submitted timely to the health department.
NHA/designee to complete review three(3) abuse allegations a week for three (3) months to ensure that the investigation was thorough, that there were interventions implemented to correct the alleged violations, and that there was protection of the alleged victim while the investigation was ongoing. The Temporary Managers will provide the community with a new daily standup meeting agenda. This agenda will include an abuse reporting log to track and trend all reported allegations for the month. The community also initiated afternoon stand down meetings (Monday through Friday) to ensure follow up items from the morning meeting were completed.
4. The NHA/designee will report findings from the audits to the QAPI Committee monthly for three (3) months. The QAPI committee will identify any trends and take corrective action as needed.
5. Please accept this abatement plan of corrective action - effective 11/10/2022 at 12PM.
On 11/14/22, after the completion of the survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 11/10/22.
Immediate Jeopardy:
1. Resident 31 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, unspecified dementia with behavioral disturbance, and depression.
Resident 31's medical record was reviewed.
An annual Minimum Data Set (MDS) dated [DATE] revealed resident 31 did not have a Brief Interview for Mental Status (BIMS) because she rarely/never understood. The MDS further revealed resident 31 had short and long term memory problems. The MDS revealed her cognitive skills for daily decision making were severely impaired. The MDS revealed resident 31 required extensive one person assistance with dressing.
Resident 31's care plan dated 3/27/17 revealed The resident has a behavior problem of wearing multiple layers of clothing and resisting to change or remove the clothing. The goal with a target date of 5/27/22 was The resident will have fewer episodes of wearing multiple layers of clothing weekly, by review date. Interventions included Assist the resident to develop more appropriate methods of coping and interacting. Encourage the resident to express feelings appropriately; Explain all procedures to the resident before starting and allow the resident 5-10 (minutes) to adjust to changes; If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Praise any indication of The resident's progress/improvement in behavior.
Another care plan for resident 31 dated 8/25/16 revealed, The resident has a behavior problem of wearing multiple layers of clothing and resisting to change or remove the clothing The goal with a target date of 5/27/22 revealed, The resident will have fewer episodes of wearing multiple layers of clothing weekly, by review date. Interventions were Assist the resident to develop more appropriate methods of coping and interacting; Encourage the resident to express feelings appropriately; Explain all procedures to the resident before starting and allow the resident 5-10 (minutes) to adjust to changes; If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Praise any indication of The resident's progress/improvement in behavior.
Resident 26 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, diabetes mellitus, and hypertension.
Resident 26's medical record was reviewed.
Resident 26's quarterly MDS dated [DATE] revealed a BIMS score of 5 which indicated severe cognitive impairment. The MDS further revealed resident 26 walked in corridor, walked in room, locomotion on the unit and locomotion off the unit required supervision and setup help only.
Resident 26's care plan 8/3/21 revealed The resident has a behavior problem r/t (related to) Schizophrenia. The goal was The resident will have no evidence/decrease of behavior problems by review date. Interventions developed were Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by; If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes.
On 8/29/21, resident 26 was found in a room with resident 31 by a surveyor during a recertification survey. Resident 26 had his penis exposed while standing directly in front of resident 31. Resident 31 had her back to the wall. This incident was cited as part of the annual recertification survey.
There were no progress notes in resident 26's or resident 31's medical record regarding the incident on 8/29/21.
A nursing progress note dated 9/4/21 at 10:41 PM revealed, resident 26 was observed touching staff and other residents without consent.
On 9/17/21 at 2:57 PM, the facility reported to the State Survey Agency that resident 31 had been found naked with resident 26 in a room in the memory care unit at 7:15 AM.
A nursing progress note by Licensed Practical Nurse (LPN) 1 in resident 31's medical record revealed on 9/17/21 at 3:24 PM, Resident was found in room [ROOM NUMBER] on the bed naked with another resident (male). CNA informed me and RN and we directed male resident back to his room and resident was assessed by RN and CNA then re-dressed while I informed the Administrator at 0645 (6:45 AM), which he addressed the occurrence to proper authorities. Resident was transported to [local hospital] ER (emergency room) to be assessed. Resident returned with order for doxycyline 100 mg one PO (by mouth) BID (twice daily) x 7 days.Incident report completed.
A nursing progress note by the DON dated 9/17/21 revealed that a physician's order was received to transfer resident 26 to the emergency room for possible transfer to a mental health facility. At 4:21 PM, resident 26 was transported to a local emergency room (ER) for mental health evaluation.
A nursing progress note by LPN 1 in resident 26's medical record revealed on 9/17/21 at 2:59 PM, Resident was found by CNA in room [ROOM NUMBER] with another resident (Female) naked on the bed at 0645 (6:45 AM). CNA informed Me (Nurse) and Charge nurse and we directed resident to his room and informed him to stay in his room until one of us (Nursing staff) comes back. RN and CNA assessed the female resident and re-dressed her and remained with her. I Phoned Facility Administrator at time of incident and informed him of the incident. Administrator stated he will advise and report to proper authorities, I informed Administrator both individuals were separated and one on one staff until further notice.
A nursing progress note dated 9/18/21 at 10:04 PM revealed, resident 26 was moved to a room outside of the locked unit. The note further revealed resident 26 frequently wandered into the rooms of female resident and was sexually inappropriate with residents and staff. Staff were to continue to monitor resident 26.
A nursing progress note dated 9/25/21 at 11:06 PM revealed resident 26 had been sexually inappropriate with the female staff.
Resident 26's Medication Administration Record indicated that staff were to monitor resident 26 for sexually inappropriate behaviors as of 9/25/21. Resident 26 was also started on Risperdol as of 9/26/21.
A physician's progress note for resident 31 dated 10/18/21 at 12:54 PM, .On 9/17 she was found naked with a male resident on top of her. She was transported to the ER where evaluation did not reveal signs of physical trauma.
A nursing progress note dated 12/4/21 at 10:18 PM revealed resident 26 was occasionally sexually inappropriate.
A nursing progress note dated 1/2/22 at 1:29 AM revealed resident 26 had not harmed anyone.
A nursing progress note dated 7/10/22 at 2:18 AM revealed resident 26 was discovered missing about 7:30 PM. Staff checked every room and the outside around the entire building. Police, Administrator and physician were notified.
A nursing progress note dated 7/10/22 at 1:22 PM revealed police returned resident 26 at approximately 10:30 AM and a physician's order was obtained to change room to memory lane. Resident 26 was happy to see his old roommate.
The facility reported resident 26's elopement on 7/11/22 at 7:41 AM. The facility reported resident 26 eloped at 12:14 AM on 7/10/22. The investigation was [Resident 26] went out for the last smoke break at 7pm then returned to his room. Later when doing rounds [resident 26] was not in his bed. Facility was searched. Police Notified. Silver alert was sent out. At approx. (approximately) 9:30am an old employee texted and notified the facility that [resident 26] was at [local convenience store] a block away. Police were notified and picked him up. Returned to the facility at 10am. There were no interviews or further investigation.
Resident 26's monthly nurses assessments for the months of September 2021, October 2021, November 2021, December 2021, January 2022, April 2022, June 2022, and July 2022 documented that resident 26 had sexual behaviors but did not indicate what the behaviors were. [It should be noted that the monthly assessments for February 2022, March 2022, May 2022, August 2022, and September 2022 were not able to be located in resident 26's medical record.]
A nursing medication administration note dated 8/28/22 at 1:32 PM, revealed resident 26 was seen by other resident pulling a female resident into his bathroom. he noticed he was caught and let her go.
The facility reported on 8/29/22 at 12:35 pm, that on 8/26/22 at 2:00 AM, resident 31 and resident 26 were found laying in bed together with no briefs. The Summary of the Investigation was Both residents live on the secured unit in the nursing facility. [Resident 31] is a constant wanderer and pacer. She wanders in and out of any room and often climbs into beds when she is tired. She also immediately takes off her briefs when they are wet. It is believed that she climbed into his bed. He often sleeps with just a tshirt or naked.
While the CNAs were doing rounds they found them both in bed with no briefs on. The RN did checks and found no evidence of any encounter. Residents were sent to their own rooms.
[Resident 26] is a client of [local mental health] the provider is looking at adjusting medications and increased visits from case manager and LCSW.
It should be noted there were no documented interviews or further investigation.
Resident 26 and 31's nursing progress notes were reviewed and there were no notes in either of the residents medical records regarding this event.
On 10/22/22 at 11:22 AM, an interview was conducted with CNA 6. CNA 6 stated she witnessed an incident between resident 26 and resident 31 a couple months ago. CNA 6 stated she finished changing resident 31's brief and went into another residents room and was changing another resident. CNA 6 stated when she went back to check resident 31, she was missing. CNA 6 stated she searched room to room and found resident 31's brief and pants were off and resident 26's brief and pants were pulled down to his knees. CNA 6 stated she told the RN 6. CNA 6 stated that she was not questioned by the Administrator or DON regarding the incident. CNA 6 stated that resident 31 was placed on 15 minutes checks. CNA 6 stated that resident 26 continued to reside on the memory care unit after the incident. CNA 6 stated resident 26 told the nurse that he was in trouble and he knew what he did was wrong. CNA 6 stated he keeps doing it and he gets caught every time he does anything to resident 31. CNA 6 stated a CNA reported to her on evening shift that resident 26 was holding the door closed in the shower room with resident 31. CNA 6 stated another time she was told that resident 31 was in resident 26's room butt naked behind the curtain. CNA 6 stated that she was told to keep an eye on him. CNA 6 stated sometimes she had to leave the memory care unit unattended to make sure other residents were receiving care.
The incident when resident 31 and resident 26 were found in the bathroom together was not reported to the State Survey Agency.
The incidents when resident 31 was found naked behind a curtain in resident 26's room was not reported to the State Survey Agency.
A nursing progress note regarding resident 26 dated 9/4/22 at 12:16 AM revealed, has been doing about the same. We have to watch him so he doesn't coax one of the ladies into his room.
On 10/1/22, resident 26 was documented as demonstrating inappropriate behavior,
such as making inappropriate comments to this nurse. Resident says 'I need you tonight' 'I love women' and trying to kiss on the hand. Resident was reminded of
appropriate communication and that these comments are unacceptable. Resident
verbalized understanding 'okay okay '.
Review of resident 26's September and October 2022 Treatment Administration Record (TAR) indicated that staff had not been consistently documenting resident 26's sexual behaviors.
Review of resident 26's care plan indicated that no interventions had been put into
place to prevent further incidents with resident 31 after the incident on 8/26/22.
An incident/accident report dated 10/5/22 at 2:15 PM, revealed resident 31 was walking through the hallway without her clothes on, CNA found resident's clothes in closet of room # 104 ? at 2:15 PM. No injuries. [It should be noted the 104 was written over another room number that was unreadable.] The additional comments and/or steps taken to prevent reoccurrence were clothes to be ordered; to remind staff that designated CNA needs to be on the unit at ALL TIMES; and ensure staff on unit. The incident report was not signed by the Medical Director or Administrator on 10/17/22 when it[TRUNCATED]
CRITICAL
(K)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Administration
(Tag F0835)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, it was determined that the facility failed to be administered in a manner t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, it was determined that the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, abuse occurred within the facility on multiple occasions,but was not identified, reported or investigated; the staffing was inadequate and resulted in falls, abuse, and activities of daily living not being completed; Quality Assurance (QA) was not completed as required for approximately one year; medically necessary appointments were not scheduled by facility staff or the administrator; wound reports and pharmacy reviews were only accessible to the Administrator, who did not provide them to nursing staff; and multiple staff reported to the Administrator their concerns about resident safety while a specific nurse was working, however no follow up by the Administrator was completed. The identified deficient practice was found to have occurred at the Immediate Jeopardy (IJ) Level. Resident identifiers: 4, 8, 9, 10, 11, 13, 22, 26, 29, 30, 31, 32, 34, 36 and 93.
Findings include:
On 10/27/22 at 7:15 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to administer the facility in a manner that enabled it to use its resources effectively.
Notice of the IJ was given verbally to the facility Administrator (ADM).
On 11/10/22 at 11:56 AM, the facility Consultant Group provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 11/10/22 at 12:00 PM:
1. Please refer to the abatement plan for F600, F609 and 610. The facility has hired an NHA (Nursing Home Administrator), who started work at the facility on 10/31/22 to oversee the daily operations of the facility.
The community has Temporary Managers who will provide mentoring and assistance to the administrator through regular contact and visitation to the building.
The NHA was provided with names of staffing agencies who are local to assist with having adequate staffing levels for CNAs (Certified Nursing Assistants) and Nurses.
The Temporary Managers provided education on the QAPI (Quality Assurance Performance Improvement) program and tools for process improvement and tracking and trending of resident care areas. The QAPI meetings will be held at least monthly with oversight of the NHA
The facility did develop, with the assistance of the Temporary Managers, a process for scheduling resident appointments, arranging for transportation to and from appointments, and obtaining information from the appointments and having that information available in the resident record. Appointments were scheduled for Resident #4 for GI (Gastroenterology) consult and Neurology appointment for Resident #30. The NHA is researching the cardiologist group that placed the pacemaker for Resident #34, and A care conference will be scheduled for resident #32 to discuss the option of a feeding tube.
The new NHA and the acting DON (Director of Nursing) will get access to the rounding wound service portal
to ensure that all recommendations and information is available in the medical record
The Consultant Pharmacist reports were received and follow up on all recommendations were completed on 11/1/22.
The facility implemented, in addition to narcotic count, a narcotic card count to be completed each shift on 11/1/22.
RN #1 is no longer employed by the facility and will be reported to the board of nursing
2. Residents in the community have the potential to be affected by this alleged deficient practice.
3. The community has Temporary Managers who will provide mentoring and assistance to the administrator through regular contact and visitation to the building. The NHA is working minimally 40 hours a week at the community. The NHA job description was reviewed to ensure that it meets acceptable standards of practice.
The Temporary Managers will provide a structured review process to the Administrator and will conduct a periodic and thorough evaluation of their performance following their job description requirements. Evaluations will be completed at 30 days, 90 days, and annually.
Additional training and/or oversight will be provided by the temporary management company and corporate office based upon the outcomes of these reviews. The community will implement bimonthly QAPI meetings for a quarter to go over audits for the survey and identify any trends and take corrective action as needed.
4. The Temporary Managers and or designee will report findings from the audits to the QAPI Committee
monthly for 3 months. The QAPI committee will identify any trends and take corrective action as needed.
5. Please accept this abatement plan of corrective action - effective 11/10/2022 at 12PM.
On 11/14/22, after the completion of the survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 11/10/22.
I. ABUSE
1. Resident 31 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, unspecified dementia with behavioral disturbance, and depression.
Resident 31's medical record was reviewed.
An annual Minimum Data Set (MDS) dated [DATE] revealed resident 31 did not have a Brief Interview for Mental Status (BIMS) because she rarely/never understood. The MDS further revealed resident 31 had short and long term memory problems. The MDS revealed her cognitive skills for daily decision making were severely impaired. The MDS revealed resident 31 required extensive one person assistance with dressing.
Resident 31's care plan dated 3/27/17 revealed The resident has a behavior problem of wearing multiple layers of clothing and resisting to change or remove the clothing. The goal with a target date of 5/27/22 was The resident will have fewer episodes of wearing multiple layers of clothing weekly, by review date. Interventions included Assist the resident to develop more appropriate methods of coping and interacting. Encourage the resident to express feelings appropriately; Explain all procedures to the resident before starting and allow the resident 5-10 (minutes) to adjust to changes; If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Praise any indication of The resident's progress/improvement in behavior.
Another care plan for resident 31 dated 8/25/16 revealed, The resident has a behavior problem of wearing multiple layers of clothing and resisting to change or remove the clothing The goal with a target date of 5/27/22 revealed, The resident will have fewer episodes of wearing multiple layers of clothing weekly, by review date. Interventions were Assist the resident to develop more appropriate methods of coping and interacting; Encourage the resident to express feelings appropriately; Explain all procedures to the resident before starting and allow the resident 5-10 (minutes) to adjust to changes; If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Praise any indication of The resident's progress/improvement in behavior.
Resident 26 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, diabetes mellitus, and hypertension.
Resident 26's medical record was reviewed.
Resident 26's quarterly MDS dated [DATE] revealed a BIMS score of 5 which indicated severe cognitive impairment. The MDS further revealed resident 26 walked in corridor, walked in room, locomotion on the unit and locomotion off the unit required supervision and setup help only.
Resident 26's care plan 8/3/21 revealed The resident has a behavior problem r/t (related to) Schizophrenia. The goal was The resident will have no evidence/decrease of behavior problems by review date. Interventions developed were Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by; If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes.
On 8/29/21, resident 26 was found in a room with resident 31 by a surveyor during a recertification survey. Resident 26 had his penis exposed while standing directly in front of resident 31. Resident 31 had her back to the wall. This incident was cited as part of the annual recertification survey.
There were no progress notes in resident 26's or resident 31's medical record regarding the incident on 8/29/21.
A nursing progress note dated 9/4/21 at 10:41 PM revealed, resident 26 was observed touching staff and other residents without consent.
On 9/17/21, the facility reported to the state survey agency that resident 31 had been found naked with resident 26 in a room in the locked unit.
A nursing progress note by Licensed Practical Nurse (LPN) 1 in resident 31's medical record revealed on 9/17/21 at 3:24 PM, Resident was found in room [ROOM NUMBER] on the bed naked with another resident (male). CNA informed me and RN and we directed male resident back to his room and resident was assessed by RN and CNA then re-dressed while I informed the Administrator at 0645 (6:45 AM), which he addressed the occurrence to proper authorities. Resident was transported to [local hospital] ER (emergency room) to be assessed. Resident returned with order for doxycyline 100 mg one PO (by mouth) BID (twice daily) x 7 days.Incident report completed.
A nursing progress note by the DON dated 9/17/21 revealed that a physician's order was received to transfer resident 26 to the emergency room for possible transfer to a mental health facility. At 4:21 PM, resident 26 was transported to a local emergency room (ER) for mental health evaluation.
A nursing progress note by LPN 1 in resident 26's medical record revealed on 9/17/21 at 2:59 PM, Resident was found by CNA in room [ROOM NUMBER] with another resident (Female) naked on the bed at 0645 (6:45 AM). CNA informed Me (Nurse) and Charge nurse and we directed resident to his room and informed him to stay in his room until one of us (Nursing staff) comes back. RN and CNA assessed the female resident and re-dressed her and remained with her. I Phoned Facility Administrator at time of incident and informed him of the incident. Administrator stated he will advise and report to proper authorities, I informed Administrator both individuals were separated and one on one staff until further notice.
A nursing progress note dated 9/18/21 at 10:04 PM revealed, resident 26 was moved to a room outside of the locked unit. The note further revealed resident 26 frequently wandered into the rooms of female resident and was sexually inappropriate with residents and staff. Staff were to continue to monitor resident 26.
A nursing progress note dated 9/25/21 at 11:06 PM revealed resident 26 had been sexually inappropriate with the female staff.
Resident 26's Medication Administration Record indicated that staff were to monitor resident 26 for sexually inappropriate behaviors as of 9/25/21. Resident 26 was also started on Risperdol as of 9/26/21.
A physician's progress note for resident 31 dated 10/18/21 at 12:54 PM, .On 9/17 she was found naked with a male resident on top of her. She was transported to the ER where evaluation did not reveal signs of physical trauma.
A nursing progress note dated 12/4/21 at 10:18 PM revealed resident 26 was occasionally sexually inappropriate.
A nursing progress note dated 1/2/22 at 1:29 AM revealed resident 26 had allegedly not harmed anyone.
A nursing progress note dated 7/10/22 at 2:18 AM revealed resident 26 was discovered missing about 7:30 PM. Staff checked every room and the outside around the entire building. Police, Administrator and physician were notified.
A nursing progress note dated 7/10/22 at 1:22 PM revealed police returned resident 26 at approximately 10:30 AM and a physician's order was obtained to change room to memory lane, despite his history of sexually abusing resident 31, who still resided on the memory care unit. The progress note indicated that resident 26 was happy to see his old roommate.
Resident 26's monthly nurses assessments for the months of September 2021, October 2021, November 2021, December 2021, January 2022, April 2022, June 2022, and July 2022 documented that resident 26 had sexual behaviors but did not indicate what the behaviors were. [It should be noted that the monthly assessments for February 2022, March 2022, May 2022, August 2022, and September 2022 were not able to be located in resident 26's medical record.]
A nursing medication administration note dated 8/28/22 at 1:32 PM, revealed resident 26 was seen by other resident pulling a female resident into his bathroom. he noticed he was caught and let her go.
An entity report dated 8/29/22 revealed that on 8/26/22 resident 31 and resident 26 lived on the secured unit in the nursing facility. Resident 31 was often found pacing. She wanders in and out of any room and often climbed into bed when she is tired. She also immediately takes off her brief when they are wet. It is believed that she climbed into his bed. He often sleeps with just a T-shirt or naked. While CNAs were doing rounds they found them both in bed with no briefs on. The RN did checks and found no evidence of any encounter. Residents were sent to their own rooms. [Resident 26] is a client of [local mental health company] the provider is looking at adjusting medications and increased visits from case manager and LCSW.
Resident 26 and 31's nursing progress notes were reviewed and there were no notes in either of the residents medical records regarding this event.
Review of resident 26's care plan indicated that no interventions had been put into place to prevent further incidents with resident 31 after the incident on 8/26/22.
A nursing progress note regarding resident 26 dated 9/4/22 at 12:16 AM revealed, has been doing about the same. We have to watch him so he doesn't coax one of the ladies into his room.
On 10/1/22, resident 26 was documented as demonstrating inappropriate behavior, such as making inappropriate comments to this nurse. Resident says 'I need you tonight' 'I love women and trying to kiss on the hand. Resident was reminded of appropriate communication and that these comments are unacceptable. Resident verbalized understanding 'okay okay '.
Review of resident 26's September and October 2022 TAR indicated that staff had not been consistently documenting resident 26's sexual behaviors.
An incident/accident report dated 10/5/22 at 2:15 PM, revealed resident 31 was walking through the hallway without her clothes on, CNA found resident's clothes in closet of room # 104 ? at 2:15 PM. No injuries. [It should be noted the 104 was written over another room number that was unreadable.] The additional comments and/or steps taken to prevent reoccurrence were clothes to be ordered; to remind staff that designated CNA needs to be on the unit at ALL TIMES; and ensure staff on unit. The incident report was not signed by the Medical Director or Administrator until 10/17/22 when it was reviewed.
A nursing progress note dated 10/5/22 at 3:48 PM by LPN 1 revealed, Resident (31) walking down hall on memory unit without her clothes on and other residents saw her naked. CNA's assisted resident to cloth (sic) her. CNA found resident's clothes in closet of room [ROOM NUMBER]. Resident's granddaughter witnessed the incident, and she is CNA here today this shift. I counseled the designated CNA working on memory unit and wrote action taken form and DON present during this write up. Copy of write up given to Admin '[name removed]'. NP (Nurse Practitioner) informed as well as family.
On 10/12/22, both residents were observed to residing on the memory care unit that was the locked unit of the facility. Resident 26 resided in room [ROOM NUMBER] and resident 31 resided in room [ROOM NUMBER].
On 10/12/22 an observation was made of resident 31. At 2:59 PM, resident 31 was observed to wander into the door way of room [ROOM NUMBER] and was redirected by staff. At 3:03 PM, resident 31 was wandering into room [ROOM NUMBER]. At 3:08 PM, resident 31 wandered into room [ROOM NUMBER].
On 10/11/22 at 4:10 AM, an observation was made of RN 1, Certified Nursing Assistant (CNA) 6 and CNA 7 at the nurses station. The memory care unit was unattended until 4:22 AM when CNA 6 was observed to enter the unit. At 4:43 AM, CNA 6 was observed to exit the memory care unit. At 5:48 AM, CNA 6 entered the memory care unit. Resident 36 was observed to be ambulating up and down the hallway during that time. [It should be noted the memory care unit was unattended for 1 hour and 5 minutes.]
On 10/22/22 at 10:40 PM, an observation was made of CNA 6, CNA 7 and RN 5 at the nurses station. The memory care unit was unattended until 10:51 PM. Resident 36 was observed wandering the hallway. At 11:19 PM, CNA 6 was observed to leave the memory care unit. At 11:25 PM, CNA 6 was observed to return to the memory care unit. At 11:56 PM, CNA 6 and CNA 7 were observed to leave the memory care unit. At 11:57 PM, RN 5 entered the memory care unit. On 10/23/22 at 12:04 AM, RN 5 was observed to leave the memory care unit and open the door to the magnet. RN 5 was observed to wheel the charts in front of the open door. Resident 36 was observed wandering the hallway. RN 5 was observed to sit behind the charts near the open door. At 12:35 AM, CNA 6 and CNA 7 were observed to enter the memory care unit. At 12:37 AM, resident 31 was observed wandering the hallway without pants, wearing only a sweatshirt and brief. Resident 36 and resident 7 were observed in the hallway.
On 10/22/22 at 11:22 AM, an interview was conducted with CNA 6. CNA 6 stated she witnessed an incident between resident 26 and resident 31 a couple of months ago. CNA 6 stated she finished changing resident 31's brief and went into another residents room and was changing another resident. CNA 6 stated when she went back to check resident 31 she was missing. CNA 6 stated she searched room to room and found resident 31's brief and pants were off and resident 26's brief and pants were pulled down to his knees. CNA 6 stated she told RN 6. CNA 6 stated that she was not questioned by the Administrator or DON regarding the incident. CNA 6 stated that resident 31 was placed on 15 minutes checks. CNA 6 stated that resident 26 continued to reside on the memory care unit after the incident. CNA 6 stated resident 26 told the nurse that he was in trouble and he knew what he did was wrong. CNA 6 stated he keeps doing it and he gets caught every time he does anything to resident 31. CNA 6 stated a CNA reported to her on evening shift that resident 26 was holding the door closed in the shower room with resident 31. CNA 6 stated another time she was told that resident 31 was in resident 26's room naked behind the curtain. CNA 6 stated that she was told to keep an eye on him. CNA 6 stated sometimes she had to leave the memory care unit unattended to make sure other residents were receiving care. [It should be noted that the incidents referenced above had not been reported to the State Survey Agency.]
On 10/12/22 at 10:17 AM, an interview was conducted with CNA 2, who was also resident 31's family member. Resident 31's family member stated on 10/5/22 it was shift change about 2:00 PM, there were no staff members on the memory care unit. Resident 31's staff member stated that a resident was banging on the doors to get staff attention outside of the memory care unit. Resident 31's family member stated she looked in and resident 31 was walking down the hall naked with no clothes on. Resident 31's family member stated that resident 31's clothes were nowhere to be found. Resident 31's family member stated that resident 31's clothing were found in room [ROOM NUMBER]'s closet. Resident 31's family member stated resident 31 was able to take her pants down but did not take her brief off and resident 31 was not capable of placing her clothing in a closet. Resident 31's family member stated that she was upset about the incident and talked to the DON. Resident 31's family member stated that DON told her to talk to the Administrator. Resident 31's family member stated she told the Administrator but the Administrator had people in her office and she stated to the resident's family member she was busy doing payroll. Resident 31's family member stated the Administrator stated to her she needed to talk to the nurse. Resident 31's family member stated she went back to the DON and demanded that something happen. Resident 31's family member stated she was trying to report an abuse allegation. Resident 31's family member stated the DON reviewed the camera footage of the memory care unit with her. Resident 31's family member stated there was nothing on the footage because room [ROOM NUMBER] was directly below the cameras. Resident 31's family member stated all they could see was resident 31 walking in the hallway naked. Resident 31's family member stated they could not see resident 31 walk into a room and when they saw her she was in the hallway with clothing and then suddenly she was naked. Resident 31's family member stated resident 26's room was joined to room [ROOM NUMBER] through a bathroom. Resident 31's family member stated that CNA 1 was counseled about not leaving the locked unit unattended. Resident 31's family member stated she felt something was happening to resident 31 from resident 26. Resident 31's family member stated that resident 26 stated to her that resident 31 was beautiful and he loved her. Resident 31's family member stated that resident 31 wandered into other resident rooms and if there was no staff in the hallway, she will go into anyone's room. Resident 31's family member stated resident 31 would not let staff take off her pants and would say No, don't touch me dirty man. Resident 31's family member stated resident 31 was very jumpy and resident 31 was never like that before.
On 10/17/22 at approximately 10:00 AM, an interview was conducted with the DON. The DON stated that CNA 2, who was a family member to resident 31, was upset on 10/5/22 and the DON stated she assumed the nurse had addressed it and that CNA 2 talked to the Administrator. The DON stated that CNA 2 returned from talking to the Administrator and CNA 2 told the DON she wanted something done. The DON stated that she reviewed camera footage because CNA 2 insisted to find out what happened to resident 31's clothing. The DON stated that resident 31 was in the memory care unit hallway with no clothing on. The DON stated that CNA 2 was very upset. The DON stated she was having a hard time remembering what she saw from the camera footage. The DON stated she thought resident 31 exited room [ROOM NUMBER] without clothing and did not see resident 31 enter a room because the video footage jumped 5 minutes at a time. The DON stated the memory care unit was unattended by staff for about 10 minutes. The DON stated the locked unit was supposed to have staff at all times. The DON stated she had LPN 1 complete an incident report. The DON stated she reported the incident to the Administrator immediately. The DON stated she put a care plan in for resident 31 after the incident. The DON stated that in the position she was in, she did everything she could by watching LPN 1 counsel CNA 1 about not leaving the unit. The DON stated she educated CNA's that this happens with dementia and with increasing dementia this can happen. The DON stated resident 31 was able to remove her own clothing. The DON stated she also would like the family to be involved with care planning and maybe getting resident 31 onesies that zip in the back so she was unable to remove her clothing. The DON stated after resident 31 was found naked in the hallway she assessed resident 31. The DON stated resident 31 was clothed and there was no bruising or red marks on her back. The DON stated that In my opinion, I couldn't tell if it was an abuse allegation or an incident.
On 10/17/22 at 11:13 AM, an interview was conducted with CNA 1. CNA 1 stated on 10/5/22 when resident 31 was found naked in the locked unit, I was off the hall. CNA 1 stated she was waiting for the next shift to come into work. CNA 1 stated she was talking to another staff member and resident 31 was walking down the hallway with no clothes on. CNA 1 stated staff ran down the hallway to resident 31. CNA 1 stated resident 31 went into room [ROOM NUMBER] which was resident 26's room and her clothes were found in room [ROOM NUMBER]'s closet. CNA 1 stated resident 26 and his roommate were in their room when resident 31 went in. CNA 1 stated resident 31 wanders everywhere. CNA 1 stated she figured out a different system for resident 31. CNA 1 stated resident 31 was changed at 12:30 PM or 1:00 PM and then at 3:00 PM because that was when she usually had a bowel movement. CNA 1 stated there should be staff in the locked unit at all times. CNA 1 stated I was not on the hall which I take responsibility for. CNA 1 stated she was not sure if resident 31's clothing was soiled or wet when they were found. CNA 1 stated resident 31 was pacing the hallway yesterday and needed to be changed and did not take her clothing off. CNA 1 stated she was instructed by LPN 1 and the DON to stay in the memory care unit at all times and keep an eye on resident 31 and anyone that tried to bother her. CNA 1 stated other staff have told her that resident 31 takes her clothing off, but she had never seen resident 31 take her clothing off. CNA 1 stated she had found resident 31 without a brief on so she figured resident 31 removed it herself.
On 10/17/22 at 2:18 PM, an interview was conducted with CNA 8. CNA 8 stated 2 or 3 weeks ago she was sitting at the desk at about 2:20 PM and was waiting for another CNA to come to the locked unit to get report. CNA 8 stated resident 9 was knocking on the door and was asking for ice. CNA 8 stated she opened the door to give resident 9 ice and saw resident 31 naked in the hallway. CNA 8 stated resident 31 was outside the dining room toward her room. CNA 8 stated she took resident 31 to her room and dressed her. CNA 8 stated CNA 2, CNA 3 and CNA 4 were at the facility. CNA 8 stated she reported to the nurse what had happened. CNA 8 stated after the incident, she was told to be in the hall and care for the residents even though she was scheduled to work another hallway. CNA 8 stated she also told the DON about the incident. CNA 8 stated the DON was mad at us because no one was in the hallway. CNA 8 stated she stayed a little bit because CNA 2 was mad and wanted to look at the cameras to see what happened. CNA 8 stated she was the first CNA to see resident 31 naked in the hallway and there were other residents in the hallway. CNA 8 stated resident 31's mind was not good, so she did not know what was happening. CNA 8 stated resident 26 knew what was happening. CNA 8 stated she did not want anything to happen to resident 31 so she puts her on the couch. CNA 8 stated a Night CNA told her that when she received report to make sure resident 26 was not close to resident 31. CNA 8 stated she did not ask why she needed to keep them apart. CNA 8 stated she had been told that resident 31 and resident 26 had been found in bed together. CNA 8 stated she would be more careful with resident 31 and not leave her alone since she knew the residents had been found in bed together. CNA 8 stated she tried not to leave her alone since then, but things happened really fast. CNA 8 stated that resident 31 was unable to remove her own clothing. CNA 8 stated resident 31 won't allow for staff to pull her pants down when she needed to be changed. CNA 8 stated resident 31 would need assistance with removing all of her clothing including her shirt.
On 10/17/22 at 11:28 AM, an interview was conducted with the Administrator. The Administrator stated it was a daily occurrence that resident 31 did not have clothing on. The Administrator stated that once resident 31 was wet, she removed her bottoms. The Administrator stated that she had been trying to find things like taking her to the bathroom, so she did not remove her clothing. The Administrator stated resident 31 wandered all the time and removed her clothing wherever she wanted and continued wandering. The Administrator stated resident 31 wandered in and out of everyone's room on the locked unit. The Administrator stated resident 31 was friendly with everyone. The Administrator stated she was not sure if resident 31 was able to remove her shirt herself. The Administrator stated resident 31 could get her bottoms off fast. The Administrator stated she would not have looked into anything or questioned possible abuse with resident 31 coming out of another residents room with no clothing. The Administrator stated there were times the memory care unit was unattended by staff when staff were coming and going but staff should ask other members to cover the hallway.
On 10/17/22 at 11:38 AM, an interview was conducted with Medical Director (MD). The MD stated there was an incident report dated 10/5/22 regarding resident 31 not having her clothing on in the hallway. The MD stated it was reported to her but when she reviewed the incident report, the room number on the incident report was changed. The MD stated she was informed that resident 31's clothing was found in room [ROOM NUMBER], but it was changed to room [ROOM NUMBER]. The MD stated she had not received all the details about the incident.
On 10/17/22 at 12:10 PM, a follow up interview was conducted with the MD. The MD stated she was informed by CNA 1 that resident 26 was found fondling resident 31 today. The MD stated she talked to resident 26 and he stated I need to go to jail. The MD stated resident 26 stated I was playing around with an older woman, [resident 31]. The MD stated he did not go into specifics but he said sexual stuff.
On 10/17/22 at 12:21 PM, an interview was conducted with resident 26. Resident 26 was observed in the locked unit dining room. Resident 26 stated he had sex and pointed to resident 31. Resident 26 stated her name was (resident 31). Resident 26 stated he needed to go to jail because resident 31 walked around with her pants down. Resident 26 stated he did not always have full sex with resident 31 sometimes it was him putting his penis from front to back on resident 31 like a hot dog. Resident 26 stated he had sex with resident 31 six times.
On 10/17/22 at 12:22 PM, an interview was conducted with CNA 2. CNA 2 stated that at approximately 11:00 AM that day, she was assisting CNA 4 in walking resident 36 to the shower room. CNA 2 stated resident 31 was sitting on a sofa in the hallway which was near resident 26's room. CNA 2 stated she helped get resident 36 into the shower room and turned on the hot water and went back to the hallway. CNA 2 stated resident 31 was nowhere to be found. CNA 2 stated she went back to CNA 4 and stated she was unable to find resident 31. CNA 2 stated she went to resident 26's room and found resident 31 standing in front of resident 26 sitting on the toilet. CNA 2 stated resident 31's pants were down and resident 26 had a couple fingers inside of resident 31's vagina. CNA 2 stated she told resident 26 you do not do that. CNA 2 stated she pulled up resident 31's pants and lead her out of the bathroom and yelled for CNA 4 to report it to the DON. CNA 2 stated she was being written up by[TRUNCATED]
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0603
(Tag F0603)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews it was determined, for 2 of 33 sampled residents, that the facility did no...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews it was determined, for 2 of 33 sampled residents, that the facility did not provide residents with the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This included but was not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Specifically, residents were placed in the locked unit without assessments to determine if the residents met the criteria for the unit and were not provided with access codes or other information for independent egress. Resident identifiers: 7 and 9.
Findings Include:
Harm
1. Resident 9 was admitted to the facility on [DATE] with diagnoses which include major depressive disorder, paranoid schizophrenia, cognitive communication deficit, type 2 diabetes mellitus, low back pain, essential hypertension, epilepsy, and hyperlipidemia.
On 10/11/22 at 6:17 AM, an interview with resident 9 was conducted. Resident 9 was observed to have a room in the memory care unit. Resident 9 stated that he previously had a room outside of the locked unit. Resident 9 stated that he had an argument with another resident and left the facility at around 12:30 AM to cool down at his brother's house. Resident 9 stated that when he returned to the facility he was locked up in the locked unit.
On 10/13/22 resident 9's medical record was reviewed.
Resident 9's Annual Minimum Data Set (MDS) completed on 7/12/22 revealed that resident 9 scored a 12 on the Brief Interview for Mental Status (BIMS). It should be noted that a score of 12 suggests moderate impairment.
A progress note from 10/30/21 at 4:45 AM stated Resident left facility at 0210 (2:10 AM) this morning. It is believed he had an argument with his room mate. Administrator notified. Police called. Description and cell phone number given to police .
A progress note from 10/30/21 at 5:30 PM stated, It was reported to me at the beginning of my shift that resident had eloped at 0210 this AM. I called the police to see if they had found him, also asked administrator if he knew where he was. He did not know. About 1400 (2:00 PM) his brother was notified and it was noted that he was visiting him and outside smoking in the garage. MD (Medical Director) notified he was located and administrator went to visit him. He was brought back to facility . at 1715 (5:15 PM).
A progress note from 10/30/21 at 5:42 PM stated, New order per MD to admit to SNU (Special Needs unit) locked unit d/t (due to) his dementia/schizophrenia and flight risk. Also to be put on assisted smoking.
A progress note from 10/21/21 at 9:06 AM stated, Resident has been in his room since the room change . He states he is upset about changing rooms .
Assessments to determine if the residents met the criteria for the unit were not found in resident 9's medical record.
On 10/12/22 at 10:17 AM, an interview with Certified Nursing Assistant (CNA) 2 was conducted. CNA 2 stated that she did not know if resident 9 was appropriate to be in the locked unit. CNA 2 stated that resident 9 often complained about being on the unit and felt like it's a prison because he was locked in.
On 10/24/22 at 2:30 PM, an interview with the Director of Nursing (DON) was conducted. The DON stated that she was not aware of any assessments regarding elopement except for the wander risk.
A review of resident 9's medical records revealed that a document titled Wander Risk Scale was completed for resident 9 on 8/12/22. It should be noted that this assessment was completed approximately 10 months after resident 9 was moved to the locked unit.
On 10/24/22 at 5:15 PM, an interview with resident 9 was conducted. Resident 9 stated he did not know that he needed to sign out or how to sign out when he left for his brother's house. Resident 9 stated that he was locked in because he did not sign out when he left the facility.
On 10/25/22 at 1:35 PM, an interview with the Administrator (ADM) was conducted. That ADM stated that nurses completed an assessment to determine if residents fit the criteria for the locked unit. The ADM stated that she did not know where the assessments were located, and she did not know what the assessments were called. The ADM stated the Wander Risk Scale was part of the assessment, but she believed there was another part to the assessment. The ADM stated that she believed resident 9 was in the locked unit because he had eloped. The ADM stated that elopement was when a person did not know what they were doing, and they were escaping. The ADM stated that she did not have a good definition of elopement. The ADM stated that residents had to sign out in a book at the nurses' station if they resident was leaving the facility. The ADM stated that she did not know how residents were informed that they needed to sign out prior to leaving the facility.
2. Resident 7 was admitted to the facility on [DATE] with diagnoses which included Schizoaffective disorder, dementia with behavioral disturbance, generalized anxiety, and type 2 diabetes.
On 10/12/22 at 2:54 PM, an interview was conducted with resident 7. Resident 7 stated he did not care where his room was located but it was weird being locked in a unit. Resident 7 stated he did not need to be locked up like an animal.
Resident 7's medical record was reviewed.
An annual MDS dated [DATE] revealed a BIMS score of 15 which indicated resident 7 was cognitively intact.
A care plan dated 8/3/21 revealed The resident requires a safe, secure, environment Elopement risk, Wandering risk. The goal with a target date of 3/30/22 was Resident will remain safe, without feelings of isolation, in the SNU (Special Needs Unit) . Interventions included to provide activities in the unit or supervised while outside of the unit, provide daily activities, provide meals in the SNU dining room and resident will reside in a room in the SNU.
Resident 7's census section revealed he was in the memory care unit from 10/26/2020 until 12/4/2020 when he was moved out of the unit. Resident 7 was moved back to the memory care unit 12/18/2020.
A physician's progress note dated 12/23/2020 revealed resident 7 was transferred to the COVID-19 unit and then back to his room.
There were no assessment or nursing progress note regarding resident 7 needing to reside in the memory care unit.
On 10/24/22 at 5:11 PM, a follow-up interview was conducted with resident 7. Resident 7 stated he did not really like being on the unit. Resident 7 stated he had his wallet and $30 stolen from his room. Resident 7 stated he had never been told why he had to be in the locked hallway. Resident 7 stated it was alright to be in the locked unit except his money had been stolen.
On 10/24/22 at 2:30 PM, an interview was conducted with the DON. The DON stated Quite honestly, I'm not aware of an assessment except for the wander risk for elopement. The DON stated Honestly, there is no wander risk, we should have had one, and I would like to believe that we would do it quarterly and on admit. The DON stated she believed resident 7 was in the memory care unit because of his Montreal Cognitive Assessment (MOCA) score. The DON stated she did not know resident 7's cognitive level and was not aware his BIMS score was a 15. The DON stated she wanted to say the physical therapist evaluated resident's need to be in the memory care unit. The DON stated she did not know but maybe we can ask the social worker who did the assessments.
On 10/26/22 at 5:46 PM, an interview was conducted with the Social Service Worker (SSW). The SSW stated she was not involved in determining if residents needed to reside in the memory care unit. The SSW stated she thought the Interdisciplinary Team (IDT) determined if a resident needed to reside in the memory care unit.
On 10/25/22 at 1:35 PM, an interview was conducted with the Administrator. The Administrator stated the nurses completed an assessment or care plan and then obtained a physician's order for residents to be in the memory care unit. The Administrator stated she did not know what the assessment was called or where it was located in the medical records. The Administrator stated she thought the assessment had information about their diagnoses, if they wander or pace and if they have behavioral issues that required more supervision. The Administrator stated the wander risk scale was part of the assessment but not all of it. The Administrator stated she was not sure about resident 7's cognitive status and why he was in the memory care unit.
The facility SNU Policy dated 3/1/18 revealed the following:
Memory Lane/Special Needs Unit
admission criteria have been established to promote proper placement of the resident with dementia and other type of impairment requiring a secured environment.
Specific admission and discharge criteria are in place for the memory care/secured unit residents in order to maximize safety and promote optimal functioning and well-being of the person.
Decision regarding admission to and discharge form the memory care/secured unit are based on an individualized assessment and/or safety of person.
1. A resident is admitted to the memory care/secured unit when his/her identified needs can be met through the unit's scope of service for eligible admissions which includes, but is not limited to:
a. A diagnosis of an irreversible dementia such as Alzheimer's disease, Lewy body dementia, vascular dementia, or Parkinson's dementia, etc. as diagnosed by a physician and with evidence of a dementia work-up
Evidence of cognitive impairment
b. The resident's behavior and behavioral needs.
c. Psychosocial needs outweigh his/her nursing needs
2. The primary care physician provides a documented health assessment of physical and mental health conditions and a statement indicating that the prospective resident is appropriate for admission.
Prospective residents are assessed by facility staff for appropriateness of admission through a comprehensive assessment of the resident's physical, psychosocial, and behavioral status including:
a. Mental status
Behavioral
b. Falls
Wandering and elopement
c. Functional
d. Psychosocial and well-being
3. Documentation in the residents record denotes the appropriateness of admission to the memory care/secured unit including:
a. The clinical criteria met for placement in the secured/locked area by the resident's physician along with information provided by members of the interdisciplinary team
b. Ongoing documentation of the review and revision of the resident's care plan as necessary, including whether he/she continues to meet the criteria for remaining in the secured/locked area, and if the interventions continue to meet the needs of the resident
The facility POLICY AND PROCEDURE FOR PROHIBITING ABUSE with no date revealed the following definition:
.Involuntary seclusion: Separation of a resident from other resident's or from his/her room or confinement to his/her room (with or without roommate) against the residents will, or the will of the resident's legal representative. This may includes residents who are living in an area of the facility which restricts their movement throughout the facility or temporarily separating a resident from other residents. [Emergency or short term monitored separation from other residents will not be considered involuntary seclusion and may be permitted if used for a limited period of time as a therapeutic intervention to reduce agitation until professional staff can develop a plan of care to meet the resident's needs.] .
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 3 of 33 sampled residents, that the facility did not en...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 3 of 33 sampled residents, that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, a resident was not provided diabetic management, antibiotics as ordered, or wound care which resulted in an amputation. Another resident was not provided treatment for a rash and the resident was unable to move in bed. These were cited at a harm level. In addition, a resident was not treated for her psoriasis. Resident identifiers: 29, 31 and 32.
Findings include:
Harm
1. Resident 29 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus with foot ulcer, schizoaffective disorder, neuropathy, generalized anxiety disorder, borderline intellectual functioning, hyperlipidemia, and hypomagnesemia.
On 10/12/22, resident 29 was observed with a dressing on her right foot. Resident 29 stated that she recently had surgery.
On 10/12/22 at 10:17 AM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated that resident 29 often came to the nursing desk to ask the nurses for her medications, but some of the nurses ignored resident 29 and told her to wait. CNA 2 stated that resident 29's family did not provide any assistance to resident 29. CNA 2 stated that resident 29 had a lot of medical needs, and CNA 2 was not sure resident 29 received all the care she needed.
On 10/11/22 at 5:05 AM, Registered Nurse (RN) 1 stated that she had not signed out resident 29's narcotic medication.
On 10/12/22 at approximately 10:00 AM, resident 29 was interviewed. Resident 29 was observed to be ambulating in a wheelchair and stated that she had an appointment with her surgeon because she had foot issues.
On 10/31/22, resident 29's medical record review was completed.
Resident 29's physician orders included the following:
a. Wound dressings were ordered for resident 29's right foot dated 11/11/21.
b. Wound order to: cleanse wound, use oil emulsion, 4X4, and ace wrap .Wound to plantar right foot, cleans, apply iodosorb, cover and change QD (daily).
c. Blood sugar checks before meals and at bedtime were initiated on 11/10/21.
d. Bacitracin ointment, 500 units/gram, apply to wound topically, initiated on 11/10/21.
e. Bactrim DS tablet, 800-160 MG (milligrams) (Sulfamethoxazole-Trimethoprim), 800 mg by mouth twice daily.
f. Lantus solution, 100 units/mL, inject 70 units subcutaneously in the morning and 60 units subcutaneously in the evening.
g. Humalog solution 100 units/mL, sliding scale.
h. Metformin 1000 mg, twice daily.
Resident 29's Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed the following:
a. In June, 2022, resident 29's Lantus was missed in the afternoon on 6/7, 6/13, 6/27, and 6/30; Metformin was missed in the afternoon on 6/7, 6/13, 6/27, and 6/30; Blood sugar checks were not done at 4:00 PM on 6/3, 6/13, 6/17, 6/20, 6/24, and 6/30; Blood sugar checks were not done at 9:00 PM - 6/7, 6/13, 6/27, and 6/30; the Humalog sliding scale was not provided at 4:00 PM on 6/3, 6/13, 6/17, 6/20, 6/24, and 6/30; the Humalog sliding scale was not provided at 9:00 PM, on 6/7, 6/13, 6/27, and 6/30; and Wound care to the right plantar foot: cleanse with wound spray, apply calcium alginate with lodosorb, cover with border gauze, wrap with Keflex and coban, change QD every day shift for wound care start 3/23/22, discontinued 8/2/22, not provided on 6/1, 6/8, 6/15, and 6/30/22.
b. In July, 2022, for resident 29's Lantus 70 units subcutaneously two times a day for diabetes, was missed on evening shift 7/5 and 7/10; Metformin 1000 mg, I tablet twice daily for DM II with foot ulcer, was missed on evenings of 7/5, and 7/10, Pain was not assessed 7/5/22 in the PM; Blood sugar was not checked at 4:00 PM check on 7/5, 7/9, 7/11, 7/15, 7/18, 7/22, 7/29, and 7/30; Blood sugar was not checked at 9:00 PM on 7/5, and 7/10; Humalog solution 100 u/ml (Insulin Lispro) checks were ordered for 7:30 AM, 11:00 AM, 4:00 PM, and 9:00 PM. The 4:00 PM check and insulin were missed on 7/1, 7/5, 7/9, 7/11, 7/15, 7/16, 7/18, 7/22, 7/25, 7/29, and 7/30; The blood glucose check and insulin administration were missed at 9:00 PM on 7/5, and 7/10.
c. In August, 2022, resident 29's Atorvastatin and Clozapine doses were missed on 8/10, and 8/28; Doxycycline was missed for the PM dose on 8/10, and the morning dose on 8/12 (with no extended doses); Doxycycline monohydrate tablet, 150 mg, Give 1 tablet by mouth two times a day for right foot for 14 Days was missed for the PM dose on 8/28/22; Lantus, Metformin, and gabapentin were not administered for the PM doses on 8/10, and 8/28; 4:00 PM Blood sugar checks missed on 8/1, 8/5, 8/10, 8/11, 8/12, 8/15, 8/22, and 8/26; 9:00 PM blood sugar checks were missed on 8/10, and 8/28; Humalog was not provided at 4:00 PM on 8/1, 8/5, 8/10, 8/11, 8/12, 8/15, and 8/22/22 and the 9:00 PM humalog was not provided on 8/10; and Wound care was not done on 8/15, and 8/27/22.
d. In September, 2022, resident 29's Clozapine was not provided in the afternoon of 9/5, and 9/14; Clozapine was not provided in the morning on 9/14/22 and 9/16/22; Lantus was not provided on 9/5, and 9/14; Metformin was not administered in the PM on 9/5, and the AM on 9/14; Clindamycin HCL capsule 300 MG, give 1 capsule by mouth three times a day related to unspecified open wound, right foot, subsequent encounter for 10 days, missed 9/14 all 3 doses (Arise, Noon, PM), and noon on 9/16 and the dosing was not extended; Humalog solution 100 unit/mL (insulin lispro)
sliding scale was not checked: 9/5 in the PM; 9/14 all day, 9/16 at noon, 9/26 at noon, and resident 29 was hospitalized on 9/28 and 9/29; Blood sugar checks were missed in the AM on 9/14, 11:00 AM on 9/14, 9/16, and 9/26, at 4:00 PM on 9/2, 9/5, 9/10, 9/11, 9/12, 9/16, 9/19, 9/20, 9/23, 9/24, 9/26, and 9/30, and at 9:00 PM on 9/5; Gabapentin was not administered on 9/5 in the PM, and on 9/14 in the AM, Noon, and PM; Magnesium not administered on 9/5 in the PM, and on 9/14 at Arise, Noon, and PM doses; Wound care was not provided on 9/1, 9/3, 9/5, 9/7, 9/24, 9/25, and 9/30/22.
e. In October, 2022, resident 29 did not received the following: Clozapine on 10/5 in the PM, on 10/17 in the AM, and on 10/24 in the PM; Humalog check and administration at Noon, missed on 10/5, and 10/17; HumaLOG Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 0 - 149 = 0; 150 - 200 = 3; 201 - 250 = 6; 251 - 300 = 9; 301 - 350 = 12; 351 - 400 = 15 Call medical provider if BS is >400, subcutaneously three times a day related to TYPE 2 DIABETES MELLITUS WITH FOOT ULCER, the afternoon Humalog was missed on 10/5, and 10/24; Blood sugar checks were missed on 10/5 at 11:00 AM and at 4:00 PM, on 10/10 at 4:00 PM, on 10/17 at 11:00 AM and at 4:00 PM; and on 10/24 at 4:00 PM and at 9:00 PM; and Magnesium was not provided on 10/5 at PM dose, 10/17 at noon, and on 10/24 at PM dose.
[Note: No charting was recorded that resident 29 refused cares or medications.]
Resident 29's nursing notes revealed the following:
a. On 11/15/21 at 2:05 PM, a Physician History and Physical (H&P) revealed that resident 29 had a chronic right heel wound.
b. On 12/7/21 at 12:20 AM, resident 29 was disrespectful condescending challenging me being a nurse [and] would not let me do dressing change and then saying that she is allergic to honey I did not clean it well enough and not to [put] the tegaderm on it .
c. On 4/26/22 at 9:00 AM, a nursing note revealed that resident 29 was examined by a wound healing company and the wound on resident 29's right foot was getting worse. Resident 29 was having delusions that the wound nurse wanted to cut her foot off. At 10:24 AM, the nurse noted a foul odor from the resident's foot and the ulceration appeared to be increasing in size and diameter.
d. On 4/30/22 at 12:03 PM, resident 29's foot wound showed signs of infection and Bactrim was ordered.
e. On 5/6/22 at 1:07 PM, resident 29's plantar foot wound had increased in size, width and depth. Wound has foul odor and drainage is thick .
f. On 5/9/22 at 1:12 PM, a physician progress note revealed that resident 29 often removed her dressings. The wound is larger and deeper and appears infected .
g. On 5/28/22 at 6:18 PM, a health status note revealed that resident 29 had redness above ankles on shin is flaring and spreading, resident continues scratching area even with anti-itch cream applied. Rash is only on the injured foot .Resident continues to sleep all day and not get out of bed even when she is encouraged to get out of bed .
h. On 6/2/22 at 5:02 AM, resident 29 was taking antibiotics for the foot infection.
i. On 6/3/22 at 2:33 AM, resident 29's antibiotics were extended for 7 more days. She is taking it for right foot ulcer which wound bed has red granulation tissue no foul odor .
[Nurses document non-compliance with cares at times, including on 6/18/22 for checking blood glucose because it was too early.]
j. On 7/14/22 at 11:06 AM, an NP (nurse practitioner)/PA (physician's assistant) progress note revealed that resident 29 had elevated blood sugars, she was noncompliant with wound care and would take the dressing off.
k. On 7/26/22 at 10:06 AM, a health status note revealed that resident has a right foot wound. The dressing was removed and the wound was cleaned. Wound area is red/swollen and shiny with foul odor. Informed Tx (treatment) nurse of wound status.
l. On 7/29/22 at 1:05 PM, resident 29 was on antibiotics for infection cellulitis. Resident continued on several types of antibiotics.
m. On 8/5/22 at 2:16 PM, resident was too tired to get out of bed and wanted to sleep all day.
n. On 8/5/22 at 4:04 PM, Noted a new sore on plantar next to the wound being treated. Appears to be a blistered ulcer, cream color appearance with blanching. 2x2 (2 inch square bandage) gauze applied and waiting for wound nurse to assess when she comes to change dressing on Tuesday 8/9/22.
o. On 8/19/22 at 3:22 AM, after continued antibiotics, Some redness on top of foot with serous sang (blood tinged clear fluid) drainage draining moderate amount especially with pressure to wound bed area. Wound bed is red granulation tissue .
p. On 9/15/22 at 6:57 PM, an order for a MRI was ordered of the right foot to check for osteomyelitis.
q. On 9/16/22 at 2:04 AM, resident 29 had an open area on the top of her foot and draining was coming through the bottom ulcer of her foot. Her right great toe and 2nd toe are red and swollen
r. On 9/22/22 at 3:41 PM, the MRI was completed at a nearby hospital. [Note: This was completed 7 days after the initial order.]
s. On 9/23/22 at 2:37 PM, resident 29 was referred to a surgeon for osteomyelitis.
t. On 9/28/22 at 1:53 PM, resident 29 was taken to the hospital for osteomyelitis.
u. On 9/30/22 at 1:30 AM, resident 29 returned to the facility after the first metatarsal and toe were removed from her right foot.
v. On 10/22/22 at 5:08 AM, resident stated that her dressing was coming off her foot. The nurse stated that the incision line that looked red and inflamed .
w. On 10/26/22 at 4:34 PM, resident 29 had mild wound breakdown .
Resident 29's wound care note from 10/18/22 revealed that resident 29 had no open areas on her foot. On 10/24/22, resident 29's wound was partially open.
Resident 29's care plan was reviewed. Resident 29 only had one focus, which was activity participation. No focus was created for diabetes, mental health, wound care, etc.
On 10/20/22 at approximately 10:00 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that he had obtained an order from the Medical Director (MD) to have a snack at bedtime for resident 29. LPN 1 stated that all residents should have a snack available, and a specific order should not have been necessary. LPN 1 stated that resident 29 had low blood sugar in the mornings. LPN 1 stated that resident 29 had significant blood glucose swings and needed to be monitored closely.
On 10/25/22 at 10:09 AM, Registered Nurse (RN) 3 was interviewed. RN 3 stated that resident 29's wound had a bit of dehiscence (opened). Resident 29 was receiving antibiotics, but the wound was looking infected again. RN 3 stated that resident 29 needed to follow up with her surgeon. RN 3 stated there was a small amount of yellow-red drainage, and resident 29 was unable to walk on her foot after her surgery. RN 3 stated that any additional wound care should have been charted in the nursing notes or on the TAR.
On 10/24/22 at 12:22 PM, the Medical Director (MD) was interviewed. The MD stated that she was not informed that resident 29's foot had reopened, and there was an area of what appeared to be necrotic tissue. The MD stated that the wound care company handled the wounds, and staff did not have the MD look at anyone's wounds.
On 10/25/22 at 1:35 PM, the Administrator (ADM) stated that she was the only staff member in the facility who had access to wound care notes. The ADM stated that she had not been able to access the notes lately. The ADM could not produce the notes for the latest wound care rounds.
Potential for Harm
3. Resident 31 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, unspecified dementia with behavioral disturbance, and depression.
On 10/12/22 at 10:42 AM, an interview was conducted with resident 31's family member. The family member stated resident 31 had a big bruise on her ankle a few weeks ago. The family member stated the family was not notified. The family member stated resident 31 had psoriasis and needed a cream but it was not applied.
On 10/21/22 at 12:59 PM, an interview was conducted with resident 31's family member. The family member stated the Power of Attorney (POA) was not notified that resident 31 had psoriasis on her ear and her ankle. The family member provided a picture of the ear and left lateral ankle and above the ankle. There were scratches on it. The family member stated the psoriasis was found by family on 9/18/22. The family member stated RN 6 was rude to the POA when he noticed a bandage on her leg with scratches. The family member stated resident 31's family was not notified of the open area, Band-Aid on her ankle and no cream was being applied.
Resident 31's medical record was reviewed.
An annual Minimum Data Set (MDS) dated [DATE] revealed resident 31 did not have skin break down.
A care plan dated 8/25/16 revealed The resident has potential for pressure ulcer development r/t (related to) Immobility. The goal had a target date 5/27/22 was The resident will have intact skin, free of redness, blisters or discoloration by/through review
date. Some of the intervention included to Administer medications as ordered. Monitor/document for side effects and effectiveness ; Follow facility policies/protocols for the prevention/treatment of skin breakdown; and Monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, s/sx (signs and symptoms) of infection, wound size (length X width X depth), stage.
A nursing progress note dated 9/18/22 at 2:18 PM, Resident's family notified me that resident has a sore on her left lateral ankle with a dressing on it and a rash on her back and on her ear. They asked me to take a look at it. They had been visiting with their mother and grandmother. I stated that we needed to take her down to her room so I can look at these skin issues. So we walked her down to her room. The family started asking why she was not being treated. She had no orders. I took off the Band-Aid off her left ankle. She had scabbed area there about 1 inches long by 1 inch wide. I cleansed the area with would cleanser, took a picture of this area to send to the house physician. The granddaughter and son also took pictures. The son asked what I put on it and I told him wound cleanser and Band-Aid. I also took a picture to send to the MD (Medical Doctor) of her mid right back rash that was about 2 inches by 3 inches. No (sic) open but she had been scratching at it. No open areas. Pictures sent to MD with a request for a tx (treatment). They were upset that I did not put anything else on it. I explained that I would need an order from the doctor before I do this. They accused me of ignoring them when I left the room. They asked me for my name and became very confrontational. I told them I was not going to argue with them and then ask the assistant DON if I could talk to her alone about the situation. I was quite upset at this time. She did go out a talk with them.
Resident 31's September 2022 Medication Administration Record (MAR) and Treatment Administration Record (TAR) was reviewed. Triamcinolone Acetonide Cream 0.1% had a start dated of 9/18/22. The instructions were to apply to affected areas topically two times a day for psoriasis. The cream was documented as applied twice daily starting 9/18/22 through 9/30/22.
Resident 31's October 2022 MAR and TAR was reviewed. The Tricamcinolone Acetonide Cream 0.1% was not applied twice daily. There was no check marks or nurses initial for hours of sleep on 10/3/22, 10/5/22, 10/10/22, 10/18/22, 10/22/22 and 10/24/22. There were no check marks or nurses initial for arise on 10/14/22 and 10/29/22.
A form with no title revealed resident 31 had a rash on her back on 9/16/22. There was no nurses signature.
On 10/18/22 at 10:04 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated when the MAR or TAR did not have a check mark or nurses initials, the it might not have gotten done those days because it wasn't charted as being done.
On 10/23/22 at 12:20 AM, an interview was conducted with CNA 6. CNA 6 stated resident 31 had psoriasis on her ear and on her back. CNA 6 stated resident 31's back was healing up and her outer ankle. CNA 6 stated a nurse should be applying the cream as a part of her treatments.
On 10/27/22 at 9:23 AM, an interview was conducted with the ADON. The ADON stated on 9/17/22, a CNA noticed an abrasion to resident 31's left ankle which was psoriasis. The ADON stated resident 31 had psoriasis on and off. The ADON stated there was Tricamcinolone cream scheduled and also as needed. The ADON stated in September 2022 her psoriasis had gotten worse. The ADON stated the Tricamcinolone cream was started it 9/18/22 after talking to the MD. The ADON stated CNA's tried to inform nursing staff if they noticed any new skin issues.
On 10/27/22 at 9:37 AM, an interview was conducted with the resident 31's POA. Resident 31's POA stated he noticed resident 31 had a patch of psoriasis on her leg, and her ear. Resident 31's POA stated the psoriasis on her ear had cleared up. Resident 31's POA stated he got upset with staff and told them she needed the cream and then the cream was applied.
On 10/24/22 at 12:19 PM, an interview was conducted with the DON. The DON stated the she did not know anything about resident 31 having psoriasis.
2. Resident 32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia, chronic obstructive pyelonephritis, severe sepsis, aspiration pneumonitus, supraventricular tachycardia, acute kidney failure, bipolar disorder, epilepsy, thyrotoxicosis and osteoarthritis.
Resident 32's medical records were reviewed between 10/11/22 and 10/31/22.
Resident 32's hospital discharge orders dated 8/18/22 were reviewed. The discharge orders included the following wound care orders: Apply zinc oxide TID (three times a day) to buttock/scrotum area. Please use baza cleanse and protect spray with gentle care touch cloths for all peri cares. Change silicone foam over LLE (left lower extremity) weekly. No other skin issues were documented on resident 32's discharge information packet provided to the facility.
No skin assessments could be located in resident 32's medical record.
Resident 32's nursing progress notes included the following entries:
a. On 8/19/22, . scrotum is red and excoriated with new order for Zinc oxide 40% to be applied TID.
b. On 9/14/22, Nystatin Powder Apply to neck [and] L (left) armpit topically two times a day for rash use until resolved.
c. On 9/18/22, . Resident has a rash on left side back that is healing.
d. On 10/1/22, . Resident has a rash on left side back that is healing.
e. On 10/9/22, . Resident has a rash on left side back that is healing.
On 10/6/22, a Nurse Practitioner Note documented that resident 32 had no skin issues, including rashes.
On 10/12/22, a physician's order was written to apply Hydrocortisone cream 1% to itchy, red areas topically every 8 hours as needed for itching. The October 2022 Medication Administration Record (MAR) for resident 32 was reviewed, and indicated that as of 10/26/22 resident 32 had not had any hydrocortisone applied.
On 10/25/22 at 10:09 AM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated that resident 32 had started with the rash on his left back/torso area since he was readmitted from the hospital in August 2022. RN 3 stated that resident 32 was being seen by a wound care provider for open areas on his ankles, but had not discussed resident 32's rash with them. When asked where those wound notes could be located, RN 3 stated that its been many months since I've seen those notes. RN 3 stated that the wound care provider would come in to see the resident, and then document their notes electronically. RN 3 stated that only the Administrator (ADM) had access to those wound care provider notes.
On 10/26/22 at 11:04 AM, an observation was made of resident 32's torso area with Certified Nursing Assistants (CNAs) 3 and 4. Resident 32 presented with red to red/purple skin on the left side of his back and bilateral lower extremities below the knees. The skin was peeling (excoriated) with open wounds that were not dressed. There were four small (less than 1 centimeter) open, bleeding areas on resident 32's back, all on the left side of the resident's spine. The skin over the spine also appeared to be peeling and red. CNA 3 stated that the Director of Nursing (DON) would come in later to assess the wound to determine the appropriate dressing/cream. CNA 3 stated that the skin did not blanch and demonstrated that the purple/red areas on resident 32's left side did not blanch. CNA 3 stated that resident 32 had a lot of pain with his brief changes, and that they worked together every day to make sure he had the Calmoseptine cream on his red areas. CNA 4 stated that resident 32's skin appeared better than a month ago. Lotion was applied by the CNAs over resident 32's legs.
On 10/24/22 at 12:20 PM, an interview was conducted with the facility Medical Director (MD). The MD stated that she had not been informed about the rash on resident 32's left torso area.
On 10/24/22 at 2:02 PM, the MD stated that she had just gone to look at resident 32's rash, and that its pretty bad. it looks like heat rash, but its so bad its draining serosanguinous fluid. The MD stated that at the time of her observation, resident 32's incontinence brief was in bad need of being changed. The MD stated that after she had observed resident 32's rash, she spoke with the DON about it. The MD stated that the DON told her that resident 32's rash had been that way since the resident was readmitted from the hospital in August 2022, but that the DON had not seen the rash since that time. The MD also stated that the DON has no idea if resident 32 had been referred to a wound clinic for his rash. The MD also stated that she was unable to locate any skin checks in resident 32's medical record.
On 10/24/22, the MD documented the following note in resident 32's medical record: A state surveyor notified me that she had been told [resident 32] has a rash on his back. The DON says this has been present for some time. [Observation]: left side of back with large area of redness with some yellow serous drainage, no signs of infection.Dermatitis - likely a heat rash. [Resident 32] lies (sic) in the same position and does not shower regularly. Will order calmoseptine and will have . wound provider look at it on next visit.
On 10/25/22 the wound provider saw resident 32, however only documented that they had evaluated resident 32's pressure injuries on his lower extremities.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included muscle wea...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included muscle weakness, schizophrenia, cognitive communication deficit, conversion disorder, anxiety disorder, chronic kidney disease, psychosis, difficulty in walking, and hyperlipidemia.
On 10/13/22 at 9:23 AM, an observation of resident 4 was made. Resident 4 was in bed and observed to have a feeding tube which entered through resident 4's nose. An interview with resident 4 was not conducted due to resident 4's cognitive communication deficit.
A review of resident 4's medical record was conducted.
Resident 4's MDS dated [DATE] revealed that resident 4 was on a feeding tube. The MDS was marked 51% or more for proportion of total calories the resident received through parenteral or tube feeding. The MDS was marked 51% or more for average fluid intake per day by IV (Intravenous therapy) or tube feeding.
Resident 4 had a care plan focus, dated 8/2/21, which stated, The resident requires tube feeding r/t (related to ) chewing problem swallowing problem. The goals were listed as, The resident will be free of aspiration through the review dated, the resident will maintain adequate nutritional and hydration status .weight stable, no s/sx (signs/symptoms) of malnutrition or dehydration through review date, [and] the resident will remain free of side effects or complications related to tube feeding through review date. The interventions/tasks listed were, The resident needs the HOB (head of bed) elevated 45 degrees during and thirty minutes after tube feed. Obtain and monitor lab/diagnostic work as ordered. Reports results to MD (medical director) and follow up as indicated. The resident is dependent with tube feeding and water flushes. See MD orders for current feeding orders.
On 10/20/22 at 10:00 AM, an interview with LPN 1 was conducted. LPN 1 stated that he was aware of a night nurse, 1 who, on multiple occasions, was not following the doctor's orders to flush resident 4's feeding tube. LPN 1 stated that on one occasion, LPN 1 came on shift in the morning and discovered that resident 4's feeding tube was clogged from 11:30 PM the night before, and RN 1 who oversaw resident 4 did not unclog it, start an IV for hydration, nor inform the doctor that the tube feeding was clogged. LPN 1 stated that he immediately got orders to send resident 4 to the emergency room to unclog the feeding tube. LPN 1 stated that he felt this occasion was neglectful. LPN 1 stated that resident 4's only source of water and nutrition was through it feeding tube. LPN 1 stated that IV fluids should have been started to avoid dehydration. LPN 1 stated that about a week after this incident, it happened again under RN 1's care.
On 9/4/22 at 10:10 AM a progress note stated, Resident pulled out NJ (nasojejunal) tube at approx [approximately] 0130 (1:30AM) per night shift report. MD notified and ordered IV fluids until NJ can be replaced. IV is infusing .
On 10/21/22 at 11:44 AM an interview with the DON was conducted. The DON reported that on one occasion the night nurse, RN 1, was on duty and did not start an IV or inform a doctor when resident 4's feeding tube was clogged. The DON stated that when she came on shift in the morning and learned that the feeding tube was clogged, the DON immediately started an IV. The DON stated that the night nurse should have started the IV and informed the doctor right away. The DON stated that resident 4 was diabetic and it would have been dangerous if resident 4 became dehydrated.
A document titled Counseling Slip dated 9/4/22 was reviewed. The counseling slip was for RN 1. The document stated, Reason for counseling: stated in report IV fluids have been infusing since 0130 (1:30 AM). Checked after report to find IV not running and bag still full. [Resident] did not receive fluids from 0130-0530 (1:30 AM - 5:30 AM). No checks to see if fluids are running.
[Note: It should be noted that this deficiency was cited during the previous annual recertification survey completed on 9/1/21.]
5. Resident 36 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, anxiety, diabetes mellitus, anemia, intellectual disabilities, and depression.
On 10/11/22 from 4:22 AM until 6:04 AM, resident 36 was observed wandering the memory care unit. Resident 36 appeared thin, and paced continuously.
On 10/13/22 at 10:30 AM, LPN 1 was observed during medication (med) pass administering medications to resident 36. LPN 1 stated that resident 36 had been asleep and did not receive any medications or supplements before med pass. LPN 1 was observed to provide eight medications and supplements. LPN 1 was not observed to provide resident 36 a mighty shake. LPN 1 stated that he did not pass any of the Mighty Shakes because they were frozen.
On 10/22/22 at 10:40 AM until 12:37 PM, resident 36 was observed wandering the hallway in the memory care unit.
On 10/24/22 at 11:12 AM until 11:50 AM, resident 36 was observed pacing the hallway in the memory care unit. Resident 36 was observed to ask CNA 4 and CNA 8 for scissors because there were wires on his bed.
On 10/31/22, resident 36's medical record review was completed.
Resident 36's physician orders included an order for a supplement called at Mighty Shake, three times daily, when resident 36 arose, at noon, and in the afternoon (time unspecified).
A diet order for an enriched diet.
Resident 36's weights were obtained by the facility. On 9/4/22, resident 36 weighed 120.8 pounds. On 10/16/22, resident 36 weighed 116.4 pounds. On 9/12/21, resident 36 weighed 123.2 pounds. Resident 36 lost 5.6% of his total body weight in one month.
On 10/26/22 at 4:08 PM, an interview was conducted with the DM. The DM stated that the fortified and enriched diets were the same, with added calories for people who had weight loss. The DM stated that the high-protein drink for most residents was the Mighty Shake. The DM stated that for resident 36, staff tried to get him finger foods because he would eat a little and walk away. The DM stated that resident 36 walked away his calories. The DM stated that the nurses provided the Mighty Shakes to the residents. The DM stated that there was butter stored on the top of the serving cart, but the butter was not always added.
6. Resident 37 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, DM II, hypokalemia, chronic pain, epilepsy, delusional disorder, dementia, osteoporosis, atherosclerotic heart disease, systemic lupus erythematosus, hypertension, and schizophrenia.
On 10/13/22 at 10:30 AM, LPN 1 was observed during medication (med) pass administering medications to resident 37. LPN 1 stated that resident 37 had been asleep and did not receive any medications or supplements before med pass. LPN 1 was observed to provide eight medications and supplements. LPN 1 was not observed to provide resident 37 a mighty shake. LPN 1 stated that he did not pass any of the Mighty Shakes because they were frozen.
Resident 37's record review was completed on 10/31/22.
Resident 37 had an order for a Mighty Shake, one time a day in the morning.
Resident 37's dietary order was for RCS, mechanical soft texture, and regular consistency, with directions for fortification and twice daily high-protein snacks.
On 10/20/22 at 10:00 AM, an interview was conducted with LPN 1. LPN 1 stated that residents did not receive Mighty Shakes unless there was an order. LPN 1 stated that the nurses were responsible to get the Mighty Shakes from the freezer and defrost them for the shift. LPN 1 stated that the Mighty Shakes were typically not available early in the morning, because they took a few hours to thaw.
On 10/26/22 at 3:51 PM, an interview was conducted with the DM. The DM stated that she purchased the Mighty Shakes as needed. The DM stated that sometimes weights were missed by the staff, but usually it was because the residents had refused. The DM stated that she did not know why the latest week's weights were not available. The DM stated that the last available weights were from 10/16/22.
On 10/28/22 at 10:55 AM, an interview was conducted with CNA 1. CNA 1 stated that resident 37 was only calm when staff fed her meals, but staff did not typically feed her, because it was not required.
[Note: The Task list for CNAs revealed that resident 37 received assistance with meals one time in the past 30 days, between 10/1/22 and 10/30/22, which was on 10/4/22.]
On 10/27/22 at 2:30 PM, an observation was made of the facility medication room. There were 25 Mighty Shakes on a tray in the medication room on the counter. An interview was immediately conducted with the Assistant Director of Nursing (ADON). The ADON stated she had received the mighty shakes that morning and had administered a few with the lunch medication pass. The ADON stated the Mighty Shakes were frozen for the morning medication pass. The ADON stated that residents cannot drink the Mighty Shakes when they're frozen, so they were not administered in the morning. The ADON stated she was thawing the Mighty Shakes on the counter so they could be administered during afternoon medication pass, and the Mighty Shakes should have been refrigerated.
Potential for Harm
2. Resident 7 was admitted to the facility on [DATE] with diagnoses which included Schizoaffective disorder, dementia with behavioral disturbance, anxiety, concussion with loss of consciousness, and diabetes mellitus.
On 10/12/22 at 11:55 AM, an interview was conducted with resident 7. Resident 7 stated he was not getting enough to eat and he was loosing weight.
On 10/12/22 at 2:53 PM, a follow up interview was conducted with resident 7. Resident 7 stated the food was not healthy and he did not like rice. Resident 7 stated he was served a lot of rice.
Resident 7's medical record was reviewed.
An annual MDS dated [DATE] revealed resident's weight was 210 and there was no significant weight loss of 5% or more in the last month or more that 10% in the last 6 months. Resident 7 was not receiving a therapeutic diet (e.g. low salt, diabetic, low cholesterol).
A care plan dated 8/10/22 revealed resident 7 was at nutritional risk as evidence by body mass index greater than 27, Reduced concentrated sweets (RCS) therapeutic diet. The goals were resident will have no significant weigh change, resident will have moist mucous membranes and no tenting of skin, no aspiration/cough while eating, no discomfort due to eating, and skin will remain intact. The approaches developed were to monitor weekly weights, encourage more that 85 % food intake, multivitamin with minerals, vitamin D and a diet order of RCS, regular texture, thin liquids.
A physician's order dated 3/2/21 revealed resident 7 was to receive a reduced concentrated sweets diet related to type 2 diabetes mellitus with diabetic neuropathy.
Resident 7's weights were: [Note: All weights were in pounds.]
a. October 2021 was 216
b. April 2022 was 207.8
c. May 2022 was 205
d. June 2022 was 202.2
e. July 2022 was 200.4
f. August 2022 was 200.1
g. September 2022 was 201.1
h. October 2022 was 197.6.
It should be noted that resident 7 experienced a 4.9% weight loss in 6 months, 1.3% in 3 months and 1.7% in a month. Resident 7's weight was trending downward.
Resident 7's amount eaten documentation by the CNA (Certified Nursing Assistant)revealed inconsistent documentation. Resident 7 did not have documentation for 10/3/22, 10/4/22, 10/5/22, 10/8/22, 10/9/22, 10/10/22, 10/11/22, 10/13/22, 10/14/22, 10/15/22, 10/16/22, 10/18/22, 10/19/22, 10/20/22 and 10/23/22. Resident 7 ate 75-100% for 10 meals, resident 7 ate 51-75% 4 times, and resident 7 ate 2 meals of 26-50% from 10/1/22 until 10/25/22.
A Quarterly Nutrition Note by the DM dated 8/10/22 revealed resident 7 was on a mechanical soft RCS diet and was eating 50-100% of his meals. Resident was dining in the secured unit and his skin was intact. The comments revealed the physician was notified of weekly weight, eating well, self directed with choices and intake. There were no changes made and would continue to monitor.
On 10/11/22 at 7:45 AM, an observation was made of resident 7. Resident 7 was observed to be served a pancake, ground meat, grapes and cream of wheat. Resident 7's meal card revealed that resident 7 was to receive a RCS mechanical soft texture diet.
On 10/20/22 at 11:49 AM, an observation was made of resident 7. Resident 7 was served a taco with shredded lettuce and lemon pie. All residents in the memory care unit were observed to be served lemon pie.
On 10/26/22 at 3:51 PM, an interview was conducted with the DM. The DM stated resident 7 ate everything and she had not been worried resident 7 weight was trending downward. The DM stated resident 7 was on a mechanical soft diet. The DM stated grapes should be cut up and lettuce should be shredded for resident with mechanical soft diet orders.
On 10/27/22 at 4:39 PM, an interview was conducted with CNA 5. CNA 5 stated that resident 7 did not like any of the food and he looked at her and said Look at this. I've lost 2 pounds.
On 10/26/22 at 5:40 PM, a phone interview was conducted with the Medical Director (MD). The MD stated the weights were printed out months and she signed the graphs. The MD stated she was not aware of the facility skin and weight meeting process. The MD stated she was not notified beyond the graphs of resident's weights.
3. Resident 13 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included encephalopathy, paroxysmal atrial fibrillation, muscle weakness, dementia, and schizoaffective disorder.
On 10/11/22 at 7:50 AM, an observation was made of resident 13. Resident 13 was observed to be served a pancake, sausage, oatmeal and grapes. Resident 13 was not observed to be served a mighty shake by nursing staff or dietary staff.
On 10/26/22 at 11:46 AM, an observation was made of resident 13. Resident 13 was not observed to be served a mighty shake. Surveyor was in the memory care unit from 1:45 PM until 2:36 PM, and there was no nurse observed in the memory care unit to administer a mighty shake.
Resident 13's medical record was reviewed.
An annual MDS dated [DATE] revealed resident was 159 pounds with no weight loss or gain of 5% or more in the last more or more than 10% in the last 6 months. Resident 13 did not have a mechanically altered diet or a therapeutic diet.
Resident 13's nutritional care plan updated on 9/9/22 revealed resident weight was down by 10.1% in 3 month and 12.2% in 6 months. Resident 13 was at risk for nutritional risk as evidence by chewing/swallowing problems with poor dentition and mechanical soft therapeutic diet. The goals were resident 6 would not have significant weight loss, maintain moist mucous membranes and no tenting of skin, no aspiration/cough while eating, tolerate diet, no discomfort due to diet and skin will remain intact. The approaches were monitor weekly weights, encourage more that 75% of meal intake, with a diet of regular, mechanical soft and thin liquids. It should be noted the physician's dietary order was for regular texture and consistency.
Physician's orders revealed the following dietary orders:
a. On 1/23/17, regular diet with regular texture and regular consistency.
b. On 8/17/22, mighty shake three times a day for a supplement
c. On 3/15/18, high protein snacks three times a day
Resident weights were as follows: [Note: All weights were in pounds.]
a. October 2021 was 186.6
b. April 2022 was 178.8
c. May 2022 was 178.2
d. June 2022 was 175.4
e. July 2022 was 174.2
f. August 2022 weight was refused
g. September 2022 was 157.6
h. October 2022 was 162.4
It should be noted that resident 7 lost 3% weight in 1 month, 6.7% in 3 months and 9.1% in 6 months.
A form titled Skin/Hydration/Weight Meeting dated 7/22/22 revealed resident 13's weight was 170.4 pounds and weight had decreased 2.1% in 1 week. Resident 7 was on a mechanical soft diet with intake amount refused to 50% to 100% and skin was intact. Resident 7's MD was notified of weekly weights, weight was trending down, resident tended to worry about weight gain, and did not want to gain weight at all. Resident 7 currently was COVID positive. The DM documented Will fortify diet as to not add more volume in suppl, (supplement) etc will follow closely. The note was co-signed by the Registered Dietitian (RD). It should be noted there was no change in resident 13's diet order to fortified.
A Skin/hydration/weight Meeting on 9/9/22 revealed that resident had 10.1% weight loss in 3 months and 12.2% in 6 months. Resident 13 was receiving a regular mechanical soft diet. It was documented that the MD was notified of weekly weight and resident 13 was eating fair to poor and refused to eat at some meals. Resident 13 was self directed with meal choices and intake. Resident 13 encourage intake and will continue to monitor.
On 10/26/22 at 4:20 PM, an interview was conducted with the DM. The DM stated resident 13's weight was bouncing up and then back down. The DM stated resident 13 did not want to gain weight and he really focused on his weight.
4. Resident 31 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, hyperlipidemia, dementia with behavioral and major depressive disorder.
On 10/11/22 at 7:50 AM, an observation was made of resident 31. Resident 31 was observed to be served a pancake, ground meat, hot cereal and grapes. Resident 31 was not served a mighty shake. Resident 31 was observed to be assisted with eating by CNA 2.
On 10/12/22 at 10:31 AM, an interview was conducted with resident 31's family member. The family member stated resident 31 had lost weight and her current weight was like 112 or 114. The family member stated resident 31 ate but staff did not give her the time of day to feed her.
On 10/18/22 at 12:14 PM, resident 31 was observed in the memory care unit dining room. Resident was observed to be eating cake with her fingers. The cake was crumbled and she was getting small amounts into her mouth. Resident 31's meal ticket was on her plate and resident was observed to pick up her meal ticket and put it between her fingers and raised the meal ticket to her mouth. Resident 31 dropped her meal ticket onto her lap. Resident 31 had rice and a orange/brown substance over the rice. Resident 31 did not have utensils. There were no staff in the dining room. LPN 1 was observed outside the dining room and CNA 1 was in another residents room.
On 10/20/22 at 11:49 AM, resident 31 was observed in the memory care unit dining room. Resident 31 was observed to be assisted by CNA 4 with eating. CNA 4 stated resident 31 sometimes received a small chocolate shake with her meals.
On 10/24/22 at 11:53 AM, resident 31 was observed in the memory care unit dining room. Resident 31 was observed to place her hands in her cake. CNA 8 was observed to remove resident 31's hands from the cake and clean them off. Resident 31 was not observed to have a mighty shake.
On 10/26/22 at 11:46 AM, resident 31 was observed in the memory care unit dining room. Resident 31 was observed to be assisted with eating by the Director of Nursing (DON). Resident 31 was not observed to have a mighty shake. A continual observation was conducted of the memory care unit until 2:36 PM. The DON was not observed to provide mighty shakes.
Resident 31's medical record was reviewed.
An annual MDS dated [DATE] revealed resident 31 was 115 pounds with no weight loss or gain of greater than 5% in a month or greater than 10% in 6 months. Resident 31 did not have a mechanically altered or therapeutic diet. The MDS revealed resident 31 required limited 1 person assistance with eating.
A nutritional care plan dated 10/14/22 revealed resident 31 was at nutritional risk as evidence by history of weight loss, enriched diet and Alzheimer's Dementia. The goals were no significant weight loss, maintain moist mucous membranes or tenting, no aspirate/cough while eating, tolerate diet, no discomfort due to diet and skin remain intact. The interventions were monitoring weekly weights, encourage more than 60%, high protein three times a day. The diet was enriched, minced and moist with thin liquids. The supplements were mighty shakes three times a day and boost breeze daily.
Resident 31's weights in the medical record were: [Note: All weights were in pounds.]
a. October 2021 was 130.4.
b. April 2022 was 116.8
c. May 2022 was 116
d. June 2022 was 117
e. July 2022 was 116.4
f. August 2022 was 115.6
g. September 2022 was 112.8
h. October 2022 was 113.6
A nutritional assessment dated [DATE] revealed that resident 31 continued on enriched, minced and moist food with thin liquids. Resident 31 had a average intake of about 70%. Resident 31 had resource breeze daily, mighty shakes three times a day and high protein snacks three times per day. Resident 31's weight increased 1.2% in the past week. The RD documented that a medication review was requested to possibly add remeron in September and it was not added. The RD documented remeron was not added and the RD will continue to current plan of care and follow-up as needed.
Resident 31's CNA documentation regarding the amount of food eaten revealed resident 31 ate 14 times over a 30 day period of time. Resident ate 75-100% 11 times and 51-75% 3 times in the previous 30 days.
Resident 31's Medication Administration Record (MAR) revealed Resource Breeze 1/2 box was not administered on 10/3/22, 10/5/22, and 10/14/22. Mighty shakes were not administered on 10/3/22, 10/5/22, and 10/14/22. Mighty Shakes were documented as administered on 10/13/22 by LPN 1 and on 10/26/22 by the DON.
On 10/13/22 from 9:30 AM to 11:30 AM, an observation was made of the facility medication pass. LPN (Licensed Practical Nurse) 1 did not administer mighty shakes to residents. LPN 1 stated that he did not pass any of the Mighty Shakes because they were frozen.
On 10/26/22 at 2:45 PM, an interview was conducted with the DON. The DON stated that she gave a resident 31 her mighty shake about 8:30 AM and resident 31 did not really drink it. The DON stated that she administered resident 31's noon mighty shake at 2:30 PM. It should be noted that there was a continual observation of the memory care unit from 1:45 PM until 2:36 PM and the DON was not observed to enter the unit during that time. The lunch meal was observed and resident 31 did not receive a mighty shake with her meal.
On 10/26/22 at 1:56 PM, an interview was conducted with CNA 1. CNA 1 stated she did not have a mighty shake to feed resident 31 with lunch.
On 10/27/22 at 9:36 AM, a phone interview was conducted with resident 31's power of attorney (POA). The POA stated he knew resident 31 was loosing weight because of the way she looked. The POA stated he had not been notified by the facility staff that resident 31 had lost weight.
On 10/26/22 at 4:11 PM, an interview was conducted with the DM. The DM stated resident 31 was loosing weight because of her dementia. The DM stated resident 31 ate sandwiches because she did not smash them into things. The DM stated every meal resident 31 needed to be provided with assistance for eating. The DM stated resident 31 was provided snacks three times a day, a box of boost breeze daily, and mighty shakes three times a day. The DM stated resident 31 drank the supplements well. The DM stated there was high protein milk for residents on enriched or fortified foods. The DM stated resident 31 should have more fats and gravies with extra calories. The DM stated the high protein drink consisted of 1 gallon of whole milk, 2 cups powdered milk, sugar and flavor. The DM stated residents were served 8 ounces of the high protein milk. The DM stated resident 31 should be getting the high protein milk with every meal.
On 10/26/22 at 11:39 AM, an interview was conducted with CNA 1. CNA 1 stated that resident 31 had lost weight because she was pacing the hallway more. CNA 1 stated most of resident 31's weight loss had experienced it gradually. CNA 1 stated if a residents weight was to low, then the resident received breezes or mighty shakes. CNA 1 stated there were sandwiches available for resident that need more food. CNA 1 stated that sometimes weight were off on the scale so a re-weigh was done. CNA 1 stated if a resident continued to loose weight then there were interventions to prevent more weight loss like sandwiches or supplements. CNA 1 stated resident 31 got a sandwich three times a day. CNA 1 stated she was given a mighty shake with her medications or with her meals.
On 10/18/22 at 1:23 PM, an interview was conducted with [NAME] 1. [NAME] 1 stated that there were mighty shakes in the freezer in the kitchen. [NAME] 1 stated the nursing staff had to come ask for the mighty shakes and they were kept in the refrigerator at the nurses station. [NAME] 1 stated that boost breeze came out with snacks at 10:00 AM, 2:00 PM and 8:00 AM.
On 10/18/22 at 1:28 PM, an interview was conducted with LPN 1. LPN 1 stated he went through about 15 mighty shakes per day. LPN 1 stated he was out of the medication pass and the mighty shakes were still frozen on 10/13/22. LPN 1 stated it took about 4 hours for the mighty shakes to thaw. LPN 1 stated if he did not have enough mighty shakes he administered boost breeze to residents. It should be noted during the medication pass on 10/13/22, LPN 1 did not administer boost breeze when he did not have mighty shakes available.
On 10/27/22 at 4:15 PM, an interview was conducted with CNA 5. CNA 5 stated resident 31 was not supposed to be fed, but she was just forgetting how to eat. CNA 5 stated resident 31 needed help eating because she did not know how to eat on her own. CNA 5 stated she tried to get resident 31 finger foods and then she could cue resident 31 to eat. CNA 5 stated she needed to be fed foods like soup. CNA 5 stated she was the only CNA for the entire facility from 2:00 PM to 10:00 PM most days. CNA 5 stated that dining rooms had to go unattended at times. CNA 5 stated residents in the main dining room were independent. CNA 5 stated the nurses sometimes helped in the dining rooms.
Based on interview, observation and record review, the facility did not ensure that 7 of 33 sample residents maintained acceptable parameters of nutritional status. Specifically, residents with weight loss did not receive timely and appropriate interventions. One resident will be cited at a harm level due to continued weight loss with no new interventions. Resident identifiers: 4, 7, 13, 31, 32, 36, and 37.
Findings include:
Harm
1. Resident 32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia, chronic obstructive pyelonephritis, severe sepsis, aspiration pneumonitus, supraventricular tachycardia, acute kidney failure, bipolar disorder, epilepsy, thyrotoxicosis and osteoarthritis.
Resident 32's medical records were reviewed between 10/11/22 and 10/31/22.
A 5 day Minimum Data Set (MDS) dated [DATE] revealed that resident 32's weight was 190 pounds (lbs) and there was no significant weight loss of 5% or more in the last month or more that 10% in the last 6 months. The MDS also indicated that the resident did not have any pressure ulcers at that time.
A Nutritional Care Plan dated 8/21/22 revealed that resident 32 was at nutritional risk, but the reasons for the risk were not documented. The goals were resident 32 will have no significant weight change, resident will have moist mucous membranes and no tenting of skin, no aspiration/cough while eating, resident will tolerate diet, no discomfort due to eating, and skin will remain intact. The approaches developed were to monitor weekly weights, encourage 90 percent food intake, and a regular diet with thin liquids. The care plan had been changed to reflect that resident 32 was changed to a mechanical soft diet, a fortified diet, and high protein snacks twice daily, but no dates were documented with the changes.
The care plan was updated on 9/9/22 indicating that resident 32's weight was down 2.3 % that week. However, no additional interventions were listed on the care plan.
The care plan was updated on 9/16/22 indicating that resident 32's weight was down 3.8% that week. However, no additional interventions were listed on the care plan.
The care plan was updated on 10/7/22 indicating that resident 32's weight was down 6.4% that month. However, no additional interventions were listed on the care plan.
On 6/27/18, a physician's order was written for resident 32 to receive a high protein snack three times a day for weight loss. Review of the October Medication Administration Record (MAR) as of 10/26/22 revealed that resident 32 was not given the high protein snack on 10/2/22 (once), 10/18/22 (once), 10/19/22 (twice) and 10/24/22 (once).
On 8/16/22, a physician's order was written for resident 32 to receive a mighty shake three times a day due to his weight loss. Review of the October 2022 MAR as of 10/26/22 revealed that resident 32 was not given the mighty shake on 10/18/22 (once), 10/19/22 (twice), and 10/24/22 (once).
Nutrition notes were reviewed and revealed the following:
a. On 8/19/22, facility staff completed a Nutritional Assessment for resident 32. His weight was documented as 219.14 pounds lbs. The assessment indicated that resident 32 received a regular mechanical soft diet.
b. On 8/26/22, facility staff completed a Skin/Hydration/Weight Meeting note. The note indicated that the resident now weighed 198.4 lbs, a weight loss of 20.7# (Ibs) that week. Facility staff documented that they questioned the accuracy of the weight, but did not obtain a repeat weight.
c. On 9/2/22, facility staff completed a Skin/Hydration/Weight Meeting note. The note indicated that resident 32 now weighed 195.4 lbs, a weight loss of 3# or 1.5% of his body weight that week. Facility staff documented that they would add high protein s[TRUNCATED]
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Tube Feeding
(Tag F0693)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 1 of 33 sampled residents, that the facility failed to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 1 of 33 sampled residents, that the facility failed to provide appropriate treatments and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. Specifically, physician orders to prevent a clogged feeding tube were not followed for a resident who was receiving enteral feeding. Resident identifier: 4.
Findings Include
1. Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included muscle weakness, schizophrenia, cognitive communication deficit, conversion disorder, anxiety disorder, chronic kidney disease, psychosis, difficulty in walking and hyperlipidemia.
On 10/13/22 at 9:23 AM, an observation of resident 4 was made. Resident 4 was in bed and observed to have a feeding tube which entered through resident 4's nose. An interview with resident 4 was not conducted due to resident 4's cognitive communication deficit.
Resident 4's medical record was reviewed.
Resident 4's Minimum Data Set (MDS) dated [DATE] revealed that resident 4 is on a feeding tube. The MDS was marked 51% or more for proportion of total calories the resident received through parenteral or tube feeding. The MDS was marked 51% or more for average fluid intake per day by IV (intravenous therapy) or tube feeding.
Resident 4 had a care plan focus, dated 8/2/21, which stated, The resident requires tube feeding r/t (related to) chewing problem swallowing problem. The goals were listed as, The resident will be free of aspiration through the review dated, the resident will maintain adequate nutritional and hydration status .weight stable, no s/sx (signs/symptoms) of malnutrition or dehydration through review date, [and] the resident will remain free of side effects or complications related to tube feeding through review date. The interventions/tasks listed were, The resident needs the HOB (head of bed) elevated 45 degrees during and thirty minutes after tube feed. Obtain and monitor lab/diagnostic work as ordered. Reports results to MD (medical director) and follow up as indicated. The resident is dependent with tube feeding and water flushes. See MD orders for current feeding orders.
The Treatment Administration Record (TAR) document was reviewed from 10/1/22 to 10/12/22. The TAR orders had multiple days with incomplete documentation:
a. An order with a start date of 1/10/21 stated, Change syringe and feed bag/tubing with date labeled Q (every) night shift There was no documentation as administered on 10/2/22, 10/3/22, 10/8/22, 10/9/22, 10/10/22, or 10/11/22. It should be noted that this order was blank in the nursing initial section 6 out of 12 times from 10/1/22 to 10/12/22.
b. An order with a start date of 4/22/22 stated, Flush feeding tube night shift every 3 hours .every night shift .to prevent clogging of tube. There was no documentation as administered on 10/2/22, 10/3/22, 10/8/22, 10/9/22, 10/10/22, or 10/11/22. It should be noted that this order was blank in the nursing initial section 6 out of 12 times from 10/1/22 to 10/12/22.
On 10/18/22 at 10:04 AM, an interview with Registered Nurse (RN) 3 was conducted. RN 3 stated when there were blank area in the nursing initial section on the Behavior Tracking document, the MAR, and the TAR, that meant the nurse did not chart whether the order was completed or not. RN 3 stated that not charting whether orders were completed or not could mean that the orders were not completed.
On 10/20/22 at 10:00 AM, an interview with Licensed Practical Nurse (LPN) 1 was conducted. LPN 1 stated that he was aware of a night nurse who, on multiple occasions, was not following the doctor's orders to flush resident 4's feeding tube. LPN 1 stated that on one occasion, LPN 1 came on shift in the morning and discovered that resident 4's feeding tube was clogged from 11:30 PM the night before, and the night nurse in charge of resident 4 did not unclog it, start an IV for hydration, nor inform the doctor that the tube feeding was clogged. LPN 1 stated that he immediately got orders to send resident 4 to the emergency room to unclog the feeding tube. LPN 1 stated that he felt this occasion was neglectful. LPN 1 stated that resident 4 has had the NJ (nasojejunal) tube for almost 2 years. LPN 1 stated an NJ tube was temporary so he should have had a PEG (percutaneous endoscopic gastrostomy) tube placed. LPN 1 stated that the facility had been discussing replacing the NJ tube with a PEG tube for about 2 years. LPN 1 stated he was not sure why the appointment for resident 4 to get a PEG tube was continuously postponed.
Resident 4's progress notes revealed multiple occasions where the NJ tube has been clogged:
a. On 1/21/22 at 3:36 PM, Resident was taken via w/c (wheelchair) to . hospital at 9:15 [AM] for a replacement of his clogged NJ tube .
b. On 3/2/22 at 8:41 PM, Resident NG (nasogastric) tube clogged and was being declogged when it burst with a hole in it. MD notified and orders for a replacement of NG .
c. On 4/16/22 at 10:16 AM, NJ tube is clogged. Radiology is unable to replace tube all weekend. Scheduling office is closed so will have to call Monday morning to schedule NJ replacement. MD notified .
d. On 5/21/22 at 8:59 PM, In to assist RN with a clogged feeding tube. Feeding tube was unhooked from machine easier as it was reported that he had a shower .
e. On 9/22/22 at 4:53 PM, NJ tube became clogged, and resident then pulled the tube out on his own. MD notified and ordered NJ tube replace by [hospital name redacted] radiology .
On 10/21/22 at 11:44 AM, an interview with the Director of Nursing (DON) was conducted. The DON reported that on one occasion the night nurse on duty did not start an IV or inform a doctor when resident 4's feeding tube was clogged. The DON stated that when she came on shift in the morning and learned that the feeding tube was clogged, she immediately started an IV. The DON stated that the night nurse should have started the IV and informed the doctor right away. The DON stated that resident 4 was diabetic and it would have been dangerous if resident 4 became dehydrated.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0697
(Tag F0697)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cellulitis and absc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cellulitis and abscess of mouth, osteoarthritis in left hip, chronic pain, metabolic encephalopathy, Wernicke's encephalopathy, dementia and psychosis.
On 10/20/22 at 12:00 PM, an interview and observation was made of resident 14. Resident 14 asked why he was in more pain and getting more medication than before he left to the hospital. Resident 14 stated he had pain in legs, hands and spine. Resident 14 stated eating hurt and pain kept him awake at night.
On 10/26/22 at 12:15 PM, an interview was conducted with resident 14. Resident 14 stated he had pain in his right leg and pain from his shoulder to his toes down his leg on his left side. Resident 14 stated he was not in pain at the hospital but since getting back to the facility he had been in pain. Resident 14 stated in the morning he was woken-up by his pain. Resident 14 stated if he got his pain medication prior to bed, then he was able to sleep. Resident 14 stated without pain killers he did not sleep at all. Resident 14 stated the cold weather made his pain worse. Resident 14 stated he didn't do much because he was in pain. Resident 14 stated if there were activities, he would not go because it hurt for him to walk. Resident 14 stated at the hospital, they were able to control his pain, but he was unable to get the same medications at the facility. At 12:42 PM, resident 14 stated that his back was hurting and he was in pain. Resident 14 stated the pain medication did not last very long.
Resident 14's medical record was reviewed.
A quarterly Minimum Data Set, dated [DATE] revealed that resident 14 had received scheduled and as needed pain medication. The MDS revealed resident had pain or was hurting any time in the last 5 days and was almost constantly experiencing pain in over the previous 5 days. The MDS revealed that resident 14's pain limited his day-to-day activities. The MDS revealed resident's worst pain intensity was very severe, horrible in the previous 5 days.
A care plan dated 6/10/13 with a target date of 5/3/22 revealed The resident has pain r/t (related to) general pain, arthritis, low back pain. The goal was The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Interventions included The resident will not have discomfort related to side effects of analgesia through the review date; The resident will not have an interruption in normal activities due to pain through the review date ; The resident will display a decrease in behaviors of inadequate pain control (SPECIFY: irritability, agitation, restlessness, grimacing, perspiring, hyperventilation, groaning, crying) through the review date; Resident's pain will be managed at an acceptable level 5 through next review date; The resident's pain is aggravated by: general pain ; The resident's pain is alleviated/relieved by: prn (as needed) medications; Administer analgesia ultram as per orders. tylenal Give 1/2 hour before treatments or care; Anticipate the resident's need for pain relief and respond immediately to any complaint of pain; Evaluate the effectiveness of pain interventions after medication administration; Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition ; Identify and record previous pain history and management of that pain and impact on function. Identify previous response to analgesia including pain relief, side effects and impact on function; Identify, record and treat the resident's existing conditions which may increase pain LPN and or discomfort; and resident usually does not remember when the nurse has given him a pain pill . ask resident too rate his pain level before and after to determine effectiveness.
Resident 14's physician's orders were reviewed prior to discharging to the hospital. The following medications were ordered:
a. Start date of 9/24/2020, Gabapentin 100 mg by mouth three times a day for low back pain.
b. Start date of 1/5/19, Oxycodone HCL 5 mg. Give 1 tablet by by mouth every 4 hours as needed for pain related to other chronic pain.
c. Start date of 1/5/19, Oxycodone HCL 5 mg. Give 1 tablet by mouth two times a day related to other chronic pain and low back pain. Discontinued on 10/13/22.
Resident 14 returned from the hospital on [DATE] with orders to discontinue the scheduled Oxycodone 5 mg twice daily. The form revealed resident 14 had a neck wound and neck abscess.
The nursing phone revealed a notification to the MD on 10/13/22 [resident 14] is back. The MD responded What was he treated for? Any new orders? Nurse responded [resident 14's] discharge orders. sent to the MD. The MD responded Please make sure they get a follow up appt (appointment) for him with the ENT (ear, nose and throat) as per discharge orders. There was no follow up information about the change in pain medication.
Resident 14's October 2022 MAR was reviewed. Resident 14 received the scheduled Oxycodone twice daily expect in the evening on 10/5/22. Resident 14's pain scores were 0 to 5 with pain at an 8 one time. Resident 14's pain score after returning from the hospital were 7 on 10/13/22, 10/14/22 and 10/15/22. Resident 14's pain was an 8 on 10/21/22, 10/22/22 and 10/23/22.
The October 2022 MAR revealed resident 14 was provided Oxycodone 5 mg on the following days:
a. On 10/6/22 at 8:33 PM, with a pain score of 8,
b. On 10/15/22 at 9:58 AM, with a pain score of 7,
c. On 10/16/22 at 3:51 PM, with a pain score of 6,
d. On 10/18/22 at 12:08 PM, with a pain score of 5,
e. On 10/20/22 at 11:56 AM, with a pain score of 5,
f. On 10/21/22 at 12:24 PM, with a pain score of 6 and the medication was ineffective.
g. On 10/21/22 at 7:40 PM, with a pain score of 8,
h. On 10/23/22 at 3:50 PM, with a pain score of 8
i. On 10/24/22 at 10:55 AM, with a pain score of 8,
j. On 10/25/22 at 11:57 AM, with a pain score of 5,
k. On 10/25/22 at 5:22 PM, with a pain score of 5,
l. On 10/26/22 at 11:57 AM, with a pain score of 5.
According to the Controlled Drug Record for the Oxycodone 10 mg the instructions were take 1/2 tablet by mouth twice daily and 1/2 every four hours as needed. Resident 14 was administered a 1/2 tablet on the following days which there were not documented in the MAR entries with pain scores:
a. On 10/13/22 at 9:35 PM
b. On 10/14/22 at 6:00 PM
c. On 10/18/22 at 9:00 AM
d. On 10/15/22 at 6:00 PM
e. On 10/14/22 with no time
f. On 10/17/22 at 9:10 PM
g. On 10/17/22 at 8:30 PM
h. On 10/18/22 at 2:00 AM
i. On 10/18/22 at 11:00 AM
j. On 10/18/22 at 4:30 PM
k. On 10/18/22 at 11:30 PM
l. On 10/19/22 at 8:00 AM
m. On 10/19/22 at 8:00 PM
n. On 10/20/22 at 8:50 AM
o. On 10/22/22 at 3:30 PM
p. On 10/23/22 at 7:00 AM
q. On 10/23/22 at 9:00 PM
r. On 10/26/22 at 8:30 AM
On 10/26/22 at 11:57 AM, an observation was made of resident 14 and the DON. The DON was observed to ask resident 14 if he wanted a pain pill. Resident 14 stated yes. The DON was observed to ask resident 14 what his pain level was and resident 14 stated 8. The DON stated that's a good level.
On 10/27/22 at 9:10 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated resident 14 always complained of pain. The ADON stated resident 14 sometimes complained of pain everywhere and other times only in his legs or back. The ADON stated when resident 14 was walking he definitely looked like he was in pain. The ADON stated resident 14 went to hospital and his oxycodone was changed to every 4 hours as needed and the twice daily was discontinued. The ADON stated resident 14 had been getting the as needed quite often. The ADON stated she offered the oxycodone when resident 14 was in pain.
On 10/28/22 at 11:26 AM, a interview was conducted with the DON. The DON stated resident 14 complained of pain. The DON stated resident 14 had scheduled and as needed pain medication. The DON stated He is one of those residents that says he's in pain. The DON stated He will say he is after he has had his pain medication. The DON stated resident 14 had not complained of more pain since going to the hospital. The DON stated staff needed to be very careful with him because of his narcolepsy. The DON stated resident 14 stayed up from noon till about 7:00 or 8:00 PM. The DON stated resident 14 slept a lot. The DON stated she was not aware of a change to his pain medication since coming back from the hospital.
On 10/31/22 at 10:59 AM, an observation and interview was conducted with resident 14. Resident 14 stated his pain is at an 8 out of 10 and was up all night in pain. Resident 14 stated his pain went straight down his spine. Resident 14 stated if he moved the pain woke him up. Resident 14 stated before going to the hospital, he was not in this much pain. Resident 14 stated the pain was in the same areas but a lot more intense. Resident 14 stated he felt like shit because I can't sleep. Resident 14 stated eating was hard and his eyes felt like they were being ripped out.
On 10/31/22 at 8:48 AM, an interview was conducted with the MD. The MD stated she was not contacted regarding resident 14 complaining of pain. The MD stated she was contacted about resident 14's stitches being removed, but that was all. The MD stated she did not know that his scheduled Oxycodone had been discontinued when he returned from the hospital. The MD stated she could address his pain if she was aware of it.
Based on observation, interview and record review it was determined, for 2 of 33 sampled residents, that the facility did not ensure pain management was provided to residents who required such services. Specifically, a resident screamed out in pain when he was repositioned. Another resident went to the hospital and his scheduled pain medication was discontinued when he returned. The resident complained of uncontrolled pain. These examples will be cited at a harm level. Resident identifiers: 14 and 32.
Findings include:
1. Resident 32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia, chronic obstructive pyelonephritis, severe sepsis, aspiration pneumonitus, supraventricular tachycardia, acute kidney failure, bipolar disorder, epilepsy, thyrotoxicosis and osteoarthritis.
Resident 32's medical records were reviewed between 10/11/22 and 10/31/22.
Resident 32's care plan dated 7/10/17 indicated that the resident was at risk for pain due to his osteoarthritis, cerebrovascular accident, and migraines. The interventions were to administer analgesia 30 minutes before treatments or care, anticipate the resident's need for pain relief and respond immediately to any complaint of pain, and evaluate the effectiveness of pain interventions. The care plan had not been updated since 7/10/17.
Two different pain assessments were located in resident 32's medical record with resident 32's name on it. However, the assessments were blank.
Resident 32's physician orders revealed that resident 32 had the following orders:
a. Acetaminophen 650 milligrams (mg) every 6 hours as needed.
b. Meloxicam 7.5 mg daily for osteoarthritis.
The September 2022 Medication Administration Record (MAR) indicated that resident 32 had not received any Acetaminophen during that month. The MAR also indicated that the highest level of pain that resident 32 was reporting was an 8 on 9/14 (twice), 9/15 (twice) and 9/16 (once). No indication was made on the MAR that resident 32 was receiving pain medication prior to cares, as suggested in the care plan.
The October 2022 MAR indicated that resident 32 had not received any Acetaminophen during the month of October 2022 as of 10/26/22. The MAR also indicated that the highest level of pain that resident 32 was reporting was a 2. No indication was made on the MAR that resident 32 was receiving pain medication prior to cares, as suggested in the care plan.
On 10/12/22 at 11:20 AM, resident 32 was interviewed. Resident 32 stated that he was only in pain when he moved. Resident 32 stated that when he was moved, such as for a brief change, his pain was an 8 on one side of his body, and a 10 on the other side. Resident 32 stated as long as he was in a middle position, he did not have any pain.
On 10/26/22 at 10:50 AM, resident 32 was re-interviewed. Resident 32 stated that his pain was shooting from his right leg and going up his left arm. Resident 32 again stated that he was only in pain if he moved. Resident 32 stated that his pain was at an 8 out of 10 when his briefs were changed.
On 10/26/22 at 11:04 AM, an observation was made of resident 32's torso area with Certified Nursing Assistants (CNAs) 3 and 4. The resident's brief change was also observed. Resident 32 presented with red to red/purple skin on the left side of his back and bilateral lower extremities below the knees. The skin was peeling (excoriated) with open wounds that were not dressed. There were four small (less than 1 centimeter) open, bleeding areas on resident 32's back, all on the left side of the resident's spine. The skin over the spine also appeared to be peeling and red. CNA 3 stated that the Director of Nursing (DON) would come in later to assess the wound to determine the appropriate dressing/cream. CNA 3 stated that the skin did not blanch and demonstrated that the purple/red areas on resident 32's left side did not blanch. CNA 3 stated that resident 32 had a lot of pain with his brief changes, and that they worked together every day to make sure he had the Calmoseptine cream on his red areas. CNA 4 stated that resident 32's skin appeared better than a month ago. Lotion was applied by the CNAs over resident 32's legs. Resident 32 stated OW! multiple times each time he was rolled during the brief change. The resident also stated that his pain was at a 10 on his left side. Resident 32 stated that his entire left side hurt, and motioned from his head to his foot. Resident stated that the right half of his body was alive and the left side was dead. The CNAs propped resident 32's left leg on a pillow, with the leg turned outward (abducted) from midline, and resident 32's right leg was placed on a pillow with the right heel floated. The right heel did not appear to have any open areas. Resident 32's head was placed on a pillow. Resident 32 stated that he did not have pain after the pillows were placed.
On 10/26/22 at 11:24 AM, an interview was conducted with Certified Nursing Assistants (CNAs) 3 and 4. CNA 3 stated that no matter what position they placed resident 32 in, he would move himself back to his favored position due to pain. CNA 3 stated that staff had to coax the resident into showers and brief changes.
On 10/25/22 at 10:09 AM, an interview was conducted with Registered Nurse (RN) 3. When asked about resident 32's pain, RN 3 stated that when resident 32 was repositioned by staff, he would complain of pain. RN 3 stated that its been going on a long time that he says he's in pain. RN 3 stated that resident 32 was being administered meloxicam every day for pain relief. RN 3 stated that resident 32 was cognitively impaired and would often say that he wasn't in pain. RN 3 further stated we should probably do a non verbal (pain scale) as well.
On 10/31/22 at 8:48 AM, an interview was conducted with the facility Medical Director (MD). The MD stated she was unaware that resident 32 did not move because he was in pain. The MD stated she would address uncontrolled pain if she had been notified.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0760
(Tag F0760)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Potential for Harm
2. Resident 22 was admitted to the facility on [DATE] and readmitted on [DATE] which included chronic diastol...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Potential for Harm
2. Resident 22 was admitted to the facility on [DATE] and readmitted on [DATE] which included chronic diastolic heart failure, hyperkalemia, chronic kidney disease, anxiety disorder, difficulty in walking, polyneuropathy, major depressive disorder, cellulitis of lower limb, and venous insufficiency.
A review of resident 22's medical record was conducted on 10/20/22.
According to resident 22's physician's orders, resident 22 was prescribed 100 mg of Doxycycline Monohydrate Tablet two times a day for 10 days which started on 10/16/22 at 3:45 PM.
A progress note from 10/16/22 at 3:52 PM stated, .Open areas of BLE (bilateral lower extremities) were larger today with some drainage. MD (Medical director) notified, ordered doxycycline 100mg BID [twice a day] x 10 days. First dose given at 1550 (3:50 PM) .
Resident 22's Medication Administration Record (MAR) was reviewed. The MAR revealed that on 10/18/22 in the evening and on 10/19/22 in the morning, the Doxycycline Monohydrate Tablet was not marked as administered or held.
On 10/27/22 at 10:06 AM, an interview with RN 3 was conducted. RN 3 stated that it was unclear if the medication was given on 10/18/22 in the evening and 10/19/22 in the morning from looking at the MAR. RN 3 stated that if there was a blank space on the MAR when a medication should have been administered, it meant that the nurse on duty did not indicate if the medication was administered or not, and the nurse did not add a reason as to why the medication was administered or not. RN 3 explained that antibiotics, like Doxycycline Monohydrate Tablets, were tracked on an antibiotic tracking paper in addition to being tracked on the MAR. RN 3 stated that the tracking sheet for Resident 22's Doxycycline Monohydrate Tablet had been turned in since the medication had been discontinued. RN 3 stated that the completed antibiotic tracking sheets were placed in one of the drawers at the nursing station, and she was unaware of where the papers went after that.
On 10/27/22 at 10:15 AM, the nursing station drawers were searched for Resident 22's antibiotic tracking sheet. Resident 22's antibiotic tracking sheet was not found. The antibiotic tracking sheet for resident 22 was requested by the facility and the facility was unable to provide it.
Based on interview and record review the facility did not ensure that 4 of 33 sampled residents were free of significant medication errors. Specifically, a resident was not administered the correct dose of insulin per physician orders resulting in uncontrolled diabetes. This example will be cited at a harm level. In addition, two residents' antibiotics were not administered according to physician orders, and another resident's coumadin was not administered according to physician orders. Resident identifiers: 22, 29, 32 and 94.
Findings include:
Harm
1. Resident 29 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus with foot ulcer, schizoaffective disorder, neuropathy, generalized anxiety disorder, borderline intellectual functioning, hyperlipidemia and hypomagnesemia.
On 10/12/22, resident 29 was observed with a dressing on her right foot. Resident 29 stated that she recently had surgery.
On 10/12/22 at 10:17 AM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated that resident 29 often came to the nursing desk to ask the nurses for her medications, but some of the nurses ignored resident 29 and told her to wait. CNA 2 stated that resident 29's family did not provide any assistance to resident 29. CNA 2 stated that resident 29 had a lot of medical needs, and CNA 2 was not sure resident 29 received all the care she needed.
On 10/11/22 at 5:05 AM, Registered Nurse (RN) 1 stated that she had not signed out resident 29's narcotic medication.
On 10/12/22 at approximately 10:00 AM, resident 29 was interviewed. Resident 29 was observed to be ambulating in a wheelchair and stated that she had an appointment with her surgeon because she had foot issues.
On 10/31/22, resident 29's medical record review was completed.
Resident 29's physician orders included the following:
a. Blood sugar checks before meals and at bedtime were initiated on 11/10/21.
b. Bacitracin ointment, 500 units/gram, apply to wound topically, initiated on 11/10/21.
c. Bactrim DS tablet, 800-160 MG (milligrams) (Sulfamethoxazole-Trimethoprim), 800 mg by mouth twice daily.
d. Lantus solution, 100 units/mL (milliliters), inject 70 units subcutaneously in the morning and 60 units subcutaneously in the evening.
e. Humalog solution 100 units/mL, sliding scale
f. Clindamycin HCL capsule 300 MG, give 1 capsule by mouth three times a day related to unspecified open wound, right foot
g. Doxycycline monohydrate tablet, 150 mg, Give 1 tablet by mouth two times a day for right foot for 14 Days
Resident 29's Medication Administration Record (MAR) revealed that resident 29 did not receive the following medications on the following dates:
a. In June, 2022, resident 29's Lantus was missed in the afternoon on 6/7, 6/13, 6/27, and 6/30; the Humalog sliding scale was not provided at 4:00 PM on 6/3, 6/13, 6/17, 6/20, 6/24, and 6/30; the Humalog sliding scale was not provided at 9:00 PM, on 6/7, 6/13, 6/27, and 6/30.
b. In July, 2022, for resident 29's Lantus 70 units subcutaneously two times a day for diabetes mellitus, was missed on evening shift 7/5 and 7/10; Humalog solution 100 u/ml (Insulin Lispro) checks were ordered for 7:30 AM, 11:00 AM, 4:00 PM, and 9:00 PM. The 4:00 PM check and insulin were missed on 7/1, 7/5, 7/9, 7/11, 7/15, 7/16, 7/18, 7/22, 7/25, 7/29, and 7/30; The blood glucose check and insulin administration were missed at 9:00 PM on 7/5, and 7/10.
c. In August, 2022, resident 29's Doxycycline was missed for the PM dose on 8/10, and the morning dose on 8/12 (with no extended doses); Doxycycline monohydrate tablet, 150 mg, Give 1 tablet by mouth two times a day for right foot for 14 Days was missed for the PM dose on 8/28/22; Lantus was not administered for the PM doses on 8/10, and 8/28; Humalog was not provided at 4:00 PM on 8/1, 8/5, 8/10, 8/11, 8/12, 8/15, and 8/22/22; and the 9:00 PM Humalog was not provided on 8/10.
d. In September, 2022, resident 29's Lantus was not provided on 9/5, and 9/14; Clindamycin HCL capsule 300 MG, give 1 capsule by mouth three times a day related to unspecified open wound, right foot, subsequent encounter for 10 days, missed 9/14 all 3 doses (Arise, Noon, PM), and noon on 9/16 and the dosing was not extended; Humalog solution 100 unit/mL (insulin lispro) sliding scale was not checked or administered on: 9/5 in the PM; 9/14 all day, 9/16 at noon, and 9/26 at noon.
e. In October, 2022, resident 29 did not received the following: Humalog check and administration at noon, missed on 10/5, and 10/17; HumaLOG Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 0 - 149 = 0; 150 - 200 = 3; 201 - 250 = 6; 251 - 300 = 9; 301 - 350 = 12; 351 - 400 = 15 Call medical provider if BS is >400, subcutaneously three times a day related to TYPE 2 DIABETES MELLITUS WITH FOOT ULCER, the afternoon Humalog was missed on 10/5, and 10/24.
[Note: No charting was recorded that resident 29 refused cares or medications.]
Resident 29's nursing notes revealed that resident 29 had a chronic right heel wound on 11/15/21 that became infected, worsened and required antibiotics in April through August. Resident 29 was lethargic in August 2022, and had new ulcers open on her foot. Resident 29 developed osteomyelitis and required a toe and metatarsal bone amputation in September, 2022.
Resident 29's wound care note from 10/18/22 revealed that resident 29 had no open areas on her foot. On 10/24/22, resident 29's wound was partially open.
On 10/25/22 at 10:09 AM, Registered Nurse (RN) 3 was interviewed. RN 3 stated that resident 29's wound had a bit of dehiscence (opened). Resident 29 was receiving antibiotics, but the wound was looking infected again. RN 3 stated that resident 29 needed to follow up with her surgeon. RN 3 stated there was a small amount of yellow-red drainage, and resident 29 was unable to walk on her foot after her surgery. RN 3 stated that any additional wound care should have been charted in the nursing notes or on the TAR.
On 10/24/22 at 12:22 PM, the Medical Director (MD) was interviewed. The MD stated that she was not informed that resident 29's foot had reopened, and there was an area of what appeared to be necrotic tissue. The MD stated that the wound care company handled the wounds, and staff did not have the MD look at anyone's wounds. The MD stated that resident 29 required good control of her diabetes to promote healing and optimal health.
3. Resident 32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia, chronic obstructive pyelonephritis, severe sepsis, aspiration pneumonitus, supraventricular tachycardia, acute kidney failure, bipolar disorder, epilepsy, thyrotoxicosis and osteoarthritis.
Resident 32's medical records were reviewed between 10/11/22 and 10/31/22.
Resident 32's hospital discharge orders dated 8/18/22 were reviewed. The discharge orders included a new prescription for Linezolid 600 mg twice a day. The hospital documented that the next dose of the antibiotic was due that same evening.
Resident 32's August 2022 MAR was reviewed. The MAR indicated that resident 32 did not receive the Linezolid on the evening of 8/18/22, or the evening of 8/22/22. The MAR indicated that resident 32 received the next dose on 8/23/22, after which the medication was discontinued by the physician.
4. Resident 94 was admitted to the facility on [DATE] with diagnoses that included chronic atrial fibrillation, aortic regurgitation and stenosis, pulmonary hypertension, hypertension, and type 2 diabetes mellitus with both diabetic nephropathy and peripheral angiopathy. Resident 94 was discharged from the facility on 9/6/22.
Resident 94's medical record was reviewed from 10/11/22 through 10/31/22.
a. Resident 94's hospital discharge orders were reviewed. The orders indicated that resident 94 should continue to be administered Coumadin 5 milligram (mg), one and half tablets every day for a total dose of 7.5 mg a day, and 52.5 mg of Coumadin per week.
Resident 94's admission orders to the facility indicated that resident 94 was to be administered Coumadin 5 mg one tablet every day (for a total dose of 35 mg per week). The admission orders were documented as having been transcribed by the DON.
Resident 94's Medication Administration Record (MAR) indicated that resident 94 received the 5 mg of Coumadin every day from 5/3/22 through 6/9/22.
On 5/24/22, an Anticoagulant Visit Summary was completed for resident 94. The summary indicated that resident 94 had Dosing Instructions to be administered Coumadin 5 mg, one and half tablets every day for a total dose of 7.5 mg a day, and 52.5 mg of Coumadin per week. Despite the dosing instructions provided on 5/24/22, the resident continued to receive only 5 mg of Coumadin daily.
On 6/10/22, resident 94's Coumadin dose was changed to 6 mg daily, for a total dose of 42 mg of Coumadin per week. It should be noted that this dose was still less than the prescribed amount listed on the hospital discharge orders.
Resident 94's August 2022 MAR indicated that on 8/1/22, the resident's Coumadin was discontinued, and the resident was now being administered Eliquis 5 mg daily.
On 10/24/22 at 2:30 PM, an interview was conducted with the DON. The DON stated that when a resident was admitted , either herself or the Assistant Director of Nursing (ADON) would transcribe the admission orders. The DON stated that sometimes facility staff started the paperwork, but then be unable to finish it at the time, and the DON would have to come back to finish it later. The DON stated that there was not a system in place to double check the admission orders for residents, but that we should be doing that. When asked about resident 94's Coumadin transcription error, the DON stated that she would have to look into that. As of exit on 10/31/22, the DON did not provide additional information about resident 94's Coumadin error.
On 10/17/22 at 11:38 AM, an interview was conducted with the facility MD. The MD stated that she was unaware of the transcription error from resident 94's admission orders.
b. On 5/24/22, an Anticoagulant Visit Summary was completed for resident 94. The summary indicated that resident 94 had had his PT/INR drawn at an outside facility. The resident's INR was listed as 1.6, with a target level of 2.5. The summary included instructions for the resident to have a double dose of Coumadin that day, for a total of 3 tablets, a dose of 10 mg. Review of resident 94's May 2022 MAR indicated that resident 94 did not receive the double dose of Coumadin that day, but instead received only the 5 mg dose.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0840
(Tag F0840)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 3 of 33 sampled residents, that the facility did not ar...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 3 of 33 sampled residents, that the facility did not arrange outside resources in a timely manner for residents. Specifically, a resident was not scheduled for a Percutaneous Endoscopic Gastrostomy (PEG) tube placement and had multiple problems with the Nasojejunal (NJ) tube which was cited at a harm level. In addition, residents were not scheduled for a neurologist appointment and a cardiologist appointment. Resident identifiers: 4, 30 and 34.
Findings include:
Harm
1. Resident 4 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included muscle weakness, schizophrenia, cognitive communication deficit, conversion disorder, anxiety disorder, chronic kidney disease, psychosis, difficulty in walking, and hyperlipidemia.
On 10/13/22 at 9:23 AM, an observation of resident 4 was made. Resident 4 was in bed and observed to have a feeding tube which entered through resident 4's nose. An interview with resident 4 was not conducted due to resident 4's cognitive communication deficit.
On 10/13/22 resident 4's medical record was reviewed.
Resident 4's order history revealed that resident 4 began receiving enteral feeding on 12/24/20.
On 10/18/22 at 10:04 AM, an interview with Registered Nurse (RN) 3 was conducted. RN 3 stated that resident 4 often had a difficult time with his feeding tube. RN 3 stated that resident 4 frequently pulled out his NJ tube. RN 3 stated that the NJ tube frequently got clogged. RN 3 stated that when the NJ tube had been pulled out or the NJ tube was clogged, the facility informed the doctor and resident 4 needed a doctor's appointment to replace or unclog the NJ tube. RN 3 stated that the facility had been talking about resident 4 getting a PEG feeding tube to replace the NJ feeding tube. RN 3 stated she did not know why that appointment had not been made.
A review of resident 4's progress notes revealed multiple issues with the NJ tube. The follow progress notes were:
a. On 1/21/22 at 3:36 PM, Resident was taken via w/c (wheelchair) to . hospital at 9:15 (AM) for a replacement of his clogged NJ tube .
b. On 3/2/22 at 8:41 PM, Resident NG tube clogged and was being declogged when it burst with a hole in it. MD (Medical Director) notified and orders for a replacement of NG .
c. On 4/16/22 at 10:16 AM, NJ tube is clogged. Radiology is unable to replace tube all weekend. Scheduling office is closed so will have to call Monday morning to schedule NJ replacement. MD notified .
d. On 5/21/22 at 8:59 PM, In to assist RN with a clogged feeding tube. Feeding tube was unhooked from machine easier as it was reported that he had a shower .
e. On 8/16/22 at 9:50 AM, Resident's NJ tube bridel (sic) was loose and tube came out by several inches and back in.
f. On 8/18/22 at 7:11 AM, Resident completed pulled out feeding tube.
g. On 8/28/22 at 1:20 PM, NOC (night) Nurse informed me during 5:00 [AM] report that resident has NJ feeding tube out at 2330 (11:30 PM) .
h. On 9/4/22 at 10:10 AM, Resident pulled out NJ tube at approx (approximately) 1:30 AM per night shift report. MD notified and ordered IV fluids until NJ can be replaced .
i. On 9/10/22 at 1:35 AM, .he had his NJ tube replaced on Tuesday. They are talking about placing a G-tube in him soon .
j. On 9/22/22 at 4:53 PM, NJ tube became clogged, and resident then pulled the tube out on his own. MD notified and ordered NJ tube replace by [hospital name redacted] radiology .
k. On 9/23/22 at 2:29 PM, Resident went to have NJ tube replaced today at 1:15 PM. In apptment [appointment] form, it was written that MD ordered a PEG tube and order attached . New feeding tube may be used. Unable to do a PEG today, and that needs to be scheduled with [hospital name redacted] radiology. Will f/u (follow-up) on Monday 9/26/22 with [hospital name] for PEG placement appointment.
l. On 10/10/22 at 6:36 AM, Notified MD that feeding tube was out. MD stated she was not notified and no orders given to place IV for fluids .
m. On 10/25/22 at 2:20 AM, resident was agitated and pulled out NG tube at 0030 (12:30 AM) on 10/25/22 . MD notified.
A review of the facilities appointment book revealed that resident 4 did not have any upcoming appointments.
On 10/20/22 at 10:11 AM, an interview with Licensed Practical Nurse (LPN) 1 was conducted. LPN 1 stated that resident 4 had a history of going to the emergency room to get his NJ tube replaced. LPN 1 stated that resident 4 had the NJ tube for almost 2 years. LPN 1 stated that the facility had been discussing replacing the NJ tube with a PEG tube for about 2 years. LPN 1 stated he was not sure why the appointment for resident 4 to get a PEG tube was continuously postponed.
On 10/18/22 at 10:53 AM an interview with the Administrator (ADMIN) was conducted. The ADMIN stated that the facility was working with the hospital to schedule an appointment for resident 4 to get a PEG tube so the NJ tube could be removed. The ADMIN stated that hospital kept rescheduling resident 4. The ADMIN stated that the facility did not keep records of any communication with the hospital regarding resident 4's appointment for the G tube.
On 10/24/22 at 2:30 an interview with the Director of Nursing (DON) was conducted. The DON stated that there were issues with the PEG tube appointment. The DON stated that resident 4 was supposed to have a PEG tube over a year ago. The DON stated that resident 4 had been pulling out his NJ tube more frequently and the NJ tube kept getting clogged. The DON stated that she took it upon herself to ask the MD to write an order for a PEG tube for resident 4. The DON stated that it should not have taken this long to get a PEG tube appointment for resident 4. The DON stated that resident 4 still did not have an appointment scheduled for a PEG tube.
Potential for Harm
2. Resident 30 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis (MS), neuropathy, insomnia, obesity, chronic pain, and depression.
On 10/11/22 at 9:40 AM, resident 30 was observed to be sitting in a wheelchair. Resident 30 stated that she needed to see her neurologist because her MS was flaring. Resident 30 stated that she had made an appointment to see her neurologist, but staff told her that they were unable to transport her, so they canceled the appointment. Resident 30 stated that it took several months to get into her neurologist, and staff had not rescheduled the appointment.
On 10/31/22, resident 30's medical record was reviewed.
Resident 30's physician and NP (Nurse Practitioner)/PA (Physician Assistant) notes revealed the following:
a. On 2/7/22 a new order was initiated that resident 30 should follow up with her neurologist because resident is c/o (complaining of) increased weakness in right arm and leg.
b. On 3/24/22 at 7:35 PM, resident 30 is followed by neurology for her MS Continue follow up with neurology.
c. On 7/21/22 at 2:16 PM, chief complaint was resident 30's multiple sclerosis. Resident was followed by neurology and .is supposed to have an appt (appointment) in September .
d. On 9/22/22 at 4:06 PM, . She is wanting to get into her neurologist .
e. On 9/26/22 at 1:07 PM, .requested appt to be made with her neurologist.
On 10/24/22 at 2:30 PM, the DON was interviewed. The DON stated that she had made appointments for residents previously, but was told that the previous Administrator (ADM) was responsible to make appointments. The DON stated that it was an issue getting residents into their doctors.
On 10/25/22 at 11:14 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that he hated the appointment book. LPN 1 stated that the process did not work. LPN 1 stated that the previous ADM and current ADM had canceled appointments for residents because of transportation issues and the ADM's wanted to schedule the appointments to ensure that someone would be available to take the resident to the appointment. LPN 1 stated that when a resident needed an appointment, staff let the ADM know, filled out a request sheet, and waited for the OK from the ADM to get an appointment for the resident. LPN 1 stated that nurses would cross our fingers that the resident went to an appointment. LPN 1 stated that the system was so broken, the nurses did not know if someone went to an appointment or not. LPN 1 stated that when residents made their own appointments, there would not be transportation, and the appointment would be canceled.
On 10/25/22 at approximately 1:00 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that she was not aware of any staff members who made appointments. The ADON stated that the receptionist or front office person would make appointments under the direction of the ADM. The ADON stated that she was aware of several residents who required physician visits, but she was unaware of when they may be scheduled. The ADON stated that the Medical Director (MD) had asked about several appointments, but the ADON stated she was not able to make the appointments, and they would have to be made by the DON or ADM.
On 10/25/22 at 1:35 PM, an interview was conducted with the ADM. The ADM stated that she had not made appointments in months, but appointments must have been made by someone because residents went out. The ADM stated that resident 30 had made her own appointment, but they were not able to take her due to staffing. The ADM stated that appointments needed to be coordinated, and sometimes there was no staff available for transportation. The ADM stated that sometimes appointments were written down on post-it notes, and they may have been misplaced.
On 10/27/22 at 1:06 PM, an interview was conducted with the MD. The MD stated that she was told the ADM made the appointments with physicians for the residents. The MD stated she had asked the nurses to make follow-up appointments for the residents and the MD stated the nurses told her that appointments had to go through the ADM.
3. Resident 34 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included atherosclerotic heart disease, hemiplegia, gout, memory deficit following cerebral infarction, diabetes mellitus, dysphagia, and hyperlipidemia.
On 10/11/22, resident 34's medical record was reviewed.
Physician progress notes indicated the following:
a. On 12/27/21, . he mentioned he has a defibrillator. He does not know who his cardiologist is. Will call patient's sister to see if she knows.
b. On 4/25/22, . Still awaiting cardiology appt.
c. On 9/12/22, . has defibrillator. Still awaiting cardiology appt.
Resident 34's medical record did not indicate that resident 34 had been seen by a cardiologist during his stay at the facility.
The facility appointment book was reviewed. The appointment book did not contain any documentation that resident 34 had been scheduled for a cardiology appointment.
On 10/24/222, an interview was conducted with resident 34. Resident 34 stated he had not seen a cardiologist since he was admitted to the facility. Resident 34 stated that his defibrillator had shifted and was lower than it once was. Resident 34 stated he was unaware if he had an appointment to see a cardiologist to have his defibrillator checked or not.
On 10/24/22, an interview was conducted with the MD. The MD stated that she had been documenting in her progress notes since December 2021 that resident 34 needed an appointment to see a cardiologist. The MD stated that resident 34 had a defibrillator, and that resident 34 should see a cardiologist at least every six months to ensure it was still functioning appropriately and the battery was at a good level. The MD stated that she had put a request in the appointment book on two occasions for resident 34 to see a cardiologist but its not there anymore.
On 10/27/22, a follow up interview was conducted with the facility MD. The MD stated that the nurses have told her they can't make any appointments, and that all appointments were made by the facility Administrator (ADM).
On 10/24/22 at 2:30 PM, an interview was conducted with the DON. The DON stated that she was aware that resident 34 had a defibrillator, and confirmed she had not made an appointment for resident 34 to see a cardiologist, even though the MD had requested it. When asked why she had not made an appointment for resident 34 to see a cardiologist, the DON stated, I made an appointment before and got my butt chewed, so I don't make them anymore. I'm not allowed to. The DON stated that it was the ADM who was prohibiting her and other nurses from making appointments for residents.
SERIOUS
(H)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0725
(Tag F0725)
A resident was harmed · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and observation, the facility did not have sufficient nursing staff with the appropriate comp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and observation, the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, residents, resident family members, and staff voiced concerns with the staffing levels. However, observations were made of the Memory Care Unit left unattended, there were not enough activity staff members, Activities of Daily Living (ADLs) were not completed, and at least one resident experienced a fall. Resident identifiers: 7, 9, 22, 26, 30, 31, 36, and 93.
Findings Include:
RESIDENT FALLS
1. Resident 30 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis (MS), neuropathy, insomnia, obesity, chronic pain, and depression.
On 10/11/22 at 9:40 AM, resident 30 was observed to be sitting in a wheelchair. Resident 30 stated that she had a recent fall because there is nobody to help get you up.
On 10/31/22, resident 30's medical record review was completed.
Fall reports were requested, and one was created for resident 30. On 6/12/22 at 11:00 AM, resident was transferring with the assistance of a Certified Nursing Assistant (CNA) from her bed to her wheelchair when resident missed the chair. Hit buttocks and head. Neuros (Neurological assessments) started. No injuries.
Nursing notes revealed the following:
a. On 11/6/21, resident 30 had a fall at approximately 8:00 AM in the dining room. Her wheelchair broke.
b. On 6/12/22 at 11:56 AM, resident 30 had a fall at approximately 11:00 AM. Fell while transferring to wheelchair, hit buttocks and head, no injuries .Will transfer resident 2 person assist today and as needed.
c. On 7/21/22 at 5:37 AM, it was charted that resident 30 slid out of her wheelchair at 9:00 PM on 7/20/22. Resident 30 had been repositioned in her wheelchair prior to the fall and resident 30 was being assisted to the restroom.
d. On 10/7/22 at 3:41 PM, it was reported that on 10/4/22, resident 30 had a fall.
Resident 30's care plan revealed that resident 30 has limited physical mobility r/t (related to) weakness. Resident 30 was identified as moderate, risk for falls r/t gait/balance problems. Additionally, resident 30 had fall checks due to taking psychotropic medications. No actual falls were documented, and no fall interventions were initiated for resident 30.
Physician and Nurse Practitioner (NP) notes on 2/7/22, 3/24/22, 7/21/22, 9/22/22, and 9/26/22 revealed that resident 30 stated her MS was getting worse and wanted to be seen by her neurologist. On 7/21/22, resident 30 had an appointment to see her neurologist in September, and resident 30 reported bowel control had decreased.
On 2/7/22 at 2:13 PM, a new order (as stated in the nursing notes) was initiated for resident 30 to follow up with her neurologist because resident 30 was complaining of increased weakness in right arm and leg.
Resident 30 was not able to follow-up with her neurologist. Resident 30 stated that she had made an appointment, but there was no one to take her, so the staff had canceled the appointment and had not made a new appointment.
On 10/18/22 at 12:22 PM, an interview was conducted with CNA 4. CNA 4 stated that resident 30 required two CNAs to safely transfer her.
On 10/27/22 at 12:24 PM, RN 3 was interviewed. RN 3 stated that resident 30 did not transfer on her own, and had not tried to self-transfer for several years. RN 3 stated that sometimes resident 30 required two people to transfer, depending on her strength.
On 10/27/22 at 4:15 PM, an interview was conducted with CNA 5. CNA 5 stated that when resident 30 fell on [DATE], Registered Nurse (RN) 1 was transferring resident 30. CNA 5 stated that she told RN 1 not to transfer resident 30 because sometimes resident 30's legs buckled when she was being transferred. CNA 5 stated that RN 1 tried to transfer resident 30 alone and dropped her. CNA 5 stated that RN 1 called her phone and said that RN 1 had dropped resident 30. CNA 5 stated that she had reported to the interim DON that the fall had occurred and RN 1's role in the fall.
RESIDENT INTERVIEWS
2. On 10/11/22 at 6:32 AM, an interview was conducted with resident 9. Resident 9 stated there were not enough staff. Resident 9 stated there were supposed to be 2 CNA's for each floor which is a joke. Resident 9 stated there was usually only 1 CNA for the entire facility. Resident 9 stated staff were expected to come to work sick. Resident 9 stated staff did not show up. Resident 9 stated he talked to the Director of Nursing (DON) about the issue. Resident 9 stated if he pushed the call light, then he had to wait 2 hours. Resident 9 stated he was only checked on every 2 hours when staff come to check briefs.
3. On 10/18/22 at 11:00 AM an interview with resident 9 was conducted. Resident 9 stated, again, that the facility did not have enough staff. Resident 9 stated that sometimes it would take staff two hours to answer his call light.
4. On 10/11/22 at 8:37 AM an interview with resident 22 was conducted. Resident 22 stated that the facility was understaffed. Resident 22 stated that it took a long time for the call light to be answered by staff.
FAMILY INTERVIEWS
5. On 10/12/22 at 10:33 AM, an interview was conducted with resident 31's family member. Resident 31's family member stated there were not enough staff for the memory care unit and it had been left unattended. Resident 31's family member stated CNA 6, the night CNA, did not change residents briefs at night. Resident 31's family member stated CNA 6 did not get everything done at night. Resident 31's family member stated only 1 CNA showed up for the evening shift.
On 10/17/22 at 12:22 PM, an interview was conducted with a family member (FM) of resident 31. The FM stated that resident 31 had been falling, and was recently abused. The FM stated that the staff weren't treating resident 31's skin issues, and when the FM attempted to talk to the Administrator (ADM), the ADM was always busy.
6. On 10/18/22 an interview was conducted with a FM for resident 93. When asked about the care at the facility, the FM stated they are terrible . If I could do it again I would never put my loved one there again. I would never say anything nice it was a hell hole. We were worried that she (resident 93) would pass and no one would know it. Resident 93's FM stated that residents in the Memory Care Unit were often left alone. Resident 93's FM also stated that the Memory Care Unit would be unlocked and then they are blocking it with resident charts. The FM stated that both she and other FMs had walked through the Memory Care Unit, and there were no staff present. The FM further stated that she had complained to the ADM multiple times about poor staffing. The FM stated that her family was so worried about their loved one, there was a family member present every day with resident 93, until resident 93's FMs were able to admit resident 93 to a different facility.
OBSERVATIONS
7. On 10/11/22 at 4:10 AM, an observation was made of RN 1, CNA 6 and CNA 7 at the nurses station. The memory care unit was unattended until 4:22 AM when CNA 6 was observed to enter the unit. At 4:43 AM, CNA 6 was observed to exit the memory care unit. At 5:48 AM, CNA 6 entered the memory care unit. Resident 36 was observed to be ambulating up and down the hallway during that time. [It should be noted the memory care unit was unattended for 1 hour and 5 minutes.]
8. On 10/22/22 at 10:40 PM, an observation was made of CNA 6, CNA 7 and RN 5 at the nurses station. The memory care unit was unattended until 10:51 PM. Resident 36 was observed wandering the hallway. At 11:19 PM, CNA 6 was observed to leave the memory care unit. At 11:25 PM, CNA 6 was observed to return to the memory care unit. At 11:56 PM, CNA 6 and CNA 7 were observed to leave the memory care unit. At 11:57 AM, RN 5 entered the memory care unit. On 10/23/22 at 12:04 AM, RN 5 was observed to leave the memory care unit and open the door to the magnet. RN 5 was observed to wheel the charts in from of the open door. Resident 36 was observed wandering the hallway. RN 5 was observed to sit behind the charts near the open door. At 12:35 AM, CNA 6 and CNA 7 were observed to enter the memory care unit. At 12:37 AM, resident 31 was observed wandering the hallway without pants, wearing a sweatshirt and brief. Resident 36 and resident 7 were observed in the hallway.
9. On 10/27/22 between 2:00 PM and 2:15 PM, the DON, CNA 4, CNA 1, and CNA 3 were observed at the nurses station talking. The DON stated that the of the two CNAs that was supposed to show up did not, so CNA 5 was the only person scheduled for the evening shift from 2:00 PM to 10:00 PM. The CNA that did not show up for the evening shift was also the only CNA scheduled to work the night shift from 10:00 PM to 6:00 AM. The DON was observed to ask CNA 5 if she could work a double shift that day, for a total of 16 hours. CNA 5 stated that this was her first shift working after being released after a week stay in the hospital, and that she did not feel physically capable of working 2 shifts.
On 10/27/22 at 4:15 PM CNA 5 was interviewed and stated she was going to work a double shift because there was no one else coming in.
STAFF INTERVIEWS
10. On 10/20/22 at 10:00 AM, an interview was conducted with Employee (E) 4. E 4 stated that RN 1 had marijuana in the building, but the ADM did not want to fire RN 1 because of staffing issues.
11. On 10/22/22 at 11:27 PM, an interview was conducted with CNA 6. CNA 6 stated she worked the night shift and there were not always 2 CNAs, so she was often by herself. CNA 6 stated she asked the nurse to help and sometimes they were not available. CNA 6 stated if there was only 1 CNA, then she opened the doors to the memory care unit so the nurse could watch the memory care unit. CNA 6 stated the nurse alerted the CNA if there was a call light alarming. CNA 6 stated there were 2 residents that required 2 person assistance with bed mobility. CNA 6 stated that there was supposed to be at least one additional CNA on her shift, but that if the other person called in sick, the ADM would not make sure the shift was covered. CNA 6 stated that she was still expected to complete all of her assigned tasks even when she was the only CNA on duty, but she was unable to do so.
12. On 10/23/22 at 12:48 AM, an interview was conducted with CNA 7. CNA 7 stated Staffing is rough. CNA 7 stated usually there were 2 CNAs, but usually Wednesday and Sundays there was only 1 CNA. CNA 7 stated the nurse did not usually help. CNA 7 stated that she had worked with RN 1 and that RN 1 was regularly sleeping on the job, and RN 1 was not really functional. CNA 7 stated that it was difficult to tell what the exact problem was with RN 1, if she was under the influence of something. CNA 7 stated that extra cleaning stuff was not completed during her shift because of staffing. CNA 7 stated there were 2 residents that needed 2 staff members to change them.
13. On 10/27/22 at 4:15 PM, an interview was conducted with CNA 5. CNA 5 stated that the facility was short-staffed, and that she had reported her concerns to the DON and the ADM, but they had replied with we're working on it. CNA 5 stated that the dining rooms have to go unattended at times because of the staffing levels. CNA 5 confirmed that there were not always staff present on the Memory Care Unit because of the staffing levels.
14. On 10/24/22 at 2:30 PM, an interview was conducted with the DON. The DON stated that she was acting as the DON on an interim basis because she did not want to be the DON. The DON stated that she had been helping in that role for three years. The DON stated that in addition to her duties as a DON, she often was also the only nurse working the floor, and responsible for 40 residents. The DON stated that she wrote up staff for not showing up to work their shifts. The DON stated that RN 1 had been written up when she appeared to be impaired. The DON stated that she needed more staff working at night. The DON stated that there were only two CNAs that worked at night, which meant that it was difficult to watch the locked unit and get everything else done. The DON stated that the facility was short staffed, usually when the CNAs didn't show up to work. The DON stated that she was concerned particularly for the locked unit. The DON stated that she had told the ADM they needed more staffing at night because anything could happen back there (the Memory Care Unit). we could have abuse, neglect, everything, you name it. these people need to have somebody . a lot of them can't function by themselves.
15. On 10/25/22 at approximately 1:00 PM, RN 3 was interviewed. RN 3 stated that residents' appointments had to be canceled because staff couldn't guarantee transportation. RN 3 stated that there was not enough staff for transportation.
On 10/27/22 at 1:36 PM, RN 3 was interviewed again. RN 3 stated that she and the DON had asked the ADM to work with an agency when they were struggling really bad in April 2022. RN 3 stated that she did not hear anything about agency staffing. RN 3 stated that the ADM called everyone who used to work there to find someone to work. RN 3 stated that she worked 5:00 AM to 5:00 PM, and had never had to work later than 9:00 PM, or 10:00 PM, but the DON had worked later many times.
16. On 10/26/22 at 6:11 PM, the Certified Therapeutic Recreation Specialist (CTRS) was interviewed. The CTRS stated that the last time she was contacted by the facility was in July, 2022. The CTRS stated that she was not consulted because no staff are working full time with activities. The CTRS stated that she found out in August, 2022, that the Therapeutic Recreational Technician (TRT) was not coming to the facility. The CTRS stated that she did not know there was no resident council, and there needed to be a minimum of 4 hours of therapeutic activities run by a TRT during the day. The CTRS stated that activities such as painting fingernails would be a diversionary activity.
17. On 10/27/22 at 1:27 PM, an interview as conducted with Employee 9 (E 9). E 9 stated that she had seen a CNA cry because the facility was short staffed. E 9 stated that the ADM was informed of the staffing issues, but nothing changed.
18. On 10/27/22 at 1:06 PM, a telephone interview was conducted with the Medical Director (MD). The MD stated that when the facility was short staffed, the ADM told her that the ADM could not afford to have agency in the building. The MD stated that she had been at the facility when there was only one nurse and one CNA working. The MD stated that she feared for the residents' safety due to the poor staffing levels.
ADMINISTRATOR INTERVIEWS
19. On 10/20/22 at 12:55 PM, the ADM was interviewed. The ADM stated that when staff were required to provide one-on-one staffing for resident 26, staff were pulled away from doing maintenance, social work, and the kitchen. The ADM stated that the medical records staff and receptionist were utilized and weren't able to get much else done. The ADM stated that the interim DON had lots of time to be the nurse, get everything done, and then sit around.
On 10/25/22 at 1:35 PM, the ADM was interviewed. The ADM stated that the facility did not have a resident advocate. The ADM stated that she was going to train the receptionist to do the resident advocate stuff. The ADM stated that when the facility has been short staffed overnight, the ADM asked the evening staff to stay, or has someone come in early to do rounds in the morning. The ADM stated, We're being real creative since nobody wants to work.
On 10/27/22 at 2:00 PM, the ADM was interviewed. The ADM stated that she was responsible for the COVID-19 testing, and was not sure when staff was testing. The ADM stated that she did not have time to follow-up with staff to ensure testing occurred. The ADM stated that there was a new office person to help file documents in the resident's charts, but she doesn't know anything yet. The ADM stated that there was an accounting firm that assisted with residents' accounts who came to the facility once a quarter, but had not been to the facility in approximately 4 months. The ADM stated that there was usually only one nurse in the building each shift, responsible for the 41 residents. The ADM stated that it may be the interim DON or assistant DON (ADON), but they had plenty of time in the afternoon to take care of their DON duties. The ADM stated that if there were staffing issues, the ADM had to contact people to try to get someone to come in. The ADM stated that sometimes nurses and CNAs had to work extra shifts, and the ADM had been trying to get a contract with some of these agency things. The ADM stated that there was never a night without coverage. The ADM stated that she had not utilized agency staffing and had no contracts. The ADM stated that sometimes she stayed late and helped with trash and other duties that the CNAs didn't have time to do. The ADM stated that she could not afford to use agency long term. The ADM stated that she had a family member who was a nurse, but thought she was too good for nursing homes but would come and help occasionally.
[Cross refer to F600, F676, F679, F689, F835, F838, and F840]
SERIOUS
(H)
Actual Harm - a resident was hurt due to facility failures
QAPI Program
(Tag F0867)
A resident was harmed · This affected multiple residents
Based on interview, record review, and interview, the facility did not develop and implement appropriate plans of action to correct identfied quality deficiencies. Specifically, multiple instances of ...
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Based on interview, record review, and interview, the facility did not develop and implement appropriate plans of action to correct identfied quality deficiencies. Specifically, multiple instances of harm or immediate jeopardy were identified during the annual recertification survey. In addition, during this survey mutliple deficiences cited on the previous annual recertification survey were not corrected, and were cited again during this survey. Resident identifiers: 4, 7, 8, 9, 10, 11, 13, 14, 15, 22, 26, 29, 30, 31, 32, 34, 36, 37, 39, 93, and 94.
Findings include:
1. Based on observations, interviews and record review, it was determined for 8 of 33 sampled residents, that the facility failed to protect the resident's right to be free from physical abuse and sexual abuse by other residents. Specifically, one resident with severe cognitive impairment was sexually abused by a resident that was congitively intact. This identified deficient practice was found to have occurred at the Immediate Jeopardy (IJ) Level. Additionally, incidents of physical abuse between residents and a bruise with an unknown origin were identified at a potiential for harm level. Resident identifiers: 7, 9, 14, 15, 26, 31, 36 and 39.
[Cross refer to F600]
2. Based on observations, interviews, and record reviews it was determined, for 2 of 33 sampled residents, that the facility did not provide residents with the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This included but was not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Specifically, residents were placed in the locked unit without assessments to determine if the residents met the criteria for the unit and were not provided with access codes or other information for independent egress. Resident identifiers: 7 and 9.
[Cross refer to F603]
3.Based on observation, interview and record review it was determined, for 8 of 33 sampled residents, that in response to an allegation of abuse the facility did not report immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse. In addition, the facility did not report the results of the investigation within 5 working days of the incident and if the alleged violation was verified appropriate corrective action was taken. Specifically, the facility did not report within 2 hours when a resident was found with another resident without clothing, the resident was found without clothing, and the same resident was found being touched in the genitals by another resident. Additional, the facility did not report when two residents, who were unable to consent, were found having oral sex. This was found to have occurred at an immediate jeopardy level. In addition, a bruise was discovered on a resident and it was not reported. In addition, there was physical abuse between residents that was not reported. Resident identifiers: 9, 13, 14, 15, 26, 31, 36 and 39.
[Cross refer to F609]
4. Based on observation, interview and record review it was determined, for 8 of 33 sampled residents, that in response to allegation of abuse, the facility did not have evidence that all all leeged violation were thoroughly investigated and reported to the State Survey Agency within 5 days of the incident, and if the alleged violations were verified appropriate corrective action was taken. Specifically, there were no thorough investigations when a severly impared cognitive resident was sexually abused by a resident that was cognitively intact and when two residents were not assessed for ablitiy to consent, engaged in oral sex. These example were cited at an Immediate Jeopary level. In addition, the facility did not thoroughly investigate when a resident eloped from the facility, a resident had a bruise of unknown source and residents had a physical altercation. These examples were cited at a potiential for harm. Resident identifiers: 9, 13, 14, 15, 26, 31, 36 and 39.
[Cross refer to F610]
5. Based on observation, interview and record review it was determined, for 3 of 33 sampled residents, that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, a resident was not provided diabetic management, antibiotics as ordered, or wound care which resulted in an amputation. Another resident was not provided treatment for a rash and the resident was unable to move in bed. These were cited at a harm level. In addition, a resident was not treated for her psoriasis. Resident identifiers: 29, 31 and 32.
[Cross refer to F684]
6. Based on interview, observation and record review, the facility did not ensure that 7 of 33 sample residents maintained acceptable parameters of nutritional status. Specifically, residents with weight loss did not receive timely and appropriate interventions. One resident will be cited at a harm level due to continued weight loss with no new interventions. Resident identifiers: 4, 7, 13, 31, 32, 36, and 37.
[Cross refer to F692]
7. Based on observation, interview, and record review it was determined, for 1 of 33 sampled residents, that the facility failed to provide appropriate treatments and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. Specifically, physician orders to prevent a clogged feeding tube were not followed for a resident who was receiving enteral feeding. Resident identifier: 4.
[Cross refer to F693]
8. Based on observation, interview and record review it was determined, for 2 of 33 sampled residents, that the facility did not ensure pain management was provided to residents who required such services. Specifically, a resident screamed out in pain when he was repositioned. Another resident went to the hospital and his scheduled pain medication was discontinued when he returned. The resident complained of uncontrolled pain. These examples will be cited at a harm level. Resident identifiers: 14 and 32.
[Cross refer to F697]
9. Based on interview, record review, and observation, the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, residents, resident family members, and staff voiced concerns with the staffing levels. However, observations were made of the Memory Care Unit left unattended, there were not enough activity staff members, Activities of Daily Living (ADLs) were not completed, and at least one resident experienced a fall. Resident identifiers: 7, 9, 22, 26, 30, 31, 36, and 93.
10. Based on interview and record review the facility did not ensure that 4 of 33 sampled residents were free of significant medication errors. Specifically, a resident was not administered the correct dose of insulin per physician orders resulting in uncontrolled diabetes. This example will be cited at a harm level. In addition, two residents' antibiotics were not administered according to physician orders, and another resident's coumadin was not administered according to physician orders. Resident identifiers: 22, 29, 32 and 94.
[Cross refer to F760]
11. Based on observation, interview and record review it was determined, for 3 of 33 sampled residents, that the facility did not arrange outside resources in a timely manner for residents. Specifically, a resident was not scheduled for a Percutaneous Endoscopic Gastrostomy (PEG) tube placement and had multiple problems with the Nasojejunal (NJ) tube which was cited at a harm level. In addition, residents were not scheduled for a neurologist appointment and a cardiologist appointment. Resident identifiers: 4, 30 and 34.
[Cross refer to F840]
12. Based on observations, interviews and record review, it was determined that the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, abuse occurred within the facility on multiple occasions,but was not identified, reported or investigated; the staffing was inadequate and resulted in falls, abuse, and activities of daily living not being completed; Quality Assurance (QA) was not completed as required for approximately one year; medically necessary appointments were not scheduled by facility staff or the administrator; wound reports and pharmacy reviews were only accessible to the Administrator, who did not provide them to nursing staff; and multiple staff reported to the Administrator their concerns about resident safety while a specific nurse was working, however no follow up by the Administrator was completed. The identified deficient practice was found to have occurred at the Immediate Jeopardy (IJ) Level. Resident identifiers: 4, 8, 9, 10, 11, 13, 22, 26, 29, 30, 31, 32, 34, 36 and 93.
[Cross refer to F835]
13. F550, F565, F568, F578, F584, F656, F679, F680, F684, F692, F760, F761, F812, F842, F867, F880, F882 were cited on the previous annual survey completed 9/1/21. These deficiencies were also cited during this recertification survey, with F684, F692, F760 being cited at a harm level during the current survey.
On 10/11/22 the sign in sheets for the last 12 months of the Quality Assurance (QA) meetings were requested verbally to the Adminstrator (ADM).
On 10/12/22 at 9:50 AM, the sign in sheets for the last 12 months of the QA meetings were requested from the ADM via email.
On 10/24/22 at 6:08 PM, an interview was conducted with the facility ADM. The ADM stated that QA meetings were conducted at least quarterly, but could not provide any sign in sheets to demonstrate who had attended and the dates the meetings were held.
As of 10/31/22 at the time of exit, no sign in sheets for QA meetings was provided.
On 10/24/22 at 2:30 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that she thought there might have been a QA meeting in July 2022, but she wasn't really involved.
On 10/24/22 at 12:20 PM, an interview was conducted with the facility Medical Director (MD). The MD stated that she had not been invited to a QA meeting since at least January 2022, and this was concerning to her.
SERIOUS
(H)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0868
(Tag F0868)
A resident was harmed · This affected multiple residents
Based on interview, record review, and interview, the facility did not maintain a quality assessment and assurance committee consisting of the Director of Nursing, Medical Director, and and least thre...
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Based on interview, record review, and interview, the facility did not maintain a quality assessment and assurance committee consisting of the Director of Nursing, Medical Director, and and least three other members of the facility's staff. In addition the committee did not meet quarterly.
Findings include:
On 10/11/22 the sign in sheets for the last 12 months of the Quality Assurance (QA) meetings were requested verbally to the Administrator (ADM).
On 10/12/22 at 9:50 AM, the sign in sheets for the last 12 months of the QA meetings were requested from the ADM via email.
On 10/24/22 at 6:08 PM, an interview was conducted with the facility ADM. The ADM stated that QA meetings were conducted at least quarterly, but could not provide any sign in sheets to demonstrate who had attended and the dates the meetings were held.
As of 10/31/22 at the time of exit, no sign in sheets for QA meetings was provided.
On 10/24/22 at 2:30 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that she thought there might have been a QA meeting in July 2022, but she wasn't really involved.
On 10/24/22 at 12:20 PM, an interview was conducted with the facility Medical Director (MD). The MD stated that she had not been invited to a QA meeting since at least January 2022, and this was concerning to her.
[Cross refer to F867]
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Resident 37 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, DM II, hypokalemia,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Resident 37 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, DM II, hypokalemia, chronic pain, epilepsy, delusional disorder, dementia, osteoporosis, atherosclerotic heart disease, systemic lupus erythematosus, hypertension, and schizophrenia.
On 10/11/22 at 10:17 AM, resident 37 was observed sitting in her wheelchair in the memory care unit, looking at the door. Resident 37 stated, They won't let me out, I have a hair appointment. CNA 2 overheard the conversation and stated to the surveyor that resident 37 always thought she had appointments. Resident 37 then responded to CNA 2 with expletives.
On 10/27/22 between 1:30 PM and 2:30 PM, resident 37 was observed in a wheelchair, next to the nursing station. Staff walked past resident without engaging her in conversation. Resident 37 was facing the door to the medication room. Staff were observed to walk past resident 37 without engaging in conversation or offering an activity.
On 10/28/22 between 10:10 AM and 12:00 PM, resident 37 was observed to be sitting in a wheelchair, near the nursing station, facing the closed doors of the memory care unit. Staff were observed to walk past resident 37 without engaging in conversation or offering an activity.
Resident 37's record review was completed on 10/31/22.
Resident 37's care plan stated:
a. On 8/3/21, an intervention to help resident 37 feel safe was initiated and was to Provide activities in the SNU (Skilled Nursing Unit) or supervised while outside of the SNU.
b. On 6/2/22, I will participate in independent activities daily such as: watch t.v, socialize, watch the news
c. I will participate in diversionary activities prn (as needed).
d. Distract resident from wandering by offering pleasant diversions, structured
activities, food, conversation, television, book. Resident prefers: [blank]
e. Give the resident as many choices as possible about care and activities
On 6/15/22 at 6:43 PM, a recreation therapy note revealed that resident 37 stated that activities that were somewhat important to her were .keeping up on news and doing things with a group and religious activities .
On 10/26/22 at 11:30 AM, CNA 1 was interviewed. CNA 1 stated that residents in the locked unit liked to watch movies, but the DVD player had been broken for about a month.
On 10/28/22 at 10:55 AM, a follow-up interview was conducted with CNA 1. CNA 1 stated that resident 37 wanted to go to the store and to have her hair done, and wanted to go buy shoes. CNA 1 stated that the CNAs brought resident 37 out of the memory care unit because resident 37 focused on leaving the facility when she was near her room. CNA 1 stated that resident 37 frequently tried to get out, so it was easier for staff to just let her out of the unit. CNA 1 stated that resident 37 was not taken to activities because resident 37 just wanted to leave immediately. CNA 1 stated that resident 37 wheeled herself down the 200 and 300 hallways, but staff didn't have time to talk with resident 37. CNA stated that resident 37 would wheel herself around every day for a few hours and then staff would take her to her room after she tired herself out. CNA 1 stated that resident 37 was only calm when staff fed her meals, but staff did not typically feed her, because it wasn't required.
[Note: The Task list for CNAs revealed that resident 37 received assistance with meals one time in the past 30 days, from 10/1/22 to 10/30/22, on 10/4/22.]
[Note: It should be noted that this deficiency was cited during the previous annual recertification survey completed on 9/1/21.]
3. On 10/20/22 at 11:49 AM, an observation was made of the memory care dining room. Residents were observed to be served lemon pie on Styrofoam plates.
On 10/24/22 at 11:45 AM, an observation was made of the memory care dining room. Residents were served peach cake on Styrofoam plates.
On 10/24/22 at 11:52 AM, an observation was made of resident 9 being served lunch in his room. [NAME] 1 was observed to use Styrofoam plates for resident 9's meal.
On 10/24/22 at 11:58 AM, an interview was conducted with [NAME] 1. [NAME] 1 stated that Styrofoam plates were used for room trays because residents did not always eat right away and the kitchen staff needed to get the dishes back to be washed for the next meal. [NAME] 1 stated she was not sure why Styrofoam plates were used in the dining room for desserts. [NAME] 1 stated kitchen staff started using Styrofoam for dessert when there was COVID-19 in the building and just kept using them. [NAME] 1 stated there were no plates for cakes and pies because they had bowls to use for desserts.
On 10/26/22 at 4:19 PM, an interview was conducted with the Dietary Manager (DM). The DM stated residents were served on regular plates in the dining room. The DM stated residents were encouraged to eat in the dining room because the facility was transitioning back from COVID-19. The DM stated residents were served on Styrofoam in their rooms. The DM stated cake did not fit in the facility's dessert bowls and there were no small plates, so the desserts were served on Styrofoam.
4. Resident 35 was admitted to the facility on [DATE] with diagnoses which included Schizophrenia, mild intellectual disabilities, and convulsions.
On 10/12/22 at approximately 8:00 AM, resident 35 was observed to be standing inside the locked Memory Care Unit (MCU) of the facility. Resident 35 was observed to be banging on the locked doors of the unit, and looking through the small window toward the nurses station. RN 4 stood up from where she was seated at the nurses station, approached the locked doors of the MCU, and stated to resident 35, What do you need? RN 4 then proceeded to have a conversation with resident 35 about what he needed. At no time did RN 4 open the doors and speak with resident 35 face to face.
Resident 35's medical record was reviewed.
An admission Minimum Data Set (MDS) dated [DATE] revealed he had a Brief Interview of Mental Status score of 6 which indicated moderately impaired cognition.
A nursing progress note dated 8/30/22 at 1:43 PM revealed, Resident has been compulsive with requests and demanding unrealistic wants. Resident is non-compliant when he is asked to not pound on the doors continuously for things hes been told he needs to wait and have patience d/t (due to) other residents needs as well. Resident is very anxious and distracted with constantly moving around and unable to relax. He has scheduled Ativan to take PO (orally) Bid (twice daily) for his anxiety, however it is not effective in managing his anxiety/compulsive/aggression. I contacted [local mental health expert] regarding behavior and she will contact [mental health expert] about managing resident's anxiety.
5. On 10/13/22 at 2:23 PM, an observation was made of Certified Nursing Assistant (CNA) 3. CNA 3 offered resident 35 a banana. CNA 3 was observed to look for a banana. CNA 3 then stated They took away my bananas. CNA 3 was observed to tell resident 35 she did not have bananas for him and did not offer anything else.
Based on observation and interview, the facility did not treat 4 of 33 sample residents with respect and dignity, and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, staff were observed to yell down the hallway during the early morning hours, staff were observed to converse in a language that was not known to a resident, a staff member was observed to speak with a resident in the locked area of the facility through the locked doors instead of face to face, residents were served on Styrofoam plates, and a resident was seated by staff facing the doors of the locked unit. Resident identifiers: 9, 25, 35 and 37.
Findings include:
1. On 10/11/22 at 4:50 AM, while many of the residents were sleeping, Registered Nurse (RN) 1 was observed to be in the 300 hall, approximately one quarter of the way down the hall. RN 1 started yelling from this location down to the 100 hall, saying [Certified Nursing Assistant (CNA) 6]! CNA 6! Is [CNA 6] down there!? It should be noted that in this particular facility, there is a nurses station located in the center of the facility, with the halls linked to it as spokes in a wheel.
On 10/11/22 at 4:51 AM, an observation was made of RN 1. RN 1 was observed to open the memory care unit door and yell CNA 6's name. There was a resident observed wandering the hallway, the remaining residents were in their rooms. A resident in their room was observed to yell yes. RN 1 was observed to yell CNA 6's name three times and then close the door.
2. On 10/12/22 at 7:40 AM, a staff member was pushing resident 25 in his wheelchair and stopped near the nurses station, where she engaged in a conversation with another staff member. The two staff members had a conversation about where resident 25 should be taken to receive a shower. The conversation was conducted entirely in Spanish, and lasted for several minutes. It should be noted that resident 25's primary language is English.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0569
(Tag F0569)
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 did not convey 1 of 33 sample residents funds to his estate within 30 days of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not convey 1 of 33 sample residents funds to his estate within 30 days of the resident's death. Resident identifier: 92.
Findings include:
Resident 92 was admitted to the facility on [DATE] with diagnoses that included dementia and schizophrenia. Resident 92's medical record indicated that resident 92 passed away at the facility on 7/12/21.
On 10/18/22 at 11:55 AM and 10/25/22, the Administrator (ADM) was asked to provide the transactions from resident 92's personal funds account with the facility. The ADM did not provide these transactions until 10/27/22 at 9:16 AM.
Review of resident 92's personal funds account transactions indicated that although the resident passed away on 7/12/21, his personal funds were not conveyed to resident 92's estate until 4/27/22, nearly nine months later.
On 10/27/22 at 10:00 AM, an interview was conducted with the facility ADM. The ADM stated that there was no good reason that resident 92's estate did not receive the resident's funds within 30 days. The ADM also added We probably just didn't have an accountant in to do that.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0573
(Tag F0573)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 33 sampled residents, that the facility did not allow a residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 33 sampled residents, that the facility did not allow a resident's representative to access personal and medical records within 24 hours of the request. Specifically, a resident family member, a hospice representative, and the county ombudsman all requested medical records for a resident, however the records were not provided at all, or not provided within 24 hours. Resident identifier: 93.
Findings include:
Resident 93 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, and dementia. The resident was discharged from the facility on 6/22/22.
On 6/10/22, a quarterly Minimum Data Set indicated that resident 93 had a Brief Interview for Mental Status score of 3, indicating severe cognitive impairment.
On 10/18/22 at 10:55 AM, an interview was conducted with resident 93's family member (FM). The FM stated that she was the resident's power of attorney, because resident 93 had severe dementia. The FM stated that the family members wanted resident 93 to apply for the New Choice Waiver (NCW), and had requested her medical records from the facility. The FM stated that facility staff had told her that all medical record requests had to go through the Administrator (ADM). The FM stated that the ADM refused to give any medical records, telling the FM that resident 93 won't qualify for the program anyway. The FM stated that she had spoken directly with the ADM several times about obtaining resident 93's medical records, but was told that it was the State's policy that she could not release the records, or that the hospice company had to request the records. The FM stated that the hospice Social Services Worker (SSW) also attempted to obtain resident 93's medical records, but the ADM also refused to release the records to the hospice SSW. The FM stated that the facility had drug their feet and resident 93 missed the application window on two different occasions. The FM also stated that the ADM delayed the process so much, that she had to fill out the NCW application multiple times. The FM stated that at the end of June 2022, after missing the application window for the NCW the second time, we just moved her (resident 93) to a different facility and that the facility was terrible to work with.
On 10/13/22 at interview was conducted with the hospice SSW. The hospice SSW stated that she had requested the medical records from the ADM multiple times, but was never provided with them.
On 10/13/22 at 9:14 AM, an interview was conducted with Ombudsman (OM) 1. OM 1 stated that she had been contacted on 5/27/22 by resident 93's family regarding obtaining medical records from the facility so that resident 93 could apply for the NCW. OM 1 stated that the family members and the hospice company working with resident 93 had reported asking the ADM for resident 93's medical records multiple times, but that the ADM refused to provide them. OM 1 stated that on 5/31/22 she obtained a list of the required documentation from resident 93's medical record that NCW would require from the facility. OM 1 stated that on 6/2/22, she asked the ADM to send the required medical records to NCW, but that the ADM told her that resident 93 didn't qualify for the NCW. OM 1 stated that regardless of the ADM opinion, the resident still had the right to apply and have NCW staff make the determination. OM 1 stated that the ADM agreed to have the medical records sent over to NCW by 6/7/22. OM 1 stated that on 6/7/22 she found out that the ADM had not sent the paperwork. OM 1 stated she reached out again to the ADM on 6/10/22, and that the ADM provided her with part of the medical record, but not all of it because she needed to fill in the missing documentation. At that time, the ADM stated she would provide the paperwork to OM 1 by 6/13/22. OM 1 stated that the ADM did not provide her with the documentation until 6/16/22. OM 1 stated that by the time she was able to obtain the paperwork from the ADM, the NCW staff told her it was too late to apply for the program that month. OM 1 stated that at that time, the family members of resident 93 decided to transfer the resident to another facility.
On 10/26/22 at 5:46 PM, an interview was conducted with the facility SSW. The SSW stated that she came in to the facility on weekday evenings to provide socializations. I just want to work here and come and spend time with the residents. The SSW stated that she was not involved in any discharge planning or NCW decisions.
On 10/25/22 at 1:35 PM, an interview was conducted with the facility ADM. The ADM stated that any paperwork requests for the NCW had to go through the facility SSW. The ADM stated that she did recall speaking to resident 93's hospice social worker, and that the ADM had provided all of the paperwork within a week.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not include provisions to inform and provide written information to 1 of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not include provisions to inform and provide written information to 1 of 33 sampled residents concerning the right to accept or refuse medical or surgical treatment and, at the residents' option formulate an advance directive. Resident identifiers: 35.
Findings include:
Resident 35 was admitted to the facility on [DATE] with diagnoses which included schizophrenia, cognitive communication deficit, muscle weakness and non-pressure chronic ulcer.
Resident 35's medical record was reviewed.
There was no advanced directive or Physicians Order of Life Sustaining Treatment (POLST) form completed and signed by the physician located in resident 35's medical record.
On 10/26/22 at 5:46 PM, an interview was conducted with the Social Service Worker (SSW). The SSW stated she was at the facility Monday through Friday from 5:30 PM until 9:30 PM. The SSW stated she socialized with the residents in the dining room while they had coffee and dinner. The SSW stated she did banking, counted cigarettes, socialized one on one, painted residents' fingernails, read newspapers, and talked about current events. The SSW stated she had not been asked to assist with discharge planning. The SSW did not say she worked with residents for their advanced directives.
On 10/27/22 at 9:14 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated resident 35 did not have an advanced directive. The ADON stated resident 35 was a full code. The ADON stated the SSW was in charge of discussing the POLST form with residents. The ADON stated the SSW came in on the evenings, so she should have completed the form with resident 35.
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 observation, interview and record review it was determined, for 2 of 33 sampled residents, that the Minimum Data Set (M...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 2 of 33 sampled residents, that the Minimum Data Set (MDS) assessment did not accurately reflect the resident's status. Specifically, residents dental status, dietary orders, and discharge plans were not assessed accurately. Resident identifiers: 31 and 34.
Findings include:
1. Resident 31 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, hyperlipidemia, dementia with behavioral and major depressive disorder.
On 10/12/22 at 10:37 AM, an interview was conducted with resident 31's family member. The family member stated resident 31 had dentures but were lost during the COVID-19 lock down when family could not visit. The family member stated resident 31 would wear dentures if she had them.
On 10/11/22 at 7:50 AM, an observation was made of resident 31 in the memory care dining room. Resident 31 was observed to not have teeth or dentures.
Resident 31's medical record was reviewed.
a. An annual MDS dated [DATE] revealed resident 31 had no broken or loosely fitting full or partial denture. Resident 31 had natural teeth or tooth fragments.
A Nursing Evaluation/Data Collection form dated 8/16/16 revealed resident 31 condition of her teeth are fair and had a complete upper and lower set of dentures.
A nursing progress note dated 1/10/18 at 10:09 PM revealed, . Has natural teeth.
There were no other nursing progress notes located in resident 31's medical record regarding dentures or teeth.
On 10/26/22 at 12:14 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated resident 31 did not have teeth or dentures since she started in 2017.
On 10/27/22 at 9:15 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated there was an initial assessment on 8/16/16 that revealed resident 31 had a complete set of dentures. The ADON stated she did not remember ever seeing resident 31 with dentures. The ADON stated that she completed the MDS assessments.
b. On 10/11/22 at 7:50 AM, an observation was made of resident 31. Resident 31 was observed to be served a pancake, ground meat, hot cereal and grapes.
Resident 31's medical record was reviewed:
An annual MDS dated [DATE] revealed resident 31 did not have a mechanically altered or therapeutic diet.
A diet order dated 9/22/21 revealed resident 31 was on a minced texture with enriched diet.
2. Resident 34 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included atherosclerotic heart disease, hemiplegia, gout, memory deficit following cerebral infarction, diabetes mellitus, dysphagia, and hyperlipidemia.
On 10/11/22, resident 34's medical record was reviewed.
A MDS annual assessment was completed for resident 34 on 3/4/22. The MDS was blank in the section that assessed the Resident's overall goal established during assessment process, Q0300A.
No discharge care plan or evaluation was located in resident 34's medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0660
(Tag F0660)
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 did not develop and implement an effective discharge planning process that fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for 2 of 33 sampled residents. In addition, the facility did not involve the resident or the interdisciplinary team in the development of a discharge plan. Resident identifiers: 20 and 34.
Findings include:
1. Resident 20 was admitted to the facility on [DATE] with diagnoses that included sepsis, osteomyelitis, hypertension, metabolic encephalopathy, diabetes mellitus, lymphedema, and atherosclerotic heart disease.
On 10/11/22 at 8:00 AM, an interview was conducted with resident 20. Resident 20 stated that he wanted to go back to the assisted living facility (ALF) that he was previously living at prior to being hospitalized , but that no one was helping him with the process.
On 10/11/22, resident 20's medical record was reviewed.
On 11/29/21, the facility completed an entry Minimum Data Set (MDS) Assessment. The MDS indicated that the resident had been admitted from a local hospital. The MDS also indicated that the resident expects to be discharged to another facility/institution.
No discharge care plan or evaluation was located in resident 20's medical record.
2. Resident 34 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included atherosclerotic heart disease, hemiplegia, gout, memory deficit following cerebral infarction, diabetes mellitus, dysphagia, and hyperlipidemia.
On 10/24/22 at 11:30 AM, an interview was conducted with resident 34. Resident 34 stated that he did not know what the plan was for him to discharge. Resident 34 stated that he had been in an ALF but that the ADM brought me over here because I've had too many falls. But I've only fallen twice this year. I've been here a year now and I want to go home.
On 10/27/22 at 9:00 AM, an interview was conducted with resident 34's sister. Resident 34's sister stated that resident 34 had been residing at an ALF, and they were going to have a family meeting to determine if the resident was still appropriate for the ALF. Resident 34's sister stated that the facility ADM, who also owned the ALF where resident 34 was residing previously, moved him to Mountain View, and they didn't tell us.
On 10/11/22, resident 34's medical record was reviewed.
No discharge care plan or evaluation was located in resident 34's medical record.
On 10/24/22 at 2:30 PM, an interview was conducted with the Director of Nursing (DON). When asked about resident 20's desire to discharge to an ALF, the DON stated that she was aware that resident 20 wanted to discharge, but that she thought resident 20 had since gotten used to the place and he is making new friends. The DON stated that all discharge planning was the responsibility of the facility Administrator (ADM). The DON stated that the facility did not have a social worker. The DON stated they did have a Social Services Worker (SSW) at the facility but that the SSW was only responsible for activities for a couple of hours each evening.
On 10/25/22 at 1:35 PM, an interview was conducted with the facility ADM. The ADM stated that she was aware that resident 20 wanted to discharge back to the ALF but that he changed his mind. When asked who did the discharge planning for the facility, the ADM stated I think my social worker would be the best one to do that.
On 10/26/22 at 5:46 PM, an interview was conducted with the facility SSW. The SSW stated that she came in to the facility on weekday evenings to provide socializations. I just want to work here and come and spend time with the residents. The SSW stated that resident 20 had mentioned once or twice that he wanted to discharge from the facility. The SSW stated that she was not involved in any discharge planning.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 of 33 sampled residents, that the facility did not ensure each res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 of 33 sampled residents, that the facility did not ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used without adequate monitoring. Specifically, residents blood pressure medications were administered when their blood pressure was outside the physician ordered parameters. Resident identifiers: 13 and 14.
Findings include:
1. Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cellulitis and abscess of mouth, osteoarthritis in left hip, chronic pain, metabolic encephalopathy, Wernicke's encephalopathy, dementia and psychosis.
Resident 14's medical record was reviewed.
A physician's order dated 3/3/18 revealed Propranolol HCL the instructions were give 20 milligrams (mg) by mouth two times daily for prophylaxis of esophageal varices hold for heart rate less than 60.
Another physician's order dated 3/30/18 revealed Blood pressure parameters - hold BP (blood pressure) meds (medications) and notify MD (Medical Doctor) if systolic is [less than] 110; notify if systolic is [greater than] 180.
Resident 14's August 2022 Medication Administration Record (MAR) revealed Propranolol HCL was administered with the following blood pressures and pulses:
a. On 8/16/22 at arise, blood pressure was 101/64 with a pulse of 68.
b. On 8/21/22 at evening, blood pressure was 106/68 with a pulse of 78.
c. On 8/22/22 at arise, blood pressure was 106/68 with a pulse of 78.
d. On 8/22/22 at evening, blood pressure was 106/68 with a pulse of 78.
Resident 14's September 2022 MAR revealed Propranolol HCL was administered with the following blood pressures and pulses:
a. On 9/5/22 at evening, there was no blood pressure or pulse and the medication was not signed as administered.
b. On 9/7/22 at arise, blood pressure was 99/50 with a pulse of 82.
c. On 9/7/22 at evening, there was no blood pressure or pulse and the mediation was not signed as administered.
c. On 9/8/22 at arise, blood pressure was 108/60 with a pulse of 78.
d. On 9/24/22 at evening, blood pressure was 106/52 with a pulse of 54.
e. On 9/25/22 at evening, blood pressure was 102/51 with a pulse of 56.
Resident 14's October 2022 MAR revealed Propranolol HCL was administered with the following blood pressures and pulses:
a. On 10/6/22 at evening, blood pressure was 108/70.
b. On 10/7/22 at arise, blood pressure was 108/70.
c. On 10/7/22 at evening, blood pressure was 108/70.
d. on 10/18/22 at arise, blood pressure was 98/55 with a pulse of 53.
e. On 10/18/22 at evening, blood pressure was 98/55 with a pulse of 53.
f. On 10/19/22 at arise, blood pressure was 98/55 with a pulse of 53
g. On 10/19/22 at evening, blood pressure was 98/55 with a pulse of 53.
h. On 10/20/22 at rise, blood pressure was 90/51 with a pulse of 69.
i. On 10/22/22 at evening, blood pressure was 90/60 with a pulse of 64.
A nursing progress note revealed on 10/6/22 at 11:02 PM, D/t (due to) resident's increased lethargy, decreased appetite and mobility. MD notified with an order for to draw labs CBC (complete blood count), CMP (comprehensive metabolic panel), ammonia and Depokote (sic) level. Also recent fall.
Resident 14's nursing progress notes from 10/7/22 revealed that resident 14 sustained a fall, was lethargic, unable to answer questions, and parotid glands were swollen. Resident 14 was transported to a local hospital.
There was no documentation that the physician was notified when resident's blood pressure or pulse were outside of parameters.
2. Resident 13 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included encephalopathy, paroxysmal atrial fibrillation, dementia, schizoaffective disorder, and obsessive-compulsive disorder.
Resident 13's medical record was reviewed.
A physician's order dated 2/1/18 revealed Cardizem LA Table Extended Release 24 Hour 120 MG. The instructions were to give 120 mg by mouth one time a day for atrial fibrillation.
Another physician's order dated 12/29/18 revealed Blood pressure parameters - hold BP meds and notify MD if systolic is less than 110 or over 180.
Resident 13's August, September and October 2022 MAR revealed Cardizem was administered with the following blood pressures and pulses:
a. On 8/16/22, blood pressure was 105/67 and pulse was 67.
b. On 10/5/22, blood pressure was 92/60 with a pulse of 82.
On 10/25/22 at 10:30 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that the Propranolol HCl Tablet should be held when blood pressure was outside the parameters. LPN 1 stated that the nurse should text the physician and see if she still wanted the medication administered if blood pressure or pulse were outside parameters. LPN 1 stated that the nurses knew resident 13 and 14 so well that nurses administered the medications if outside parameters. LPN 1 stated that he did not trust the blood pressure readings from the wrist cuff because sometimes it was low and then when the blood pressure was taken again a few minutes later on the other arm it might be high. LPN 1 stated that sometimes the medication was held, but still documented as administered.
On 10/27/22 at 10:00 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that if the blood pressure was outside parameters, the medication should not be administered.
On 10/28/22 at 11:30 AM, an interview was conducted with the DON. The DON stated that the blood pressure medication should have been held, but sometimes resident 13 was sleeping so his blood pressure was lower and we should wait until he got up and then take his BP because it would be higher when he was up. The DON stated administering the blood pressure medications when the blood pressure and pulse were outside the parameters was a mistake and the medication should not have been administered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility did not ensure safe and secure storage of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined that the facility did not ensure safe and secure storage of drugs and biological's in accordance with accepted professional principles; or include the appropriate accessory and cautionary instructions, and the expiration date on the medication. Specifically, tuberculin solution was expired, and narcotics were missing. Resident identifiers: 8, 10, 11 and 29
Findings include:
1. On [DATE] at 4:58 AM, Registered Nurse (RN) 1 was observed performing the narcotic reconciliation with RN 3. RN 1 stated that she forgot to sign out narcotics that she had administered overnight. RN 1 was observed to sign out narcotics for residents 8, 10, 11, 29, and three unsampled residents. RN 1 stated that she did not administer any narcotics to resident 10, but one narcotic was missing from resident 10's narcotic medications. RN 1 was observed to sign out the narcotic as having been administered to resident 10.
[Note: The missing medication was not located. The narcotic medication storage count and administration records were inaccurate.]
On [DATE] at 2:53 PM, RN 3 was interviewed. RN 3 stated that usually when she performed narcotic reconciliation with RN 1, there were at least two or three narcotics that were not signed out. RN 3 stated that the Director of Nursing (DON) was informed about the discrepancies. RN 3 stated that RN 1 was forgetful.
Review of medications revealed that the missing medications included dilaudid, oxycodone, and tramadol.
2. On [DATE] at 4:58 AM, the medication room was observed with Registered Nurse (RN)
3. An opened vial of tuberculin solution was observed with an open date of [DATE]. RN 3 was immediately interviewed. RN 3 stated the tuberculin expired 28 days after being opened.
Three residents were admitted in August, 2022. One unsampled resident received the expired tuberculin solution and two residents were not tested for tuberculosis (TB).
On [DATE] at 11:44 AM, an interview was conducted with the DON. The DON stated that she had requested a new vial of tuberculin, but had not received one. The DON stated that the expired tuberculin vial was the only tuberculin the facility had. The DON stated that residents who were admitted after [DATE] received expired tuberculin, but some residents were not tested for tuberculosis due to the expired tuberculin.
Resident records were reviewed. Three residents were admitted to the facility between [DATE] and [DATE]. One resident received the expired tuberculin. The other two residents were not tested for tuberculosis.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0773
(Tag F0773)
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 did not obtain laboratory services only when ordered by a physician for 1 of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not obtain laboratory services only when ordered by a physician for 1 of 33 sample residents. Specifically a resident had laboratory services completed without a physician's order. Resident identifier: 94.
Findings include:
Resident 94 was admitted to the facility on [DATE] with diagnoses that included chronic atrial fibrillation, aortic regurgitation and stenosis, pulmonary hypertension, hypertension, and type 2 diabetes mellitus with both diabetic nephropathy and peripheral angiopathy. Resident 94 was discharged from the facility on 9/6/22.
Resident 94's medical record was reviewed from 10/11/22 through 10/31/22.
A lab results sheet for resident 94 revealed that on 6/28/22, resident 94 had a Prothrombin Time/International Normalized Ratio (PT/INR) drawn.
A physician's order for this lab to be drawn could not be located.
On 10/24/22 at 2:30 PM, an interview was conducted with the Director of Nursing (DON). When asked about the process for labs, the DON stated that lab results were faxed to the facility, and someone should tell the doctor. The DON stated that she had been trying to implement new ways to do the lab process, but that any changes to nursing systems had to go through the Administrator. The DON was asked to provide additional information regarding the missing physician's order for resident 94. As of 10/31/22, when the exit conference was conducted, no additional information had been provided.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility did not ensure that residents were afforded the right to organize and participate in resident groups in the facility. Specifically, no resident counc...
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Based on interview and record review, the facility did not ensure that residents were afforded the right to organize and participate in resident groups in the facility. Specifically, no resident council had been formed and held since June of 2022.
Findings include:
On 10/12/22, the facility Administrator (ADM) was asked to provide the resident council minutes for the previous six months. The ADM provided the resident council minutes the same day they were requested, however the last resident council notes were from June 2022.
On 10/11/22 at 8:22 AM, Ombudsman (OM) 2 sent an email to the surveyors stating that she was concerned about the lack of resident council meetings at the facilty. OM 2 stated that she had brought this to the Administrator's (ADM) attention multiple times.
On 10/18/22 at 1:48 PM, an interview was conducted with the ADM. The ADM confirmed that the resident council had not been conducted since June 2022.
On 10/12/22 at 10:17 AM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated she did not know if there was a resident council and further stated that there were no activities for residents.
On 10/25/22 at 1:35 PM, an interview was conducted with the Administrator. The Administrator stated the Social Service Worker (SSW) and Therapeutic Recreation Therapy (TRT) worked together for resident councils. The Administrator stated she tried to review the activity calendar monthly but the resident council was not on the activity calendar for October 2022. The Administrator stated the last resident council was at the end of June 2022 because the TRT's family was sick and she had not been to the facility since July 2022.
On 10/26/22 at 3:30 PM, an interview was conducted with the TRT. The TRT stated she had not been at the facility regularly since July 2022.
On 10/26/22 at 5:46 PM, an interview was conducted with the SSW. The SSW stated she had not conducted a resident council meeting. The SSW stated the TRT was in charge of resident council.
On 10/26/22 at 6:11 PM, an interview was conducted with the Certified Therapeutic Recreation Specialist (CTRS). The CTRS stated the last time she was at the facility was in July 2022. The CTRS stated she called monthly and talked to the Administrator regarding activities. The CTRS stated she did not know if there was a resident council done monthly.
[Note: It should be noted that this deficiency was cited during the previous annual recertification survey completed on 9/1/21.]
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0567
(Tag F0567)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility did not act as a fiduciary of the resident's funds and hold, safeguard, manage, and account for the personal funds of the residents deposited with th...
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Based on interview and record review, the facility did not act as a fiduciary of the resident's funds and hold, safeguard, manage, and account for the personal funds of the residents deposited with the facility. In addition, the facility did not deposit resident funds into an interest bearing account. Resident identifiers: 2, 10, 28, and 30.
Findings include:
On 10/11/22 at 10:23 AM, an interview was conducted with resident 2. Resident 2 stated that the facility was not providing him with the $45 he was entitled to every month, because they say I owe them $20,000.
On 10/18/22 at 11:55 AM, the Administrator (ADM) was asked to provide the transactions from resident 2's personal funds account with the facility. The ADM did not provide these transactions until 10/27/22 at 9:16 AM.
Review of resident 2's personal funds account transactions from 1/1/22 to current, indicated that no transactions had been listed since 7/6/22. In addition, the account did not list any interest paid to the resident, and no evidence that his funds had been deposited into an interest bearing account. The transactions also indicated that the resident had a balance of over $700 in his account, but no withdrawals. In addition, the transactions did not indicate that resident 2's $45 was being deposited into his account each month.
On 10/27/22 at 10:39 AM, the Administrator was interviewed. The ADM stated that the accountant had not been at the facility since July 2022. The ADM stated that all residents' accounts should be in interest-bearing accounts, and did not know why there was no interest listed on resident 2's list of transactions. The ADM stated that for resident 2, he owed the facility approximately $18,000 due to a penalty after his family member sold his trailer and took the proceeds. The ADM stated that resident 2 had approximately $700 in his account, but since his income and payment amount was the same amount, resident 2 did not receive his monthly allowance of $45. The ADM stated that she was unable to access the accountant's computer program and was therefore unable to let the residents know how much money they had in their accounts. The ADM stated that the account information she had available was not current because the accountant had not worked on the accounts. The ADM stated that some residents had extra money, but the ADM could not tell the residents how much money they had. The ADM stated that the bookkeeper calculated the resident's contribution amounts and the ADM did not know how those amounts were calculated. The ADM produced a spiral notebook with penciled-in figures for amounts spent by the residents. The ADM stated that two additional staff members assisted with bookkeeping, but no staff had access to the accountant's program. The ADM stated that, for example, resident 28 took out little bits of money all the time, but finances weren't calculated more than quarterly. The ADM did not have resident 28 on the list of the residents for which the facility was the representative payee, because her money came in differently. When asked for additional examples, the ADM stated that resident 30's family sometimes brought in additional money. The ADM stated that the family received a deposit slip, and if resident 30 asked for money, staff had to find the deposit slip to know if resident 30 had additional funds. The ADM stated that every deposit was made into the general account, and when the accountant came into the facility, the accountant would figure out in whose account deposits were made. The ADM had a running total of the money for all representative payees, but not individual accounts. The ADM was asked to provide the personal funds account transactions for residents 10, 28, 30.
On 10/31/22 at 9:10 AM, the ADM was re-interviewed. The ADM stated that she was unable to retrieve the financial statements that were requested for residents 10, 28, and 30. The ADM stated that because the accountant came into the facility in July, it was time for another quarterly accounting. The ADM again confirmed that if a resident requested a current balance available in their personal funds account, it was not available.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0568
(Tag F0568)
Could have caused harm · This affected multiple residents
On 10/27/22 at 10:39 PM, the ADM was interviewed. The ADM stated that the accountant had not been at the facility since July, 2022. The ADM stated that all resident's accounts should be in interest-be...
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On 10/27/22 at 10:39 PM, the ADM was interviewed. The ADM stated that the accountant had not been at the facility since July, 2022. The ADM stated that all resident's accounts should be in interest-bearing accounts. The ADM stated that she was unable to access the accountant's computer program and was therefore unable to let the residents know how much money they had in their accounts. The ADM stated that the account information she has available is not current because the accountant had not worked on the accounts. The ADM stated that some residents had extra money, but the ADM could not tell the residents how much money they had. The ADM stated that the bookkeeper calculated the resident's contribution amounts and the ADM did not know how those amounts were calculated. The ADM produced a spiral notebook with penciled-in figures for amounts spent by the residents. The ADM stated that two additional staff members assisted with bookkeeping, but no staff had access to the accountant's program. The ADM stated that resident 28 took out little bits of money all the time, but finances aren't calculated more than quarterly. The ADM did not have resident 28 on the list of the residents for which the facility was the representative payee, because her money came in differently. The ADM stated that resident 30's family sometimes brought in additional money. The ADM stated that the family received a deposit slip, and if resident 30 asked for money, staff had to find the deposit slip to know if resident 30 had additional funds. The ADM stated that every deposit was made into the general account, and when the accountant came into the facility, the accountant would figure out in whose account deposits were made. The ADM had a running total of the money for all representative payees, but not individual accounts. The ADM stated that for resident 92, the ADM was unaware of when residents' families received their funds. The ADM stated that she would produce the statements for those residents and for residents 10 and 2.
On 10/31/22 at 9:10 AM, the ADM was re-interviewed. The ADM stated that she was unable to retrieve the financial statements that were requested. The ADM stated that because the accountant came into the facility in July, it was time for another quarterly accounting.
Based on interview and record review, the facility did not establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf. In addition, the facility did not ensure that the individual financial record was available to the residents and surveyors upon request. Resident identifiers: 2, 10, 28, and 30.
Findings include:
On 10/11/22 at 10:23 AM, an interview was conducted with resident 2. Resident 2 stated that the facility was not providing him with the $45 he was entitled to every month, because they say I owe them $20,000.
On 10/18/22 at 11:55 AM, the Administrator (ADM) was asked to provide the transactions from resident 2's personal funds account with the facility. The ADM did not provide these transactions until 10/27/22 at 9:16 AM.
Review of resident 2's personal funds account transactions from 1/1/22 to current, indicated that no transactions had been listed since 7/6/22. In addition, the account did not list any interest paid to the resident, and no evidence that his funds had been deposited into an interest bearing account. The transactions also indicated that the resident had a balance of over $700 in his account, but no withdrawals. In addition, the transactions did not indicate that resident 2's $45 was being deposited into his account each month.
On 10/27/22 at 10:39 AM, the ADM was interviewed. The ADM stated that the accountant had not been at the facility since July 2022. The ADM stated that all residents' accounts should be in interest-bearing accounts, and did not know why there was no interest listed on resident 2's list of transactions. The ADM stated that for resident 2, he owed the facility approximately $18,000 due to a penalty after his family member sold his trailer and took the proceeds. The ADM stated that resident 2 had approximately $700 in his account, but since his income and payment amount was the same amount, resident 2 did not receive his monthly allowance of $45. The ADM stated that she was unable to access the accountant's computer program and was therefore unable to let the residents know how much money they had in their accounts. The ADM stated that the account information she had available was not current because the accountant had not worked on the accounts. The ADM stated that some residents had extra money, but the ADM could not tell the residents how much money they had. The ADM stated that the bookkeeper calculated the resident's contribution amounts and the ADM did not know how those amounts were calculated. The ADM produced a spiral notebook with penciled-in figures for amounts spent by the residents. The ADM stated that two additional staff members assisted with bookkeeping, but no staff had access to the accountant's program. The ADM stated that, for example, resident 28 took out little bits of money all the time, but finances weren't calculated more than quarterly. The ADM did not have resident 28 on the list of the residents for which the facility was the representative payee, because her money came in differently. When asked for additional examples, the ADM stated that resident 30's family sometimes brought in additional money. The ADM stated that the family received a deposit slip, and if resident 30 asked for money, staff had to find the deposit slip to know if resident 30 had additional funds. The ADM stated that every deposit was made into the general account, and when the accountant came into the facility, the accountant would figure out in whose account deposits were made. The ADM had a running total of the money for all representative payees, but not individual accounts. The ADM was asked to provide the personal funds account transactions for residents 10, 28, 30.
On 10/31/22 at 9:10 AM, the ADM was re-interviewed. The ADM stated that she was unable to retrieve the financial statements that were requested for residents 10, 28, and 30. The ADM stated that because the accountant came into the facility in July, it was time for another quarterly accounting. The ADM again confirmed that if a resident requested a current balance available in their personal funds account, it was not available.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility did not consult with 1 of 33 sample resident's physician when th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility did not consult with 1 of 33 sample resident's physician when there was a change in the resident's status. Specifically, a resident had an ongoing rash that the physician was not notified about. Resident identifier: 32.
Findings include:
Resident 32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia, chronic obstructive pyelonephritis, severe sepsis, aspiration pneumonitus, supraventricular tachycardia, acute kidney failure, bipolar disorder, epilepsy, thyrotoxicosis and osteoarthritis.
Resident 32's medical records were reviewed between 10/11/22 and 10/31/22.
Resident 32's nurses notes included the following entries:
a. On 8/19/22, . scrotum is red and excoriated with new order for Zinc oxide 40% to be applied TID (three times a day).
b. On 9/14/22, Nystatin Powder Apply to neck [and] L (left) armpit topically two times a day for rash use until resolved.
c. On 9/18/22, . Resident has a rash on left side back that is healing.
d. On 10/1/22, . Resident has a rash on left side back that is healing.
e. On 10/9/22, . Resident has a rash on left side back that is healing.
On 10/6/22, a Nurse Practitioner Note documented that resident 32 had no skin issues, including rashes.
No skin assessments could be located in resident 32's medical record.
On 10/25/22 at 10:09 AM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated that resident 32 had started with the rash on his left back/torso area since he was readmitted from the hospital in August 2022. RN 3 stated that resident 32 was being seen by a wound care provider for open areas on his ankles, but had not discussed resident 32's rash with them.
On 10/26/22 at 11:04 AM, an observation was made of resident 32's torso area with Certified Nursing Assistants (CNAs) 3 and 4. Resident 32 presented with red to red/purple skin on the left side of his back and bilateral lower extremities below the knees. The skin was peeling (excoriated) with open wounds that were not dressed. There were four small (less than 1 centimeter) open, bleeding areas on resident 32's back, all on the left side of the resident's spine. The skin over the spine also appeared to be peeling and red. CNA 3 stated that the Director of Nursing (DON) would come in later to assess the wound to determine the appropriate dressing/cream. CNA 3 stated that the skin did not blanch and demonstrated that the purple/red areas on resident 32's left side did not blanch. CNA 3 stated that resident 32 had a lot of pain with his brief changes, and that they worked together every day to make sure he had the Calmoseptine cream on his red areas. CNA 4 stated that resident 32's skin appeared better than a month ago. Lotion was applied by the CNAs over resident 32's legs.
On 10/24/22 at 12:20 PM, an interview was conducted with the facility Medical Director (MD). The MD stated that she had not been informed about the rash on resident 32's left torso area.
On 10/24/22 at 2:02 PM, the MD stated that she had just gone to look at resident 32's rash, and that its pretty bad. it looks like heat rash, but its so bad its draining serosanguinous fluid. The MD stated that at the time of her observation, resident 32's incontinence brief was in bad need of being changed. The MD stated that after she had observed resident 32's rash, she spoke with the DON about it. The MD stated that the DON told her that resident 32's rash had been that way since the resident was readmitted from the hospital in August 2022, but that the DON had not seen the rash since that time. The MD also stated that the DON has no idea if resident 32 had been referred to a wound clinic for his rash. The MD also stated that she was unable to locate any skin checks in resident 32's medical record.
On 10/24/22, the MD documented the following note in resident 32's medical record: A state surveyor notified me that she had been told [resident 32] has a rash on his back. The DON says this has been present for some time. [Observation]: left side of back with large area of redness with some yellow serous drainage, no signs of infection.Dermatitis - likely a heat rash. [Resident 32] likes in the same position and does not shower regularly. Will order calmoseptine and will have . wound provider look at it on next visit.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected multiple residents
Based on observation and interview it was determined that the facility did not provide each resident the right to have secured and confidential personal and medical records. Specifically, resident cha...
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Based on observation and interview it was determined that the facility did not provide each resident the right to have secured and confidential personal and medical records. Specifically, resident charts were on a rolling cart that was placed in front of the memory care unit open door.
Findings include:
On 10/23/22 at 12:04 AM, an observation was made of Registered Nurse (RN) 5. RN 5 was observed to open the locked door to the memory care unit. RN 5 moved a cart with residents medical records from the memory care unit in front of the open door.
On 10/17/22 at 11:13 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated when she was the only CNA for the facility, the staff opened the door to the memory care unit and placed the medical record cart in front of the open door. CNA 1 stated staff were able to see what was going on in the memory care hallway with the door open. CNA 1 stated she glanced down the memory care unit hallway and then obtained vital signs from residents outside of the locked unit. CNA 1 stated the nurse sometimes watched the hallway.
On 10/17/22 at 2:20 PM, a phone interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated there were not enough CNA's in the facility at times, so staff leave the doors open to the locked unit. LPN 1 stated staff put the cart with medical records in front of the open door. LPN 1 stated that way we can see or hear residents in the locked unit. LPN 1 stated there should always be staff on the locked unit.
On 10/18/22 at 10:55 AM, an interview was conducted with resident 93's family member. Resident 93's family member stated that when she visited her mother, who resided in the facility Memory Care Unit (MCU), the doors to the MCU were often propped open. Resident 93's family member stated that facility staff used a rolling cart that contained resident medical records to prop the doors to the MCU open.
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 interview, observation, and record review, it was determined that the facility did not provide a safe, clean, comfortab...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, it was determined that the facility did not provide a safe, clean, comfortable, and homelike environment. In addition, the facility did not exercise reasonable care for the protection of the resident's property from loss or theft. Specifically, rooms were dirty, flooring was in disrepair, blinds were broken, a resident's recliner was soiled, linens were thread [NAME], and a resident's dentures were lost. Resident identifier: 7, 9, 13, 14, 22, 31 and 39.
Findings include:
1. On 10/11/22 at 4:34 AM, an observation was made of the memory care unit. There was a wet substance on the floor next to the doors entering the memory care unit.
2. On 10/11/22 at 6:06 AM, an observation was made of resident 9's bedding. Resident 9's bottom sheet had holes in it and was thread [NAME]. Resident 9 stated all the sheets were like that.
3. On 10/11/22 at 8:37 AM, an observation of resident 22's room was made. A hospital gown was on the floor next to the bed. The bed was unmade, and a blanket was on the floor. The floor appeared to have debris and dust, along with multiple black scuff marks next to the bed.
On 10/11/22 at 8:38 AM, an interview with resident 22 was conducted. Resident 22 stated that he did not know what the black scuff marks were from. Resident 22 stated that the hospital gown on the floor was his nightgown. Resident 22 stated that housekeeping sometimes cleaned his room. Resident 22 did not know how many times a week housekeeping cleaned his room.
4. On 10/12/22 at 1:35 PM, a tour of the facility was conducted. The following observations were included:
a. A dip in the flooring in the middle of the memory care unit hallway.
b. There was black tape that outlined a floor drain in the dining room.
c. There were broken blinds observed in rooms 303, 311, 312, 205, 313.
d. There were broken blinds in the memory care unit dining room.
e. rooms [ROOM NUMBERS] had scraped bedside the table tops.
f. The drywall around the heaters in rooms [ROOM NUMBERS] was bubbled and cracked.
5. On 10/12/22 at 2:57 PM, resident 7's recliner was observed. Resident 7's recliner was soiled with crumbs and debris. Resident 7's chair was torn. Resident 7 stated he would like to have his chair cleaned.
6. On 10/24/22 at 11:40 AM, an observation was made of resident 13's bedding. Resident 13's bottom sheet had holes in it and was thread [NAME].
7. On 10/26/22 at 11:00 AM, an observation was made of resident 7's room. Resident 7's room had bubbled paint and missing pieces of dry wall around the heating and cooling unit.
8. On 10/26/22 at 2:19 PM, an observation was made of resident 39's wheelchair. Resident 39's wheelchair cushion was soiled. There were crumbs and debris on the cushion, seat and foot rests.
9. On 10/27/22 at 10:30 AM, a follow-up tour was conducted of the facility. The following additional observations were made:
a. rooms [ROOM NUMBERS] had large scuff marks on the wall.
b. room [ROOM NUMBER] had a dirty privacy curtain between the two residents.
c. room [ROOM NUMBER]'s sink did not work.
d. room [ROOM NUMBER] had debris in most areas of the room.
10. On 10/28/22 at 10:19 AM, an observation was made of resident 14's bedding. Resident 14's sheets had holes in them and were thread [NAME].
The maintenance binder was observed at the nurses' station. Projects were dated back to 11/11/21. No broken blinds or holes in the floor were included on the project list.
On 10/27/22 at 9:10 AM, Certified Nursing Assistant (CNA) 3 was interviewed. CNA 3 stated that the only projects she put in the maintenance folder were clogged toilets or showers. CNA 3 stated that she was not told about what to put into the maintenance folder.
On 10/27/22 at 9:35 AM, an interview was conducted with CNA 4. CNA 4 stated that she told maintenance about broken light bulbs, stopped clocks, and clogged sinks. CNA 4 stated that at one time a call light would not turn off, so that was a high priority. CNA 4 stated that she reported any messes to housekeeping if it was not something she could fix, like wiping a spill off a floor. CNA 4 stated that she was not told what to report as a maintenance problem, she just reported whatever she saw.
On 10/27/22 at 10:19 AM, an interview was conducted with RN 3. RN 3 stated that maintenance fixed issues with call lights, toilets and sinks. RN 3 stated that she was not aware of broken blinds and water damage to the facility, but those would be the responsibility of the Maintenance Staff (MS).
On 10/27/22 at 10:35 AM, a tour was conducted with the Administrative Assistant (AA). The AA stated that he had experience with performing maintenance in other locations. The AA stated that while the MS was out of town, the AA assisted with maintenance. The AA stated that the bubbled walls in the 100 hall were due to drywall compound getting wet, and did not pose a structural problem. The AA stated that the walls could be fixed in about an hour. The AA stated that the floor in the memory care unit could easily be fixed with a plate.
On 10/27/22 at 10:45, the Administrator (ADM) was interviewed. The ADM stated that the Maintenance Staff (MS) was out of the facility for the week. The ADM stated that there was no other staff member that regularly did the maintenance besides the MS, and the MS carried out his daily routines. The ADM stated that the MS had a checklist. The ADM stated that when she was told about broken blinds, she would go to a local hardware store and buy multiple sets of blinds. The ADM stated that the housekeepers pulled down the dirty privacy curtains and washed them on the same shift, because they did not have spare curtains, since many of the curtains were different sizes. The ADM stated that the MS worked part time, and the MS doesn't help a lot, he gets behind.
[Note: The ADM provided the maintenance checklist. The daily checklist only included reviewing the maintenance binder for new issues. Blinds were to be checked monthly, along with furniture that needed repair. Checking for holes was to be done quarterly.]
11. Resident 31 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, hyperlipidemia, dementia with behavioral and major depressive disorder.
On 10/12/22 at 10:37 AM, an interview was conducted with resident 31's family member. The family member stated resident 31 had dentures but the dentures were lost during the COVID-19 lock down when family could not visit. The family member stated resident 31 would wear dentures if she had them.
On 10/11/22 at 7:50 AM, an observation was made of resident 31 in the memory care dining room. Resident 31 was observed to not have teeth or dentures.
Resident 31's medical record was reviewed.
An annual Minimum Data Set (MDS) dated [DATE] revealed resident 31 had no broken or loosely fitting full or partial denture. Resident 31 had natural teeth or tooth fragments.
A care plan dated 8/25/16 revealed The resident has oral/dental health problems r/t (related to) Poor oral hygiene. The goal developed was The resident will comply with mouth care at least daily through review date. Interventions developed were Coordinate arrangements for dental care, transportation as needed/as ordered; Monitor/document/report PRN (as needed) any s/sx (signs and symptoms) of oral/dental problems needing attention: Pain (gums, toothache, palate), Abscess, Debris in mouth, Lips cracked or bleeding, Teeth missing, loose, broken, eroded, decayed, Tongue (black, coated, inflamed, white, smooth), Ulcers in mouth, Lesions; and Provide mouth care as per ADL (activities of daily living) personal hygiene.
A Nursing Evaluation/Data Collection form dated 8/16/16 revealed resident 31's condition of her teeth are fair and had a complete upper and lower set of dentures.
A nursing progress note dated 1/10/18 at 10:09 PM revealed, . Has natural teeth.
There were no other nursing progress notes located in resident 31's medical record regarding dentures or teeth.
On 10/26/22 at 12:14 PM, an interview was conducted with CNA 1. CNA 1 stated resident 31 did not have teeth or dentures since she started in 2017.
On 10/27/22 at 9:15 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated there was an initial assessment on 8/16/16 that revealed resident 31 had a complete set of dentures. The ADON stated she did not remember ever seeing resident 31 with dentures.
On 10/27/22 at 9:36 AM, an interview was conducted with resident 31's power of attorney (POA). The POA stated resident 31 had dentures but he was not sure what happened to them.
On 10/27/22 at 11:01 AM, an interview was conducted with the Administrator. The Administrator stated there was a new dentist that came to the facility. The Administrator stated resident names were engraved in the dentures. The Administrator stated she was not sure what happened to resident 31's dentures. The Administrator stated she did not know resident 31 had dentures. The Administrator stated the Social Service Worker (SSW) handled lost items. The Administrator stated she had not heard anything about dentures.
On 10/26/22 at 5:46 PM, an interview was conducted with the SSW. The SSW stated she worked from 5:30 PM to 9:30 PM and socialized with the residents. The SSW stated she wanted to come spend time with the residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 8 of 33 sampled residents, that the facility did not im...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 8 of 33 sampled residents, that the facility did not implement their written policies and procedures to prevent abuse and investigate any allegations. Specifically, allegations of sexual, physical abuse and a bruise of unknown origin were not reported and investigated according to facility policy and procedures. Resident identifiers: 9, 13, 14, 5, 26, 36, 31 and 39.
Findings include:
1. Resident 31 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, unspecified dementia with behavioral disturbance, and depression.
Resident 31's medical record was reviewed.
An annual Minimum Data Set (MDS) dated [DATE] revealed resident 31 did not have a Brief Interview for Mental Status (BIMS) because she rarely/never understood. The MDS further revealed resident 31 had short and long term memory problems. The MDS revealed her cognitive skills for daily decision making were severely impaired. The MDS revealed resident 31 required extensive one person assistance with dressing.
Resident 31's care plan dated 3/27/17 revealed The resident has a behavior problem of wearing multiple layers of clothing and resisting to change or remove the clothing. The goal with a target date of 5/27/22 was The resident will have fewer episodes of wearing multiple layers of clothing weekly, by review date. Interventions included Assist the resident to develop more appropriate methods of coping and interacting. Encourage the resident to express feelings appropriately; Explain all procedures to the resident before starting and allow the resident 5-10 (minutes) to adjust to changes; If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Praise any indication of The resident's progress/improvement in behavior.
Another care plan for resident 31 dated 8/25/16 revealed, The resident has a behavior problem of wearing multiple layers of clothing and resisting to change or remove the clothing The goal with a target date of 5/27/22 revealed, The resident will have fewer episodes of wearing multiple layers of clothing weekly, by review date. Interventions were Assist the resident to develop more appropriate methods of coping and interacting; Encourage the resident to express feelings appropriately; Explain all procedures to the resident before starting and allow the resident 5-10 (minutes) to adjust to changes; If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Praise any indication of The resident's progress/improvement in behavior.
Resident 26 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, diabetes mellitus, and hypertension.
Resident 26's medical record was reviewed.
Resident 26's quarterly MDS dated [DATE] revealed a BIMS score of 5 which indicated severe cognitive impairment. The MDS further revealed resident 26 walked in corridor, walked in room, locomotion on the unit and locomotion off the unit required supervision and setup help only.
Resident 26's care plan 8/3/21 revealed The resident has a behavior problem r/t (related to) Schizophrenia. The goal was The resident will have no evidence/decrease of behavior problems by review date. Interventions developed were Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by; If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident; Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes.
On 8/29/21, resident 26 was found in a room with resident 31 by a surveyor during a recertification survey. Resident 26 had his penis exposed while standing directly in front of resident 31. Resident 31 had her back to the wall. This incident was cited as part of the annual recertification survey.
There were no progress notes in resident 26's or resident 31's medical record regarding the incident on 8/29/21.
A nursing progress note dated 9/4/21 at 10:41 PM revealed, resident 26 was observed touching staff and other residents without consent.
On 9/17/21 at 2:57 PM, the facility reported to the State Survey Agency that resident 31 had been found naked with resident 26 in a room in the memory care unit at 7:15 AM.
A nursing progress note by Licensed Practical Nurse (LPN) 1 in resident 31's medical record revealed on 9/17/21 at 3:24 PM, Resident was found in room [ROOM NUMBER] on the bed naked with another resident (male). CNA informed me and RN and we directed male resident back to his room and resident was assessed by RN and CNA then re-dressed while I informed the Administrator at 0645 (6:45 AM), which he addressed the occurrence to proper authorities. Resident was transported to [local hospital] ER (emergency room) to be assessed. Resident returned with order for doxycyline 100 mg one PO (by mouth) BID (twice daily) x 7 days.Incident report completed.
A nursing progress note by the DON dated 9/17/21 revealed that a physician's order was received to transfer resident 26 to the emergency room for possible transfer to a mental health facility. At 4:21 PM, resident 26 was transported to a local emergency room (ER) for mental health evaluation.
A nursing progress note by LPN 1 in resident 26's medical record revealed on 9/17/21 at 2:59 PM, Resident was found by CNA in room [ROOM NUMBER] with another resident (Female) naked on the bed at 0645 (6:45 AM). CNA informed Me (Nurse) and Charge nurse and we directed resident to his room and informed him to stay in his room until one of us (Nursing staff) comes back. RN and CNA assessed the female resident and re-dressed her and remained with her. I Phoned Facility Administrator at time of incident and informed him of the incident. Administrator stated he will advise and report to proper authorities, I informed Administrator both individuals were separated and one on one staff until further notice.
A nursing progress note dated 9/18/21 at 10:04 PM revealed, resident 26 was moved to a room outside of the locked unit. The note further revealed resident 26 frequently wandered into the rooms of female resident and was sexually inappropriate with residents and staff. Staff were to continue to monitor resident 26.
A nursing progress note dated 9/25/21 at 11:06 PM revealed resident 26 had been sexually inappropriate with the female staff.
Resident 26's Medication Administration Record indicated that staff were to monitor resident 26 for sexually inappropriate behaviors as of 9/25/21. Resident 26 was also started on Risperdol as of 9/26/21.
A physician's progress note for resident 31 dated 10/18/21 at 12:54 PM, .On 9/17 she was found naked with a male resident on top of her. She was transported to the ER where evaluation did not reveal signs of physical trauma.
A nursing progress note dated 12/4/21 at 10:18 PM revealed resident 26 was occasionally sexually inappropriate.
A nursing progress note dated 1/2/22 at 1:29 AM revealed resident 26 had not harmed anyone.
A nursing progress note dated 7/10/22 at 2:18 AM revealed resident 26 was discovered missing about 7:30 PM. Staff checked every room and the outside around the entire building. Police, Administrator and physician were notified.
A nursing progress note dated 7/10/22 at 1:22 PM revealed police returned resident 26 at approximately 10:30 AM and a physician's order was obtained to change room to memory lane. Resident 26 was happy to see his old roommate.
The facility reported resident 26's elopement on 7/11/22 at 7:41 AM. The facility reported resident 26 eloped at 12:14 AM on 7/10/22. The investigation was [Resident 26] went out for the last smoke break at 7pm then returned to his room. Later when doing rounds [resident 26] was not in his bed. Facility was searched. Police Notified. Silver alert was sent out. At approx. (approximately) 9:30am an old employee texted and notified the facility that [resident 26] was at [local convince store] a block away. Police were notified and picked him up. Returned to the facility at 10am. There were no interviews or further investigation.
Resident 26's monthly nurses assessments for the months of September 2021, October 2021, November 2021, December 2021, January 2022, April 2022, June 2022, and July 2022 documented that resident 26 had sexual behaviors but did not indicate what the behaviors were. [It should be noted that the monthly assessments for February 2022, March 2022, May 2022, August 2022, and September 2022 were not able to be located in resident 26's medical record.]
A nursing medication administration note dated 8/28/22 at 1:32 PM, revealed resident 26 was seen by other resident pulling a female resident into his bathroom. he noticed he was caught and let her go.
The facility reported on 8/29/22 at 12:35 pm, that on 8/26/22 at 2:00 AM, resident 31 and resident 26 were found laying in bed together with no briefs. The Summary of the Investigation was Both residents live on the secured unit in the nursing facility. [Resident 31] is a constant wanderer and pacer. She wanders in and out of any room and often climbs into beds when she is tired. She also immediately takes off her briefs when they are wet. It is believed that she climbed into his bed. He often sleeps with just a tshirt or naked.
While the CNAs were doing rounds they found them both in bed with no briefs on. The RN did checks and found no evidence of any encounter. Residents were sent to their own rooms.
[Resident 26] is a client of [local mental health] the provider is looking at adjusting medications and increased visits from case manager and LCSW.
It should be noted there were no documented interviews or further investigation.
Resident 26 and 31's nursing progress notes were reviewed and there were no notes in either of the residents medical records regarding this event.
On 10/22/22 at 11:22 AM, an interview was conducted with CNA 6. CNA 6 stated she witnessed an incident between resident 26 and resident 31 a couple months ago. CNA 6 stated she finished changing resident 31's brief and went into another residents room and was changing another resident. CNA 6 stated when she went back to check resident 31, she was missing. CNA 6 stated she searched room to room and found resident 31's brief and pants were off and resident 26's brief and pants were pulled down to his knees. CNA 6 stated she told the RN 6. CNA 6 stated that she was not questioned by the Administrator or DON regarding the incident. CNA 6 stated that resident 31 was placed on 15 minutes checks. CNA 6 stated that resident 26 continued to reside on the memory care unit after the incident. CNA 6 stated resident 26 told the nurse that he was in trouble and he knew what he did was wrong. CNA 6 stated he keeps doing it and he gets caught every time he does anything to resident 31. CNA 6 stated a CNA reported to her on evening shift that resident 26 was holding the door closed in the shower room with resident 31. CNA 6 stated another time she was told that resident 31 was in resident 26's room butt naked behind the curtain. CNA 6 stated that she was told to keep an eye on him. CNA 6 stated sometimes she had to leave the memory care unit unattended to make sure other residents were receiving care.
The incident when resident 31 and resident 26 were found in the bathroom together was not reported to the State Survey Agency.
The incidents when resident 31 was found naked behind a curtain in resident 26's room was not reported to the State Survey Agency.
A nursing progress note regarding resident 26 dated 9/4/22 at 12:16 AM revealed, has been doing about the same. We have to watch him so he doesn't coax one of the ladies into his room.
On 10/1/22, resident 26 was documented as demonstrating inappropriate behavior,
such as making inappropriate comments to this nurse. Resident says 'I need you tonight' 'I love women' and trying to kiss on the hand. Resident was reminded of
appropriate communication and that these comments are unacceptable. Resident
verbalized understanding 'okay okay '.
Review of resident 26's September and October 2022 Treatment Administration Record (TAR) indicated that staff had not been consistently documenting resident 26's sexual behaviors.
Review of resident 26's care plan indicated that no interventions had been put into
place to prevent further incidents with resident 31 after the incident on 8/26/22.
An incident/accident report dated 10/5/22 at 2:15 PM, revealed resident 31 was walking through the hallway without her clothes on, CNA found resident's clothes in closet of room # 104 ? at 2:15 PM. No injuries. [It should be noted the 104 was written over another room number that was unreadable.] The additional comments and/or steps taken to prevent reoccurrence were clothes to be ordered; to remind staff that designated CNA needs to be on the unit at ALL TIMES; and ensure staff on unit. The incident report was not signed by the Medical Director or Administrator on 10/17/22 when it was reviewed.
A nursing progress note dated 10/5/22 at 3:48 PM by LPN 1 revealed, Resident walking down hall on memory unit without her clothes on and other residents saw her naked. CNA's assisted resident to cloth her. CNA found resident's clothes in closet of room [ROOM NUMBER]. Resident's granddaughter witnessed the incident, and she is CNA here today this shift. I counseled the designated CNA working on memory unit and wrote action taken form and DON present during this write up. Copy of write up given to Admin '[name removed]'. NP informed as well as family.
On 10/12/22, both residents were observed to residing on the memory care unit that was the locked unit of the facility. Resident 26 resided in room [ROOM NUMBER] and resident 31 resided in room [ROOM NUMBER].
On 10/12/22 an observation was made of resident 31. At 2:59 PM, resident 31 was observed to wander into the door way of room [ROOM NUMBER] and was redirected by staff. At 3:03 PM, resident 31 was wandering into room [ROOM NUMBER]. At 3:08 PM, resident 31 wandered into room [ROOM NUMBER].
On 10/11/22 at 4:10 AM, an observation was made of RN 1, Certified Nursing Assistant (CNA) 6 and CNA 7 at the nurses station. The memory care unit was unattended until 4:22 AM when CNA 6 was observed to enter the unit. At 4:43 AM, CNA 6 was observed to exit the memory care unit. At 5:48 AM, CNA 6 entered the memory care unit. Resident 36 was observed to be ambulating up and down the hallway during that time. [It should be noted the memory care unit was unattended for 1 hour and 5 minutes.]
On 10/22/22 at 10:40 PM, an observation was made of CNA 6, CNA 7 and RN 5 at the nurses station. The memory care unit was unattended until 10:51 PM. Resident 36 was observed wandering the hallway. At 11:19 PM, CNA 6 was observed to leave the memory care unit. At 11:25 PM, CNA 6 was observed to return to the memory care unit. At 11:56 PM, CNA 6 and CNA 7 were observed to leave the memory care unit. At 11:57 PM, RN 5 entered the memory care unit. On 10/23/22 at 12:04 AM, RN 5 was observed to leave the memory care unit and open the door to the magnet. RN 5 was observed to wheel the charts in front of the open door. Resident 36 was observed wandering the hallway. RN 5 was observed to sit behind the charts near the open door. At 12:35 AM, CNA 6 and CNA 7 were observed to enter the memory care unit. At 12:37 AM, resident 31 was observed wandering the hallway without pants, wearing only a sweatshirt and brief. Resident 36 and resident 7 were observed in the hallway.
On 10/12/22 at 10:17 AM, an interview was conducted with resident 31's family member. Resident 31's family member stated on 10/5/22 it was shift change about 2:00 PM, there were no staff members on the memory care unit. Resident 31's staff member stated that a resident was banging on the doors to get staff attention outside of the memory care unit. Resident 31's family member stated she looked in and resident 31 was walking down the hall naked with no clothes on. Resident 31's family member stated that resident 31's clothes were nowhere to be found. Resident 31's family member stated that resident 31's clothing were found in room [ROOM NUMBER]'s closet. Resident 31's family member stated resident 31 was able to take her pants down but did not take her brief off and resident 31 was not capable of placing her clothing in a closet. Resident 31's family member stated that she was upset and talked to the DON. Resident 31's family member stated that DON told her to talk to the Administrator. Resident 31's family member stated she told the Administrator but the Administrator had family in her office and she stated to the resident's family member she was busy doing payroll. Resident 31's family member stated the Administrator stated to her she needed to talk to the nurse. Resident 31's family member stated she went back to the DON and demanded that something happen. Resident 31's family member stated she was trying to report an abuse allegation. Resident 31's family member stated the DON reviewed the camera footage of the memory care unit with her. Resident 31's family member stated there was nothing on the footage because room [ROOM NUMBER] was directly below the cameras. Resident 31's family member stated all they could see was resident 31 walking in the hallway naked. Resident 31's family member stated they could not see resident 31 walk into a room and when they saw her she was in the hallway with clothing and then suddenly she was naked. Resident 31's family member stated resident 26's room was joined to room [ROOM NUMBER] through a bathroom. Resident 31's family member stated that CNA 1 was counseled about not leaving the locked unit unattended. Resident 31's family member stated she felt something was happening to resident 31 from resident 26. Resident 31's family member stated that resident 26 stated to her that resident 31 was beautiful and he loved her. Resident 31's family member stated that resident 31 wandered into other resident rooms and if there was no staff in the hallway, she will go into anyone's room. Resident 31's family member stated resident 31 she would not let staff take off her pants and would say No, don't touch me dirty man. Resident 31's family member stated resident 31 was very jumpy and resident 31 was never like that.
On 10/17/22 at approximately 10:00 AM, an interview was conducted with the DON. The DON stated that CNA 2, who was a family member to resident 31, was upset on 10/5/22 and the DON stated she assumed the nurse had addressed it and that CNA 2 talked to the Administrator. The DON stated that CNA 2 returned from talking to the Administrator and CNA 2 told the DON she wanted something done. The DON stated that she reviewed camera footage because CNA 2 insisted to find out what happened to resident 31's clothing. The DON stated that resident 31 was in memory care unit hallway with no clothing on. The DON stated that CNA 2 was very upset. The DON stated she was having a hard time remembering what she saw from the camera footage. The DON stated she thinks resident 31 exited room [ROOM NUMBER] without clothing and did not see resident 31 enter a room because the video footage jumped 5 minutes at a time. The DON stated the memory care unit was unattended by staff for about 10 minutes. The DON stated the memory care unit was supposed to have staff at all times. The DON stated she had LPN 1 complete an incident report. The DON stated she reported the incident to the Administrator immediately. The DON stated she put a care plan in for resident 31 after the incident. The DON stated that in the position she was in, she did everything she could by watching LPN 1 counsel CNA 1 about not leaving the unit. The DON stated she educated CNA's that this happens with dementia and with increasing dementia this can happen. The DON stated resident 31 was able to removed her own clothing. The DON stated she also would like the family to be involved with care planning and maybe getting resident 31 onesies that zip in the back so she was unable to remove her clothing. The DON stated after resident 31 was found naked in the hallway she assessed resident 31. The DON stated resident 31 was clothed and there was no bruising or red marks on her back. The DON stated that In my opinion, I couldn't tell if it was an abuse allegation or an incident.
On 10/17/22 at 11:13 AM, an interview was conducted with CNA 1. CNA 1 stated on 10/5/22 when resident 31 was found naked in the locked unit, I was off the hall. CNA 1 stated she was waiting for the next shift to come into work. CNA 1 stated she was talking to another staff member and resident 31 was walking down the hallway with no clothes on. CNA 1 stated staff ran down the hallway to resident 31. CNA 1 stated resident 31 went into room [ROOM NUMBER] which was resident 26's room and her clothes were found in room [ROOM NUMBER]'s closet. CNA 1 stated resident 26 and his roommate were in their room when resident 31 went in. CNA 1 stated resident 31 wanders everywhere. CNA 1 stated she figured out a different system for resident 31. CNA 1 stated resident 31 was changed at 12:30 PM or 1:00 PM and then at 3:00 PM because that was when she usually had a bowel movement. CNA 1 stated there should be staff in the locked unit at all times. CNA 1 stated I was not on the hall which I take responsibility for. CNA 1 stated she was not sure if resident 31's clothing was soiled or wet when they were found. CNA 1 stated resident 31 was pacing the hallway yesterday and needed to be changed and did not take her clothing off. CNA 1 stated she was instructed by LPN 1 and the DON to stay in the memory care unit at all times and keep an eye on resident 31 and anyone that tried to bother her. CNA 1 stated other staff have told her that resident 31 takes her clothing off, but she had never seen resident 31 take her clothing off. CNA 1 stated she had found resident 31 without a brief on so she figured resident 31 removed it herself.
On 10/17/22 at 2:18 PM, an interview was conducted with CNA 8. CNA 8 stated 2 or 3 weeks ago she was sitting at the desk at about 2:20 PM and was waiting for another CNA to come to the locked unit to get report. CNA 8 stated resident 9 was knocking on the door and was asking for ice. CNA 8 stated she opened the door to give resident 9 ice and saw resident 31 naked in the hallway. CNA 8 stated resident 31 was outside the dining room toward her room. CNA 8 stated she took resident 31 to her room and dressed her. CNA 8 stated CNA 2, CNA 3 and CNA 4 were at the facility. CNA 8 stated she reported to the nurse what had happened. CNA 8 stated after the incident, she was told to be in the hall and care for the residents even though she was scheduled to work another hallway. CNA 8 stated she also told the DON about the incident. CNA 8 stated the DON was mad at us because no one was in the hallway. CNA 8 stated she stayed a little bit because CNA 2 was mad and wanted to look at the cameras to see what happened. CNA 8 stated she was the first CNA to see resident 31 naked in the hallway and there were other residents in the hallway. CNA 8 stated resident 31's mind was not good, so she did not know what was happening. CNA 8 stated resident 26 knew what was happening. CNA 8 stated she did not want anything to happen to resident 31 so she puts her on the couch. CNA 8 stated a Night CNA told her that when she received report to make sure resident 26 was not close to resident 31. CNA 8 stated she did not ask why she needed to keep them apart. CNA 8 stated she had been told that resident 31 and resident 26 had been found in bed together. CNA 8 stated she would be more careful with resident 31 and not leave her alone since she knew the residents had been found in bed together. CNA 8 stated she tried not to leave her alone since then, but things happened really fast. CNA 8 stated that resident 31 was unable to remove her own clothing. CNA 8 stated resident 31 won't allow for staff to pull her pants down when she needed to be changed. CNA 8 stated resident 31 would need assistance with removing all of her clothing including her shirt.
On 10/17/22 at 11:28 AM, an interview was conducted with the Administrator. The Administrator stated it was a daily occurrence that resident 31 did not have clothing on. The Administrator stated that once resident 31 was wet, she removed her bottoms. The Administrator stated that she had been trying to find things like taking her to the bathroom, so she did not remove her clothing. The Administrator stated resident 31 wandered all the time and removed her clothing wherever she wanted and continued wandering. The Administrator stated resident 31 wandered in and out of everyone's room on the locked unit. The Administrator stated resident 31 was friendly with everyone. The Administrator stated she was not sure if resident 31 was able to remove her shirt herself. The Administrator stated resident 31 could get her bottoms off fast. The Administrator stated she would not have looked into anything or questioned possible abuse with resident 31 coming out of another residents room with no clothing. The Administrator stated there were times the memory care unit was unattended by staff when staff were coming and going but staff should ask other members to cover the hallway.
On 10/17/22 at 11:38 AM, an interview was conducted with Medical Director (MD). The MD stated there was an incident report dated 10/5/22 regarding resident 31 not having her clothing on in the hallway. The MD stated it was reported to her but when she reviewed the incident report, the room number on the incident report was changed. The MD stated she was informed that resident 31's clothing was found in room [ROOM NUMBER], but it was changed to room [ROOM NUMBER]. The MD stated she had not received all the details about the incident.
The incident on 10/5/22 was not reported to the State Survey Agency. There was no investigation documented regarding the incident besides the information on the incident report.
On 10/17/22 at 12:10 PM, a follow up interview was conducted with the MD. The MD stated she was informed by CNA 1 that resident 26 was found fondling resident 31 today. The MD stated she talked to resident 26 and he stated I need to go to jail. The MD stated resident 26 stated I was playing around with an older woman, [resident 31]. The MD stated he did not go into specifics but he said sexual stuff.
On 10/17/22 at 12:21 PM, an interview was conducted with resident 26. Resident 26 was observed in the locked unit dining room. Resident 26 stated he had sex and pointed to resident 31. Resident 26 stated her name was (resident 31). Resident 26 stated he needed to go to jail because she walked around with her pants down. Resident 26 stated he did not always have full sex sometimes it was him putting his penis from front to back on resident 31 like a hot dog. Resident 26 stated he had sex with her six times.
On 10/17/22 at 12:22 PM, an interview was conducted with CNA 2. CNA 2 stated that at approximately 11:00 AM that day, she was assisting CNA 4 in walking resident 36 to the shower room. CNA 2 stated resident 31 was sitting on a sofa in the hallway which was near resident 26's room. CNA 2 stated she helped get resident 36 into the shower room and turned on the hot water and went back to the hallway. CNA 2 stated resident 31 was nowhere to be found. CNA 2 stated she went back to CNA 4 and stated she was unable to find resident 31. CNA 2 stated she went to resident 26's room and found resident 31 standing in front of resident 26 sitting on the toilet. CNA 2 stated resident 31's pants were down and resident 26 had a couple fingers inside of resident 31's vagina. CNA 2 stated she told resident 26 you do not do that. CNA 2 stated she pulled up resident 31's pants and lead her out of the bathroom and yelled for CNA 4 to report it to the DON. CNA 2 stated she was being written up by management because of the incident for leaving resident 31 unattended.
A nursing progress note from resident 26's medical record dated 10/17/22 at 11:30 AM by the DON revealed, Report from CNA about incident on Memory Lane where resident was in bathroom with a male resident with her pants down. Upon arriving to scene, resident had her pants up and walking in hallway. Took resident to her room with a CNA and did a physical assessment. No bruising, contusions noted to peri area. While removing brief, resident had a soiled brief. MD notified immediately, after reports by CNA family notified. Spoke with [name removed] (son) and told him that I was investigating the incident and MD was aware. He requested resident to be sent out to be eval/tx (evaluated and treatment). Family took resident to hospital per their choice. Notified son of the current status of the incident.
The facility reported to the State Survey Agency on 10/17/2022 at 2:40 pm, that on 10/17/2022 at 11:30 AM, resident 26 was touching resident 31's private area in with her pants down and resident 26 was fully clothed. There were written interviews from CNA 4 and CNA 2.
On 10/17/22 at 2:20 PM, an interview was conducted with LPN 1. LPN 1 stated resident 26 and resident 31 had some interactions with being in each others rooms. LPN 1 stated he believed about a month ago a CNA reported the residents were in the same room and resident 31's shirt was off. LPN 1 stated he reported the interaction to the DON and the DON reported it to the Administrator. LPN 1 stated he wrote an incident report about it. LPN 1 stated he did not witness anything, so he did not consider it potential abuse. LPN 1 stated the DON and him talked to the CNA regarding the need for staff members to be in the memory care unit at all times. LPN 1 stated a staff member was not in the locked unit when the incident occurred. LPN 1 stated he was not sure if resident 31 wandered into a room or if she was guided into a room. LPN 1 stated staff should have eyes on resident 31 at all times. LPN 1 stated there was another incident with resident 26 and resident 31 about a year ago around survey time. LPN 1 stated a CNA reported the same situation, both of them were in the same room with the door open. LPN 1 stated he could not remember the room number. LPN 1 stated he hurried to the room, separated the residents, had a CNA stay with resident 31 and walk her back to her room for an assessment. LPN 1 stated he reported the incident to the previous Administrator. LPN 1 stated resident 26 was moved out of the memory care unit. LPN 1 stated resident 31 was obviously vulnerable so we have to keep an eye on her. LPN 1 stated he did not know why resident 26 was residing in the memory care unit currently. LPN 1 stated an intervention to keep resident 26 safe was to make sure there were staff on the memory care unit at all times. LPN 1 stated the memory care unit required 2 CNAs because there were residents with behaviors, residents were more at risk for accidents and injuries and without enough staff members those were hard to prevent. LPN 1 stated there was sometimes only one CNA on shift, so the locked doors were propped open which was not the best solution but it was what happened.
On 10/17/22 at 2:53 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated there had not been any incidents with resident 26 and resident 31 for a while. The ADON stated there was an incident when staff found resident 26 and resident 31 without their clothes on in a room together. The ADON stated there was an investigation and resident 26 was moved out of the locked unit. The ADON stated on 10/5/22 she heard that resident 31 had a be[TRUNCATED]
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
Based on interview and record review, it was determined the facility did not send a copy of resident 30-day discharge notices or hospitalizations to the Long-Term Care Ombudsman.
Findings include:
O...
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Based on interview and record review, it was determined the facility did not send a copy of resident 30-day discharge notices or hospitalizations to the Long-Term Care Ombudsman.
Findings include:
On 10/11/22 at 8:22 AM, Ombudsman (OM) 2 sent an email to the surveyors stating that there has been no monthly transfer logs sent to the state ombudsman notifying of resident transfers since May 2022. OM 2 stated that she had brought this to the Administrator's (ADM) attention multiple times.
On 10/25/22 at 1:35 PM, an interview was conducted with the facility ADM. The ADM was asked if she was completing the monthly transfer logs for the state ombudsman. The ADM stated I did not know we were supposed to do that. I guess I missed a memo or something. The ADM confirmed however, that OM 2 had talked to her about filling out the logs prior.
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** 9. Resident 5 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia, type 2 diabetes mellitu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9. Resident 5 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia, type 2 diabetes mellitus, essential hypertension, hyperlipidemia, major depressive disorder, and unspecified osteoarthritis.
On 10/14/22 resident 5's care plan was reviewed.
Resident 5 had a care plan for activities/diversionary which was initiated on 10/14/21. The goal was use of 1:1 activities with resident, movies, puzzles. The intervention included, Entertain and encourage resident about the availability and use of activities. Additionally, resident 5 had a care plan with the focus being, resident has an alteration in through process and potential for social isolation r/t [related to] resident has a severe thought process impairment. Resident has a d/x [diagnoses] of Dementia. Resident has a short attention span and difficulties with recall and orientation skill. Resident will isolate in room. The goal was, Resident will accept 1x1 visits weekly to check on leisure needs, socialize and to encourage group activity participation by next review. Resident will participate in 1 group activity weekly by next review. The interventions included, Provide resident with a calendar of group activities so he choose what I want to attend. Invite resident to diversionary activities of voiced interest of those you think might be of interest and hold his attention when they are available such as: music, word games, trivia. Resident will participate in independent activities daily such as: watch t.v, movies, watch the news, socialize, get fresh air on a good day. Help resident to have involvement with the church of Jesus Christ of Latter Day Saints when available. Resident will wear a mask and social distance himself when in common areas when required to do so. Help me get recreation supplies when I request them. 1x1 visits 1 x per week to check on my leisure needs, encourage group activity participation and or to socialize by next review.
On 10/13/22 at 3:14 PM an interview with resident 5 was conducted. Resident 5 stated, If there are activities going on, I don't know about them. Nobody comes to ask me about activities. All I can do here is watch television. Resident 5 stated that he would enjoy doing some activities. Resident 5 stated that he used to do leather work and he enjoyed playing pool, so having activities similar to that would be enjoyable for him.
On 10/12/22 at 10:17 AM an interview with CNA 2 was conducted. CNA 2 stated that there were never activities on the locked unit, where resident 5 resides. CNA 2 stated that residents in the locked unit wander the halls, sit around, or lay in their beds all day.
On 10/20/22 at 12:17 PM an observation of the activities calendar in the locked unit was made. The activities calendar stated the activities on 10/20/22 were Fresh air, music and relaxation, and 1x1's. An interview with Licensed Practical Nurse (LPN) 1 was conducted. LPN 1 stated that he did not know what the activity Fresh air was. LPN 1 stated that the activities department needed help. LPN 1 stated that the resident need more to do because boredom is not good for the residents. LPN 1 stated that sometimes singers came in to preform for the residents, but the residents needed activities to do daily.
On 10/26/22 an interview with the TRT was conducted. The TRT stated that she came to help the facility when she was available, however she was only able to make it once every few weeks for a couple of hours.
6. Resident 24 was admitted to the facility on [DATE] with diagnoses that included senile degeneration of the brain, dementia, history of TIA (transient ischemic attack), chronic kidney disease, mild cognitive impairment, depression, severe malnutrition, hypertension, and a history of falls.
On 10/31/22, resident 24's medical record review was completed.
Resident 24's nursing notes contained the following:
a. On 4/5/22 at 9:04 AM, resident 24 ,had a fall from low floor bed (sic) at approx 0620 (6:20 AM). Abrasions to left leg, denies hitting head .
b. On 4/5/22 at 3:07 PM, resident 24 .had another fall from bed at approx 1420 (2:20 PM). No injuries, denies hitting head and denies pain .
c. On 4/13/22 at 11:30 AM, resident 24 .was sitting at nurses station when she leaned forward and fell head first to floor. Sustained a lac (laceration) to forehead .
d. On 5/29/22 at 1:23 PM, resident 24 had a fall from bed at approx 1120 (11:20 AM). Unwitnessed, resident states she was uncomfortable .
e. On 6/19/22 at 5:12 AM, resident 24 .was found on floor next to her bed. Assessed for injuries. Resident confused, said she hit her head. No injuries sustained .
f. On 9/27/22 at 8:26 AM, resident 24 .moved self from low bed to floor mat during the night shift, has redness on left side face and knee, skin tear on left forearm. Skin tear cleaned and dressed. Hospice nurse notified.
Resident 24's care plan revealed the following:
a. On 4/13/22, after a fall, an intervention was established to Assess resident . Follow Facility fall protocol . Lower bed while in bed .
b. On 5/13/22, an intervention was established to Ensure resident has proper footwear on with traction
c. On 5/29/22, an intervention was established to Remind resident to use call light for repositioning and needs.
d. On 6/18/22, an intervention was established to Assess/provide needs prior to putting in bed
No interventions were established to assist resident 24 from incurring additional falls and no changes were made to resident 24's care plan following the falls on 6/19/22 and 9/27/22.
7. Resident 36 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, anxiety, diabetes, anemia, intellectual disabilities, and depression.
On 10/31/22, resident 36's record review was completed.
Resident 36's care plan included the following:
a. A focus revealed: The resident requires a safe, secure environment Elopement risk, Wandering risk with an intervention of Provide activities in the SNU (Skilled Nursing Unit) or supervised while outside of the SNU, initiated on 8/3/21.
b. A focus revealed: Alteration in thought process r/t I have a severe thought process impairment. I have difficulties with recall and orientation skills. I will participate in select groups and will sometimes isolate in my room to do my own activities, initiated on 6/20/22. Interventions included, Invite me to activities of voiced interest or those you think I might enjoy as a passive onlooker such as: music. and I will participate in independent activities daily such as: watch t.v., movies, socialize. and I will participate in diversionary activities prn (as requested).
A nursing note created on 6/15/22 at 6:54 PM, revealed that resident 36 .participates in some activities such as trivia and sensory as a passive onlooker [resident 36] independently walks around the hall and will sometimes watch tv
On 2/28/22 at 3:04 PM, an activities note revealed that resident 36 currently participates in some activities as a positive onlooker .
On 10/12/22 at 4:25 AM, RN 1 stated that resident 36 paced in the evening and throughout the night.
On 10/12/22 at 2:38 PM, an activity was held in the activity room. Four residents were brought out of the Memory Care Unit, but resident 36 was not observed to be invited to the activity.
On 10/24/22 at 11:12 AM, resident 36 was observed pacing the hallway. Resident 36 was observed to ask for scissors because he needed to cut wires on his bed. Resident 36 was observed to continue walking in the hallway asking staff for scissors. CNA 4 stated she was not the maintenance director. and was unable to help him. CNA 4 was observed to look at resident 36's bed and stated she did not see any wires. Resident 35 was yelling to cut the wires. At 11:33 AM, an observation was made of resident 36's thumb and he stated it hurt. Resident 36 stated he needed clippers to clip the wires on his bed because he hurt his finger. Resident 36's thumb was bleeding. CNA 8 stated to resident 36 that maintenance would look at his bed at 2:00 PM. At 11:34 AM, CNA 4 stated she hoped lunch came soon to distract the residents especially resident 36. At 11:36 AM, another resident yelled at resident 36 to be quiet because he was told the same thing a bunch of times. At 11:37 AM, resident 36 asked to call the maintenance director on the phone. There were no activities or re-direction offered to resident 36.
8. Resident 37 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, DM II, hypokalemia, chronic pain, epilepsy, delusional disorder, dementia, osteoporosis, atherosclerotic heart disease, systemic lupus erythematosus, hypertension, and schizophrenia.
On 10/11/22 at 10:17 AM, resident 37 was observed sitting in her wheelchair in the memory care unit, looking at the door. Resident 37 stated, They won't let me out, I have a hair appointment. CNA 2 overheard the conversation and stated that resident 37 always thought she had appointments. Resident 37 then responded to CNA 2 with expletives.
On 10/27/22 between 1:30 PM and 2:30 PM, resident 37 was observed in a wheelchair, next to the nursing station. Staff walked past resident without engaging her in conversation. Resident 37 was facing the door to the medication room. Staff were observed to walk past resident 37 without engaging in conversation or offering an activity.
On 10/28/22 between 10:10 AM and 12:00 PM, resident 37 was observed to be sitting in a wheelchair, near the nursing station, facing the closed doors of the memory care unit. Staff were observed to walk past resident 37 without engaging in conversation or offering an activity.
On 10/31/22, resident 37's medical record was reviewed.
Resident 37's care plan included the following:
a. A focus was initiated on 8/3/22 of The resident requires a safe, secure, environment Elopement risk, Wandering risk. Interventions included to Provide activities in the SNU or supervised while outside of the SNU, Provide activities of daily living within the safety of the SNU .
b. A focus was initiated on 6/20/22 of Alterations in thought process r/t I have a severe thought process impairment. I sometimes yell out. Interventions included, Invite me to activities of voiced interest or those you think I might enjoy such as: music; I will participate in independent activities daily such as: watch t.v, socialize, watch the news; I will participate in diversionary activities prn.
c. A focus was initiated on 3/7/15 of he resident is an elopement risk/wanderer r/t Impaired safety awareness requiring placement on secured unit. Interventions included: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers:
d. A focus was initiated on 8/2/21 of The resident is/has potential to be verbally abusive (yelling profanities) r/t Dementia, Mental/Emotional illness. Interventions included Give the resident as many choices as possible about care and activities.
On 10/24/22 at 5:37 PM, an interview was conducted with the Administrator (ADM). The ADM stated that the activities person was out for the previous week and the ADM did not know if she would return this week.
10/25/22 at 1:35 PM, the ADM was re-interviewed. The ADM stated that there were no activities in the locked unit, that it was easier to keep track of residents if they just brought them out. The ADM stated that there were two activities staff in the past year, because they had stopped working.
On 10/26/22, the TRT was interviewed by telephone. The TRT stated that there were many times she could not do activities at the facility due to family concerns. The TRT stated that she did an activity on 10/24 with a couple people but could not do more due to how late she arrived at the facility and that residents were getting into bed. The TRT stated that the time before that, she was in the facility on 10/3/22, when she was in the locked unit working on word games and a sensory activity. The TRT stated that if a resident did not attend activities, she would do one-on-one activities with them, but she did not have a helper if she wasn't in the building. The TRT stated that there were three months in 2022 that she was not in the facility.
Based on observation, interview, and record review it was determined, for 10 of 33 sample resident, the facility did not develop and implement a comprehensive person-centered care plan for each resident. Specifically, residents that had care areas trigger on the Minimum Data Set (MDS) Care Area Assessment (CAA) Summary did not have care plans developed and implemented in a timely manner. In addition, residents care plans were not updated regarding specific needs. Resident identifiers: 5, 12, 13, 14, 24, 26, 32, 35, 36 and 37.
Findings include:
1. Resident 35 was admitted to the facility on [DATE] with diagnoses which included Schizophrenia, cognitive communication deficit, and non-pressure chronic ulcer.
On 10/11/22 at 7:59 AM, resident 35 was observed in the dining room. Resident 35 was observed to wear blue plaid pajama pants. Resident 35 was observed with greasy hair and beard.
On 10/20/22 at 12:05 PM, resident 35 was observed in blue plaid pajama pants. Resident 35's hair and beard were observed to be greasy.
On 10/24/22 at 11:45 AM, resident 35 was observed in blue plaid pajama pants. Resident 35's hair and beard were observed to be greasy.
Resident 35's medical record was reviewed.
An admission MDS dated [DATE] revealed resident 35 required one person physical assistance with bathing. The Care Area Assessment revealed that Activities of Daily Living (ADL) function triggered and would be addressed in a care plan.
There were no comprehensive care plans completed.
The Resident Shower List for October 2022 revealed resident 35 was not showered in October 2022.
On 10/27/22 at 4:15 PM, an interview was conducted with Certified Nursing Assistant (CNA) 5. CNA 5 stated she has been the only CNA for the evening shift. CNA 5 stated if she was the only CNA for the building showers were not completed. CNA 5 stated that resident 35 was independent and he wanted staff to wait outside so he could call if he needed assistant.
2. Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included metabolic encephalopathy, Wernicke's encephalopathy, dementia, osteoarthritis, and psychosis.
On 10/20/22 at 12:00 PM, resident 14 was observed in the dining room. Resident 14 was observed to have long hair that was greasy and standing up.
On 10/26/22 at 1:59 PM, resident 14 was observed sitting on a sofa in the hallway. Resident 14 was observed to have greasy hair that was standing up.
On 10/28/22 at 10:19 AM, resident 14 was observed in laying in his bed. Resident 14 was observed to have greasy hair that was standing up.
On 10/31/22 at 11:01 AM, an interview was conducted with resident 14. Resident 14 stated he wanted to be showered more. Resident 14 stated his hair was greasy and his head was itching. Resident 14 was observed to have flies on his food, around his head and around his feet.
Resident 14's medical record was reviewed.
A quarterly MDS dated [DATE] revealed resident 14 had a BIMS of 00 which indicated severe cognitive impairment. Resident 14 required one person physical assistance with bathing activity.
A care plan dated 6/10/13 revealed [Resident 14] has limited physical mobility r/t (related to) Neurological deficits. The goal with a target date of 5/3/22 was The resident will remain free of complications related to immobility, including contractures, thrombus
formation, skin-breakdown, fall related injury through the next review date. The interventions included LOCOMOTION: The resident is able to: supervision and Monitor/document/report PRN (as needed) any s/sx (signs and symptoms) of immobility: contractures forming or worsening, thrombus formation, skin-breakdown, fall related injury. It should be noted there was no care plan regarding the needs for other ADL assistance.
A form titled Resident Shower List for October 2022 revealed resident 14 was not shower for the month. Resident 14 was scheduled to have shower Tuesday, Thursday and Saturday in the afternoon.
On 10/27/22 at 4:23 PM, an interview was conducted with CNA 5. CNA 5 stated resident 14 could shower himself. CNA 5 stated she used a double was cloth with resident 14. CNA 5 stated he used one of the was clothes and the CNA used another to ensure he was getting himself clean. CNA 5 stated resident 14 was incontinent and needed to be cleaned in the shower.
3. Resident 12 was admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder, dementia, anxiety disorder, and severe protein-calorie malnutrition.
On 10/11/22 at 7:35 AM, an observation was made of resident 12 in the dining room. Resident 12 was observed to have greasy and stringy chin length hair. Resident 12 was observed with a gray cardigan with stains on the front of it.
On 10/24/22 at 5:22 PM, an observation was of resident 12. Resident 12 was in her room and had greasy and stringy hair. Resident 12 was observed with a gray cardigan with stains on the front of it.
On 10/26/22 at 10:00 AM, an observation was made of resident 12. Resident 12's hair was greasy and stringy. Resident 12 stated she was showered and her hair was washed once a week. Resident 12 was observed with a gray cardigan with stains on the front of it.
On 10/31/22 at 10:55 AM, an observation was made of resident 12. Resident 12 was observed with greasy and stringy hair. Resident 12 was observed with a gray cardigan with stains on the front of it.
Resident 12's medical record was reviewed.
A quarterly MDS dated [DATE] revealed that resident 12 had a BIMS score of 15. The MDS further revealed resident 12 required 1 person physical help in part of bathing.
A care plan dated 3/13/18 revealed [Resident 12] has an ADL self-care performance
deficit r/t Confusion, Dementia. The goal with a target date of 3/23/22 revealed The resident will have ADL needs met through staff assist as needed. The interventions were Encourage the resident to participate to the fullest extent possible with each interaction; Encourage the resident to use bell to call for assistance and; Monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function.
A review of the October 2022 Resident Shower List on 10/24/22 revealed resident 12 was showered on 10/15/22. There were no other showers signed off by a CNA October. Resident 12 was scheduled to be showered Monday, Wednesday, and Friday in the afternoon.
On 10/27/22 at 4:15 PM, an interview was conducted with CNA 5. CNA 5 stated resident 12 did not need a lot of help with showering. CNA 5 stated resident 12 needed to be cued and reminded to wash her hair. CNA 5 stated she thought resident 12 washed her hair twice. CNA 5 stated her hair was so greasy and she needed showered more often.
4. Resident 13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Schizoaffective disorder, encephalopathy, obsessive compulsive disorder, and dementia.
On 10/11/22 at approximately 6:45 AM, an observation was made resident 13. Resident 13 was observed in the dining room with a blue shirt on that was soiled down the front of it.
On 10/24/22 at 11:30 AM, resident 13 was observed to have a red shirt with stains on it. Resident 13 had a football team mask that was soiled on the side next to mouth and nose. Observed resident 13 had stains on his bed sheets.
On 10/28/22 at 10:19 AM, resident 13 was observed to have a brown jacket with stain on it. Resident 13 was also observed with an football coat with stains on it.
Resident 13's medical record was reviewed.
An annual MDS dated [DATE] revealed resident 13 had a BIMS score of 5. The MDS revealed resident 13 required 1 person physical help on part of bathing.
A care plan dated 8/2/21 revealed The resident has an ADL self-care performance deficit r/t muscle weakness. The goal with a target date of 3/23/22 revealed The resident will maintain current level of function in ADLs through the review date. Some of the interventions included BATHING/SHOWERING: The resident requires extensive by 1 staff with (SPECIFY bathing/showering) (SPECIFY FREQ (frequency)) and as necessary ; and DRESSING: The resident requires extensive assistance by 1 staff to dress.
A form titled Resident Shower List revealed that resident 13 had not received a shower during the month of October 2022. Resident 13 was scheduled to have showers in the afternoon on Tuesday, Thursday, and Saturday.
5. Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cellulitis and abscess of mouth, osteoarthritis in left hip, chronic pain, metabolic encephalopathy, Wernicke's encephalopathy, dementia and psychosis.
On 10/20/22 at 12:00 PM, an interview and observation was made of resident 14. Resident 14 asked why he was in more pain and getting more medication than before he left to the hospital. Resident 14 stated he had pain in legs, hands and spine. Resident 14 stated eating hurt and pain kept him awake at night.
On 10/26/22 at 12:15 PM, an interview was conducted with resident 14. Resident 14 stated he had pain in his right leg and pain from his shoulder to his toes down his leg on his left side. Resident 14 stated he was not in pain at the hospital but since getting back to the facility he had been in pain. Resident 14 stated in the morning he was woken-up by his pain. Resident 14 stated if gets his pain medication prior to bed, then he was able to sleep. Resident 14 stated without pain killers he did not sleep at all. Resident 14 stated the cold weather made his pain worse. Resident 14 stated he didn't do much because he was in pain. Resident 14 stated if there were activities, he would not go because it hurt for him to walk. Resident 14 stated at the hospital, they were able to control his pain, but he was unable to get the same medications at the facility. At 12:42 PM, resident 14 stated that his back was hurting and he was in pain. Resident 14 stated the pain medication did not last very long.
Resident 14's medical record was reviewed.
A quarterly MDS dated [DATE] revealed that resident 14's BIMS score was 00 which indicated severe cognitive impairment. The MDS further revealed resident 14 had received scheduled and as needed pain medication. The MDS revealed resident had pain or was hurting any time in the last 5 days and was almost constantly experiencing pain in over the previous 5 days. The MDS revealed that resident 14's pain limited his day-to-day activities. The MDS revealed resident's worst pain intensity was very severe, horrible in the previous 5 days.
A care plan dated 6/10/13 with a target date of 5/3/22 revealed The resident has pain r/t general pain, arthritis, low back pain. The goal was The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Interventions included The resident will not have discomfort related to side effects of analgesia through the review date; The resident will not have an interruption in normal activities due to pain through the review date ; The resident will display a decrease in behaviors of inadequate pain control (SPECIFY: irritability, agitation, restlessness, grimacing, perspiring, hyperventilation, groaning, crying) through the review date; Resident's pain will be managed at an acceptable level 5 through next review date; The resident's pain is aggravated by: general pain ; The resident's pain is alleviated/relieved by: prn medications; Administer analgesia ultram as per orders. tylenal Give 1/2 hour before treatments or care; Anticipate the resident's need for pain relief and respond immediately to any complaint of pain; Evaluate the effectiveness of pain interventions after medication administration; Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition ; Identify and record previous pain history and management of that pain and impact on function. Identify previous response to analgesia including pain relief, side effects and impact on function; Identify, record and treat the resident's existing conditions which may increase pain LPN and or discomfort; and resident usually does not remember when the nurse has give him a pain pill . ask
resident too rate his pain level before and after to determine effectiveness.
Resident 14's physician's orders were reviewed prior to discharging to the hospital. The following medications were ordered:
a. Start date of 9/24/2020, Gabapentin 100 mg by mouth three times a day for low back pain.
b. Start date of 1/5/19, Oxycodone HCL 5 mg. Give 1 tablet by by mouth every 4 hours as needed for pain related to other chronic pain.
c. Start date of 1/5/19, Oxycodone HCL 5 mg. Give 1 tablet by mouth two times a day related to other chronic pain and low back pain. Discontinued on 10/13/22.
Resident 14 returned from the hospital on [DATE] with orders to discontinue the scheduled Oxycodone 5 mg twice daily.
The nursing phone revealed a notification to the Medical Director (MD) on 10/13/22 [resident 14] is back. The MD responded What was he treated for? Any new orders? Nurse responded [resident 14's] discharge orders. sent to the MD. The MD responded Please make sure they get a follow up appt (appointment) for him with the ENT as per discharge orders. There was no follow up information about the change in pain medication.
Resident 14's October 2022 Medication Administration Record (MAR) was reviewed. Resident 14 received the scheduled Oxycodone twice daily expect in the evening on 10/5/22. Resident 14's pain scores were 0 to 5 with pain at an 8 once. Resident 14's pain score after returning from the hospital were 7 on 10/13/22, 10/14/22 and 10/15/22. Resident 14's pain was an 8 on 10/21/22, 10/22/22 and 10/23/22.
On 10/26/22 at 11:57 AM, an observation was made of resident 14 and the Director of Nursing (DON). The DON was observed to ask resident 14 if he wanted a pain pill. Resident 14 stated yes. The DON was observed to ask resident 14 what his pain level was and resident 14 stated 8. The DON stated that's a good level.
10. Resident 32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia, chronic obstructive pyelonephritis, severe sepsis, aspiration pneumonitus, supraventricular tachycardia, acute kidney failure, bipolar disorder, epilepsy, thyrotoxicosis and osteoarthritis.
Resident 32's medical records were reviewed between 10/11/22 and 10/31/22.
Resident 32's care plan dated 7/10/17 indicated that the resident was at risk for pain due to his osteoarthritis, cerebrovascular accident, and migraines. The interventions were to administer analgesia 30 minutes before treatments or care, anticipate the resident's need for pain relief and respond immediately to any complaint of pain, and evaluate the effectiveness of pain interventions. The care plan had not been updated since 7/10/17.
Two different pain assessments were located in resident 32's medical record with resident 32's name on it. However, the assessments were blank.
Resident 32's physician orders revealed that resident 32 had the following orders:
a. Acetaminophen 650 milligrams (mg) every 6 hours as needed.
b. Meloxicam 7.5 mg daily for osteoarthritis.
The September 2022 MAR indicated that resident 32 had not received any Acetaminophen during that month. The MAR also indicated that the highest level of pain that resident 32 was reporting was an 8 on 9/14 (twice), 9/15 (twice) and 9/16 (once). No indication was made on the MAR that resident 32 was receiving pain medication prior to cares, as suggested in the care plan.
The October 2022 MAR indicated that resident 32 had not received any Acetaminophen during the month of October 2022 as of 10/26/22. The MAR also indicated that the highest level of pain that resident 32 was reporting was a 2. No indication was made on the MAR that resident 32 was receiving pain medication prior to cares, as suggested in the care plan.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, it was determined, for 5 of 33 sampled residents, the facility did not ensure that services provided met professional standards of quality. Specific...
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Based on observation, interview, and record review, it was determined, for 5 of 33 sampled residents, the facility did not ensure that services provided met professional standards of quality. Specifically, a nurse did not sign out narcotics when they were administered, one resident who had not been administered their narcotic was recorded as having received the narcotic, and expired Tuberculin solution was used when determining if residents had tuberculosis. Resident identifiers: 8, 10, 11, 29 and 30.
Findings include:
On 10/11/22 at 4:10 AM, an observation was made of Registered Nurse (RN) 1. RN 1 was observed to have greasy hair that was knotted in the back. RN 1 was also observed to have restless movements of her hands. At 4:58 AM, RN 1 was observed to perform the narcotic reconciliation with RN 3. RN 1 stated that she forgot to sign out narcotics that she had administered overnight. RN 1 was observed to sign out narcotics for residents 8, 10, 11, 29, and three unsampled residents. RN 1 stated that she did not administer any narcotics to resident 10, but one narcotic was missing from resident 10's narcotic medications. RN 1 was observed to sign out the narcotic as having been administered to resident 10. At 5:05 AM, RN 1 was observed to give report to the oncoming nurse, RN 3. While receiving report, RN 3 had to remind RN 1 that she had forgotten to give report for one of the halls at the facility. RN 1 then left the nurses' station and stated that before she left work she was going to check a resident's blood sugar. However, RN 1 picked up her purse and jacket and started to leave the facility. RN 3 asked RN 1 if she was going to check the resident's blood sugar, and RN 1 stated that she had forgotten. RN 1 was observed to be slurring her words. RN 1 stated to the surveyors, I hope you looking for what you find. RN 1 then attempted 2 more times to form an appropriate sentence to the surveyors but was unable to, and left the facility.
RN 1's employee file was reviewed. The following were identified:
a. On 11/20/21, RN 1 was written up due to dropping narcotics and a missing Fentanyl patch due to the statement they are small.
b. On 8/29/22, RN 1 received a counseling slip due to two nurses found a package of marijuana in RN 1's bag; a resident did not receive antibiotics as prescribed; a resident pulled out his JG (gastrostomy-jejunostomy) tube. RN 1 did not place Intravenous (IV) therapy for fluids. RN 1 also had medication errors and was crossing boundaries professionally with residents.
c. On 8/31/22, RN 1 had an Employee Conferencing document. RN 1 was placed on probation for Violation of company policy; Violation of work rules. RN 1 had an issue of Bringing inappropriate items to work - smoking with residents. RN 1's statement was I will do my best to do my job and not break any rules or policies.
Additionally, an Incident report revealed the following:
On 10/4/22 at 8:00 PM, RN 1 was transferring resident 30 when resident 30 fell.
On 10/27/22 at 4:15 PM, an interview was conducted with CNA 5. CNA 5 stated that RN 1 was unsafe when transferring residents. CNA 5 stated that RN 1 had previously called CNA 5 to help lift residents off the floor who RN 1 had dropped. CNA 5 stated that RN 1 dropped resident 30 on 10/4/22. CNA 5 stated that she had witnessed RN 1 misplacing medications. CNA 5 stated that RN 1 had misplaced the medication keys several times and was often shaky. CNA 5 stated that RN 1 used to be a good nurse, but for the last few months, RN 1 had problems.
On 10/27/22 at approximately 4:30 PM, Employee 6 (E 6) was interviewed. E 6 stated that they witnessed RN 1 smoking marijuana with residents. E 6 stated that RN 1 had offered them an orange colored pill because they were tired. E 6 stated that RN 1 gave a resident marijuana and then that resident had to go to the hospital with respiratory failure. E 6 stated that they witnessed RN 1 with a little pouch before smoking marijuana with residents.
On 10/17/22 at 2:53 PM, RN 3 was interviewed. RN 3 stated that usually when she performed narcotic reconciliation with RN 1, there were at least two or three narcotics that were not signed out. RN 3 stated that the Director of Nursing (DON) was informed about the discrepancies. RN 3 stated that RN 1 was forgetful.
On 10/20/22 at 10:00 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that RN 1 had illegal drugs in the building, and had multiple complaints against her. LPN 1 stated that RN 1 had told LPN 1 that she did not administer a narcotic but signed it out. LPN 1 stated that he reported to the DON that the narcotic counts were off. LPN 1 stated that RN 1 either did not care or was impaired.
On 10/21/22 at 11:44 AM, the DON was interviewed. The DON stated that staff should always chart the narcotics as soon as they were given. The DON stated that the narcotics should also be signed off in the electronic medical record (EMR). The DON stated that RN 1 was written up for missing narcotics multiple times. The DON stated that the nursing standard of practice was to chart the narcotics when they were administered. The DON stated that nurses reported when RN 1 was shaky on shift, but stated that she did not hear that RN 1 was signing out medications that she did not administer. The DON stated that there were previous narcotic diversions related to RN 1, but there did not appear to be any action taken by the facility. The DON stated that she was concerned about the missing narcotics and changed the way narcotics were counted with another nurse. The DON stated that there were sometimes four or five pills were in the bottom of the narcotic (narc) drawer, under the cards.
On 10/26/22 at 4:57 PM, the DON was interviewed. The DON stated she had written RN 1 up for multiple things and she kept a copy of all the write ups she did with RN 1.
The counseling slips and medications errors were reviewed and revealed the following that were not in her employee file:
a. On 1/14/21 a form titled Medication Inadvertent Incident Report revealed a Fentanyl patch was signed out twice. There was no follow up or recommendations to prevent future incidents.
b. On 4/14/21 a form titled Medication Inadvertent Incident Report revealed Oxycodone 20 milligrams (mg) was signed out 2 different times at 8:00 PM and there was no witness to one the medication being wastes. There was no follow up information. The recommendation to prevent further incident was keep narcotics and waste with DON or another RN.
c On 4/28/21 a form titled Medication Inadvertent Incident Report revealed RN 1 administered Tramadol to close together. There was no follow up information. The recommendation to prevent further incident were give medications as ordered.
d. On 3/28/22 a form titled Medication Inadvertent Incident Report revealed Morphine was administered to the incorrect resident with an incorrect dosage. Resident requested morphine accidentally gave 5mg/.25mL (mililiter) rather than 100/5ml which was [name removed] medication.
e. On 4/4 with no year, a form titled Medication Inadvertent Incident Report revealed RN 1 signed out Fentanyl patches 2 times and lost a Fentanyl patch and was unable to locate a patch. RN 1 had a restricted nurse sign out as a witness even though it was never witnessed it. There was no follow up information on the form. The recommendations to prevent further incidents were to notify the DON immediately and have approved witness sign. The nurse did not sign the form.
f. On 8/1/22 a counseling slip revealed that RN 1 did not do the midnight census and giving residents that were ordered nothing by mouth food. The action taken was verbal warning and administration notified. The follow up was to check each midnight census and staff works to check of inconsistencies.
g. On 8/7/22 a counseling slip revealed there was a resident with a blood sugar of 20 , the MD was not notified, the resident was non-responsive and put at risk for aspiration while given oral food and drink. RN 1 failed to respond to signs and symptoms of hypoglycemia and the family was not notified. RN 1 was Placing resident at risk for diabetic related Coma. The action taken was MD notified immediately of incident. There was no information in the follow up section.
h. On 8/12/22 a counseling slip revealed that CNA's were reporting staff nurse asking them to go to liquor store to purchase liquors for her during work hours. There was to be no smoking with resident during work hours. If staff is giving residents food outside of building the admins (administration) should be advised due to possible money mgement (sic) (management) issues and medical issues such as diabetes. In addition, CNA reported she saw RN smoking pot with a resident and smelled it. The action taken was met with nurse and told her that she was not to ask co-workers to purchase liquor during business hours or have it on premises or give to a resident. The follow up was that the afternoon and night shift CNA's were spoken to about the policy, reporting and professionalism. The nurse was not to bring in treats or drinks for residents. In addition, will meet with administration Assistant Director of Nursing (ADON) and DON for discussion.
i. On 9/4/22 a counseling slip revealed RN 1 had stated in nursing report that IV fluids had been infusing since 1:30 AM. The IV was found to not be running and the IV bag was still full. The resident did not receive fluids from 1:30 AM until 5:30 AM. There was no information in the action taken and follow up section of the form.
j. On 10/11/22 a counseling slip revealed RN 1 narcotics that were given during the shift were not signed out until the end of the shift when report was given. There was no information in action taken and follow up section of the form.
On 10/22/22 at 10:57 PM, an interview was conducted with RN 5. RN 5 stated one resident told her that she did not feel safe when RN 1 worked. RN 5 stated she reported that the resident did not feel safe to the DON. The DON stated to RN 5 I know. RN 5 stated RN 1 was shaky and inconsistent with narcotic counts. RN 5 stated she reported it to the DON and the DON stated we are keeping track of it. RN 5 stated she quit in March 2022 because of RN 1. RN 5 stated she recently started working 1 night a week because RN 1 was working 5 nights in a row of 12 hours, so the Administrator asked her to come back to work. RN 5 stated RN 1 wrote the refrigerator temperatures weird and the glucometer lot numbers.
On 10/22/22 at 11:22 PM, an interview was conducted with CNA 6. CNA 6 stated that she reported thing to RN 1 and she would deny it. CNA 6 stated that a resident in the 300 hallway needed some pain cream and it had a very strong smell. CNA 6 stated RN 1 told her she administered it but the resident stated she did not receive it. CNA 6 stated there was no strong smell and no small cup with the cream in it, so it did not seam like the resident received it.
On 10/23/22 at 12:48 AM, an interview was conducted with CNA 7. CNA 7 stated RN 1 was not really functional. CNA 7 stated it was hard to tell if RN 1 was under the influence of something. CNA 7 stated RN 1 sleeps and had been snoring at the nurses station during her shift. CNA 7 stated she reported it to the DON and Administrator and they stated they knew because she slept in front of the camera. CNA 7 stated she had to go back and remind RN 1 of things multiple times.
On 10/27/22 at approximately 4:00 PM, an interview was conducted with Employee 6. Employee 6 (E 6) stated that she witnessed RN 1 smoking pot (marijuana) at the facility and E 6 stated that the DON was notified.
On 10/27/22 at 4:15 PM, an interview was conducted with CNA 5. CNA 5 stated that she had worked with RN 1 when RN 1 lost medications in the 300 hall. CNA 5 stated that RN 1 instructed the CNAs to look for the missing medications, that were in a small cup.
On 10/27/22 at 8:52 AM, an interview was conducted with the consulting Pharmacist. The Pharmacist stated that the facility Administrator (ADM) contracted with him for recommendations, but did not have him reconcile the narcotics. The Pharmacist stated that he told the ADM that a third party should reconcile the narcotics.
On 10/25/22 at 1:35 PM, the Administrator (ADM) was interviewed. The ADM stated that she did not have a random drug testing policy. The ADM stated that sometimes there were four or five narcotics in the bottom of the narcotic lock box on the medication cart. The ADM stated that RN 1 had been counseled about missing narcotics on three occasions.
On 10/27/22 at 1:06 PM, an interview was conducted with the facility Medical Director (MD). The MD stated that she had spoken with the ADM approximately three months ago regarding her concerns with RN 1's ability to perform her work duties appropriately. The MD stated that she had told the ADM about the safety concerns with regard to RN 1 through multiple text and verbal conversations, but that nothing had been done.
On 10/24/22 at 5:50 PM, the DON reported to the surveyors that she was concerned about RN 1's behavior. The DON reported that RN 1 arrived at work that evening at 5:00 PM for her scheduled shift, but that RN 1 appeared confused, and impaired in some way. At 5:55 PM, an interview was conducted with RN 1. RN 1 denied illicit drug use in the last 30 days, and stated that she felt competent to work. The questions were repeated to RN 1 multiple times because she seemed unable to understand the questions being asked. RN 1's eyes glazed over multiple times during the interview, and she was unable to focus. RN 1's eyes were also observed to be red, watery, and dilated. RN 1 had several red marks consistent with flushing on her forehead and neck. RN 1 was moving her right leg back and forth quickly, in a shaking motion, while she was standing. During the interview, RN 1 repeatedly scratched at her chest and face. RN 1's arms were moving with jerky motions.
At 6:08 PM, an interview was conducted with the ADM, and the LTC Manager (LTCM). The ADM stated she never saw write ups for RN 1. The ADM stated that she had never witnessed RN 1 arriving at work impaired, or demonstrating concerning behavior. The ADM stated, is she the sharpest nurse? No, but she's got lots of experience. The ADM was informed of both the DON's statement to surveyors at 5:50 PM, as well as the surveyors' observations. The ADM stated that she could not send RN 1 home even if she was impaired because I don't have anyone else to work, and agency nurses charge $85 an hour.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Resident 37 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, diabetes mellitus, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Resident 37 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, diabetes mellitus, hypokalemia, chronic pain, epilepsy, delusional disorder, dementia, osteoporosis, atherosclerotic heart disease, systemic lupus erythematosus, hypertension, and schizophrenia.
On 10/11/22 at 7:41 AM, an observation was made of resident 37 in the dining room. Resident 37 was observed with bed head. At 10:17 AM, resident 37 was observed sitting in her wheelchair in the memory care unit, looking at the door. Resident 37 stated, They won't let me out, I have a hair appointment. CNA 2 overheard the conversation and stated that resident 37 always thought she had appointments. Resident 37 then responded to CNA 2 with expletives. Resident 37 was observed to have bed head.
On 10/20/22 at 11:49 AM, an observation was made of resident 37 in the dining room. Resident 37 was observed with bed head.
On 10/27/22 between 1:30 PM and 2:30 PM, resident 37 was observed in a wheelchair, next to the nursing station. Staff walked past resident without engaging her in conversation. Resident 37 was facing the door to the medication room. Staff were observed to walk past resident 37 without engaging in conversation or offering an activity. Resident 37 stated that she had somewhere to go. Resident 37 was observed to have bed head.
On 10/28/22 between 10:10 AM and 12:00 PM, resident 37 was observed to be sitting in a wheelchair, near the nursing station, facing the closed doors of the memory care unit. Staff were observed to walk past resident 37 without engaging in conversation or offering an activity. Resident 37 was observed attempting to reach the door of the unit. Resident 37 was observed to have bed head.
Resident 37's record review was completed on 10/31/22.
A quarterly MDS dated [DATE] revealed that resident 37 required 1 person physical assistance with bathing. The MDS further revealed resident 37 required 1 person extensive assistance with personal hygiene.
Resident 37's care plan stated:
a. On 8/3/21, an intervention to help resident 37 feel safe was initiated and was to Provide activities in the SNU (Skilled Nursing Unit) or supervised while outside of the SNU.
b. On 6/2/22, I will participate in independent activities daily such as: watch t.v, socialize, watch the news
c. I will participate in diversionary activities prn (as needed).
d. Distract resident from wandering by offering pleasant diversions, structured
activities, food, conversation, television, book. Resident prefers: [blank]
e. Give the resident as many choices as possible about care and activities
Nursing notes revealed the following:
a. On 9/15/22 at 2:27 AM, a weekly note revealed that resident 37 sometimes refused to eat independently. Set-up assistance was noted.
b. On 10/6/22 at 2:51 AM, a weekly note revealed that resident 37 sometimes refused to eat independently. Set-up assistance was noted.
A form titled Resident Shower List for October 2022 revealed resident 37 was bathed on 10/6/22 and 10/15/22. Resident 37 was scheduled to be bathed Tuesday, Thursday and Saturday in the morning.
On 10/28/22 at 10:55 AM, an interview was conducted with CNA 1. CNA 1 stated that resident 37 wanted to go to the store and to have her hair done, and wanted to go buy shoes. CNA 1 stated that the CNAs brought resident 37 out of the memory care unit because resident 37 focused on leaving the facility when she was near her room. CNA 1 stated that resident 37 was only calm when staff fed her meals, but staff did not typically feed her, because it wasn't required.
[Note: The Task list for CNAs revealed that resident 37 received assistance with meals one time in the past 30 days, from 10/1/22 to 10/30/22, on 10/4/22.]
Based on observation, interview and record review it was determined, for 7 of 33 sampled residents, based on the resident comprehensive assessments that each resident was not given appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. Specifically, residents were not bathed, residents were not provided personal hygiene, residents were not provided assistance with eating, and a resident was not changed for 44 minutes after having a bowel movement. Resident identifiers: 10, 12, 13, 14, 31, 35 and 37.
Findings include:
1. Resident 12 was admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder, dementia, anxiety disorder, and severe protein-calorie malnutrition.
On 10/11/22 at 7:35 AM, an observation was made of resident 12 in the dining room. Resident 12 was observed to have greasy and stringy chin length hair. Resident 12 was observed with a gray cardigan with stains on the front of it.
On 10/24/22 at 5:22 PM, an observation was made of resident 12. Resident 12 was in her room and had greasy and stringy hair. Resident 12 was observed with a gray cardigan with stains on the front of it.
On 10/26/22 at 10:00 AM, an observation was made of resident 12. Resident 12's hair was greasy and stringy. Resident 12 stated she was showered and her hair was washed once a week. Resident 12 was observed with a gray cardigan with stains on the front of it.
On 10/31/22 at 10:55 AM, an observation was made of resident 12. Resident 12 was observed with greasy and stringy hair. Resident 12 was observed with a gray cardigan with stains on the front of it.
Resident 12's medical record was reviewed.
A quarterly Minimum Data Set (MDS) dated [DATE] revealed that resident 12 had a Brief Interview of Mental Status (BIMS) score of 15. The BIMS score revealed resident 12 was cognitively intact. The MDS further revealed resident 12 required 1 person physical help in part of bathing.
A care plan dated 3/13/18 revealed [Resident 12] has an ADL (activities of daily living) self-care performance deficit r/t (related to) Confusion, Dementia. The goal with a target date of 3/23/22 revealed The resident will have ADL needs met through staff assist as needed. Some of the interventions were Encourage the resident to participate to the fullest extent possible with each interaction and Monitor/document/report PRN (as needed) any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function.
A review of the October 2022 Resident Shower List revealed resident 12 was showered on 10/15/22. There were no other showers signed off by a Certified Nursing Assistant (CNA) in October. Resident 12 was scheduled to be showered Monday, Wednesday, and Friday in the afternoon.
2. Resident 13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Schizoaffective disorder, encephalopathy, obsessive compulsive disorder, and dementia.
On 10/11/22 at approximately 6:45 AM, an observation was made of resident 13. Resident 13 was observed in the dining room with a blue shirt on that was soiled down the front of it.
On 10/24/22 at 11:30 AM, resident 13 was observed to have a red shirt with stains on it. Resident 13 had a football team mask that was soiled on the side for the nose and mouth. Resident 13's bed was observed to have stains on his sheets.
On 10/28/22 at 10:19 AM, resident 13 was observed to have a brown jacket with stain on it. Resident 13 was also observed with an football coat with stains on it brown substance on it.
Resident 13's medical record was reviewed.
An annual MDS dated [DATE] revealed resident 13 had a BIMS score of 5. The BIMS score revealed resident 13 had severe cognitive impairment. The MDS revealed resident 13 required 1 person physical help on part of bathing.
A care plan dated 8/2/21 revealed The resident has an ADL self-care performance deficit r/t muscle weakness. The goal with a target date of 3/23/22 revealed The resident will maintain current level of function in ADLs through the review date. Some of the interventions included BATHING/SHOWERING: The resident requires extensive by 1 staff with (SPECIFY bathing/showering) (SPECIFY FREQ (frequency)) and as necessary ; and DRESSING: The resident requires extensive assistance by 1 staff to dress.
A form titled Resident Shower List revealed that resident 13 had not received a shower during the month of October 2022. Resident 13 was scheduled to have showers in the afternoon on Tuesday, Thursday, and Saturday.
3. Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included metabolic encephalopathy, Wernicke's encephalopathy, dementia, osteoarthritis, and psychosis.
On 10/20/22 at 12:00 PM, resident 14 was observed in the dining room. Resident 14 was observed to have long hair that was greasy and standing up.
On 10/26/22 at 1:59 PM, resident 14 was observed sitting on a sofa in the hallway. Resident 14 was observed to have greasy hair that was standing up.
On 10/28/22 at 10:19 AM, resident 14 was observed in laying in his bed. Resident 14 was observed to have greasy hair that was standing up.
On 10/31/22 at 11:01 AM, an interview was conducted with resident 14. Resident 14 stated he wanted to be showered more. Resident 14 stated his hair was greasy and his head was itching. Resident 14 was observed to have flies on his food, around his head and around his feet.
Resident 14's medical record was reviewed.
A quarterly MDS dated [DATE] revealed resident 14 had a BIMS of 00 which indicated severe cognitive impairment. Resident 14 required one person physical assistance with bathing activity.
A care plan dated 6/10/13 revealed [Resident 14] has limited physical mobility r/t Neurological deficits. The goal with a target date of 5/3/22 was The resident will remain free of complications related to immobility, including contractures, thrombus
formation, skin-breakdown, fall related injury through the next review date. The interventions included LOCOMOTION: The resident is able to: supervision and Monitor/document/report PRN any s/sx (signs and symptoms) of immobility: contractures forming or worsening, thrombus formation, skin-breakdown, fall related injury. It should be noted there was no care plan regarding the need for other ADL assistance.
A form titled Resident Shower List for October 2022 revealed resident 14 was not shower for the month. Resident 14 was scheduled to have a shower Tuesday, Thursday and Saturday in the afternoon.
On 10/27/22 at 4:23 PM, an interview was conducted with Certified Nursing Assistant (CNA) 5. CNA 5 stated resident 14 could shower himself. CNA 5 stated she used a double was cloth with resident 14. CNA 5 stated he used one of the was clothes and the CNA used another to ensure he was getting himself clean. CNA 5 stated resident 14 was incontinent and needed to be cleaned in the shower.
4. Resident 35 was admitted to the facility on [DATE] with diagnoses which included Schizophrenia, cognitive communication deficit, and non-pressure chronic ulcer.
On 10/11/22 at 7:59 AM, resident 35 was observed in the dining room. Resident 35 was observed to wear blue plaid pajama pants. Resident 35 was observed with greasy hair and beard.
On 10/20/22 at 12:05 PM, resident 35 was observed in blue plaid pajama pants. Resident 35's hair and beard were observed to be greasy.
On 10/24/22 at 11:45 AM, resident 35 was observed in blue plaid pajama pants. Resident 35's hair and beard were observed to be greasy.
Resident 35's medical record was reviewed.
An admission MDS dated [DATE] revealed resident 31 required one person physical assistance with bathing.
A baseline care plan dated 8/25/22 had an initial from the Director of Nursing (DON) for ADL ability. There were no goals of interventions checked off for the baseline care plan. There were no comprehensive care plans completed.
The Resident Shower List for October 2022 revealed resident 35 was not showered in October 2022.
On 10/17/22 at 2:18 PM, an interview was conducted with CNA 8. CNA 8 stated she did not feel like there was enough staff. CNA 8 stated she worked part time. CNA 8 stated there were only 1 or 2 CNA's in the afternoon, so there were no showers completed. CNA 8 stated the day shift CNA's were asked to complete more showers, but they were unable to complete more showers.
On 10/27/22 at 3:20 PM, an interview with the Assistant Director of Nursing (ADON). The ADON stated there was a shower schedule provided for the CNA's. The ADON stated when a shower was completed then CNA's initial the Resident Shower List form. The ADON stated evening shift had been really bad about getting showers because of staffing. The ADON stated CNA's might also be forgetting to sign off the shower in the book. The ADON stated there had been a staffing issue for the evening shift. The ADON stated there should be 3 CNA's for the evening shift but one was in the hospital and another one had not been showing up. The ADON stated another CNA came in at 4:00 PM. The ADON stated usually a day shift CNA stayed late to answer call lights.
On 10/27/22 at 4:15 PM, an interview was conducted with CNA 5. CNA 5 stated she had been the only CNA for the evening shift. CNA 5 stated if she was the only CNA for the building showers were not completed. CNA 5 stated that resident 35 was independent and he wanted staff to wait outside so he could call if he needed assistant. CNA 5 stated resident 12 did not need a lot of help with showering. CNA 5 stated resident 12 needed to be cued and reminded to wash her hair. CNA 5 stated she thought resident 12 washed her hair twice. CNA 5 stated her hair was so greasy and she needed showered more often.
5. Resident 31 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, dementia, major depressive disorder and hyperlipidemia.
a. On 10/26/22 at 1:45 PM, an observation was made of resident 31. Resident 31 was observed pacing the hallway in the locked unit. Resident 31 had a bowel movement odor. At 2:01 PM, resident 31 was observed to continue to wander. Resident 31 was observed to walked by CNA 1 and CNA 5 and patted the front of her with her hand. Resident 31 was observed patting her butt and walked into room [ROOM NUMBER]. Resident 31 was observed to wander to the outside door and look out the window. At 2:10 PM, resident 31 was observed to walk into her room. CNA 5 was observed to direct her out and into the hallway. At 2:29 PM, CNA 4 entered the hallway and was observed to take resident 31 to her room. At 2:36 PM, CNA 4 returned to the hallway and stated resident 31 had a bowel movement and she changed resident 31. CNA 4 stated she changed her as soon as she smelled resident 31.
Resident 31's medical record was reviewed.
An annual MDS dated [DATE] revealed resident 31 required one person physical assistance with toileting. The MDS revealed resident 31 required limited 1 person assistance with eating.
A care plan dated 8/25/16 revealed The resident has an ADL self-care performance deficit r/t Alzheimer's dementia. The goal was the resident will maintain current level of function in (sic) through the review date. Some interventions developed were Toilet use: The resident requires extensive assist by 1 staff for toileting and Eating: The resident requires supervision by 1 staff to eat.
b. On 10/12/22 at 10:31 AM, an interview was conducted with resident 31's family member. The family member stated resident 31 ate but staff did not give her the time of day to feed her.
On 10/18/22 at 12:14 PM, resident 31 was observed in the memory care unit dining room. Resident 31 was observed to be eating cake with her fingers. The cake was crumbled and she was getting small amounts into her mouth. Resident 31's meal ticket was on her plate and resident 31 was observed to pick up her meal ticket and put it between her fingers. Resident 31 dropped her meal ticket onto her lap. Resident 31 had rice and a orange/brown substance over the rice. Resident 31 did not have utensils. There were no staff in the dining room. LPN 1 was observed outside the dining room and CNA 1 was in a resident room.
On 10/24/22 at 11:53 AM, resident 31 was observed in the memory care unit dining room. Resident 31 was observed to place her hands in her cake. CNA 8 was observed to remove resident 31's hands from the cake and clean them off.
On 10/26/22 at 4:11 PM, an interview was conducted with the Dietary Manager (DM). The DM stated resident 31 ate sandwiches good because she did not smash them into things. The DM stated every meal resident 31 needed to be provided with assistance for eating.
On 10/27/22 at 4:15 PM, an interview was conducted with CNA 5. CNA 5 stated resident 31 was not supposed to be fed, but she was just forgetting how to eat. CNA 5 stated resident 31 needed help eating because she did not know how to eat on her own. CNA 5 stated she tried to get resident 31 finger foods and then just cue her. CNA 5 stated she needed to be fed foods like soup. CNA 5 stated she was the only CNA for the entire facility from 2:00 PM to 10:00 PM. CNA 5 stated that dining rooms had to go unattended at times. CNA 5 stated residents in the main dining room were independent. CNA 5 stated the nurses sometimes helped in the dining rooms.
7. Resident 10 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, vascular dementia, diabetes mellitus, and mild intellectual disabilities.
On 10/12/22, resident 10 was observed to be in his room, laying in his bed on his back. A significant body odor was emanating from resident 10's room.
Resident 10's medical record was reviewed on 10/24/22.
On 7/11/22, facility staff completed a quarterly MDS assessment for resident 10. The MDS indicated that resident 10 required physical assistance while bathing, and extensive assistance for personal hygiene and dressing.
Resident 10's care plan dated 11/1/18 indicated that the resident had an ADL self-care performance deficit related to his dementia. Interventions included to discuss with the resident's Power of Attorney any concerns, monitor and document any changes, praise all efforts at self care. The care plan did not indicate specific requirements that resident 10 had for ADL assistance. In addition, the care plan had not been updated since 11/1/18.
The daily shower sheets for October indicated that resident 10 had only received one shower during the month of October 2022 (as of 10/24/22). A form titled Resident Shower List for October 2022 revealed that resident 10 was bathed on 10/13/22. Resident 10 was scheduled to be bathed on Tuesday. Thursday and Saturday in the evening.
On 10/27/22 at 4:20 PM, an interview was conducted with Certified Nurse Assistant (CNA) 5. CNA 5 stated that resident 10 required staff to remind him to go to the bathroom, or the resident would soil himself. CNA 5 stated that resident 10 could not change his own incontinence brief. CNA 5 also stated that resident 10 could not shower himself, because he doesn't know how to clean himself. CNA 5 stated that when resident 10 needed a shower, CNA 5 would assist him by giving him a washcloth while telling him to do what he can, and CNA 5 would do the rest.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 24 was admitted to the facility on [DATE] with diagnoses that included senile degeneration of the brain, dementia, h...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 24 was admitted to the facility on [DATE] with diagnoses that included senile degeneration of the brain, dementia, history of transient ischemic attack , chronic kidney disease, mild cognitive impairment, depression, severe malnutrition, hypertension, and a history of falls.
On 10/11/22 at 7:42 AM, resident 24 was observed at breakfast. Resident 24 required assistance with eating.
On 10/31/22, resident 24's medical record review was completed.
Resident 24 was admitted to hospice services upon admit, on 2/1/21.
Incident reports revealed that resident 24 had the following falls:
a. On 4/5/22 at 6:20 AM, resident fell from the bed in her room, and received an abrasion to her left lower leg.
b. On 4/5/22 at 2:20 PM, resident fell out of bed with no injuries noted.
c. On 4/13/22 at 11:30 AM, resident leaned forward out of her wheelchair and hit her head on the floor, sustaining a laceration.
d. On 5/29/22 at 11:20 AM, resident was found on the floor and stated she was uncomfortable.
Additionally, nursing notes revealed the following falls:
a. On 6/19/22 at 5:12 AM, resident was found on the floor and stated she hit her head.
b. On 9/27/22 at 8:26 AM, resident found on the floor mat during the night, had redness on left side of face and knee, skin tear on left forearm.
Resident 24's care plan revealed that resident 24 had a fall on 4/13/22. Interventions were established on 4/22/22 and included:
a. Assess resident to assist physician to determine cause: vital signs appetite, recent
relocation, possible hearing or vision losses, change in LOC medications.
b. Follow facility fall protocol for post fall interventions.
c. Lower bed while in bed.
On 5/13/22, resident 24's care plan revealed that resident 24 had an intervention was initiated to Ensure resident has proper foot wear on with traction.
On 5/29/21, resident 24's care plan included an intervention to Remind resident to use call light for repositioning and needs.
On 6/18/22, resident 24's care plan included an intervention to Assess/provide needs prior to putting in bed.
No additional care plan interventions were created for resident 24's falls on 6/19/22 and 9/27/22.
On 10/11/22 at 5:23 PM, a telephone interview was conducted with resident 24's hospice nurse. The hospice nurse stated that falls had not been reported to them, but they were a new hospice company for resident 24.
On 10/12/22 at 10:17 AM, an interview was conducted with CNA 2. CNA 2 stated that not all falls in the facility were reported.
On 10/25/22 at 1:35 PM, an interview was conducted with the Administrator (ADM). The ADM stated that staff usually reported to her when a resident had a fall, and then she had them complete an incident report. The ADM stated that charts were not reviewed for documentation of falls, and nurses should know to report falls. The ADM stated that she learned about many of the falls by going through the doctor's box and reading the incident reports.
4. Resident 30 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis (MS), neuropathy, insomnia, obesity, chronic pain, and depression.
On 10/11/22 at 9:40 AM, resident 30 was observed to be sitting in a wheelchair. Resident 30 stated that she had a recent fall because there is nobody to help get you up.
On 10/31/22, resident 30's medical record review was completed.
An incident report dated 6/12/22 at 11:00 AM, resident 30 was transferring with the assistance of a CNA from her bed to her wheelchair when resident missed the chair. Hit buttocks and head. Neuros started. No injuries.
Nursing notes revealed the following:
a. On 11/6/22, resident 30 had a fall at approximately 8:00 AM in the dining room. Her wheelchair broke.
b. On 6/12/22 at 11:56 AM, resident 30 had a fall at approximately 11:00 AM. Fell while transferring to wheelchair, hit buttocks and head, no injuries .Will transfer resident 2 person assist today and as needed.
c. On 7/21/22 at 5:37 AM, it was charted that resident 30 slid out of her wheelchair at 9:00 PM on 7/20/22. Resident 30 had been repositioned in her wheelchair prior to the fall and resident 30 was being assisted to the restroom.
d. On 10/7/22 at 3:41 PM, it was reported that on 10/4/22, resident 30 had a fall.
Resident 30's care plan revealed that resident 30 has limited physical mobility r/t weakness. Resident 30's was identified as moderate, risk for falls r/t gait/balance problems. Additionally, resident 30 had fall checks due to taking psychotropic medications. No actual falls were documented, and no fall interventions were initiated for resident 30.
Physician and Nurse Practitioner (NP) notes on 2/7/22, 3/24/22, 7/21/22, 9/22/22, and 9/26/22 revealed that resident 30 stated her MS was getting worse and wanted to be seen by her neurologist.
On 7/21/22, resident 30 had an appointment to see her neurologist in September, and resident 30 reported bowel control had decreased.
On 2/7/22 at 2:13 PM, a new order (as stated in the nursing notes) was initiated for resident 30 to follow up with her neurologist because resident 30 was complaining of increased weakness in right arm and leg.
Resident 30 did not follow-up with her neurologist. Resident 30 stated that she had made an appointment, but there was no one to take her, so the staff had canceled the appointment and had not made a new appointment.
On 10/18/22 at 12:22 PM, an interview was conducted with CNA 4. CNA 4 stated that resident 30 required two CNAs to safely transfer her.
On 10/27/22 at 12:24 PM, RN 3 was interviewed. RN 3 stated that resident 30 did not transfer on her own, and had not tried to self-transfer for several years. RN 3 stated that sometimes resident 30 required two people to transfer, depending on her strength.
On 10/27/22 at 4:15 PM, an interview was conducted with CNA 5. CNA 5 stated that when resident 30 fell on [DATE], RN 1 was transferring resident 30. CNA 5 stated that she told RN 1 not to transfer resident 30 because sometimes resident 30's legs buckled when she was being transferred. CNA 5 stated that RN 1 tried to transfer resident 30 alone and dropped her. CNA 5 stated that RN 1 called her phone and said that RN 1 had dropped resident 30. CNA 5 stated that she had reported to the DON that the fall had occurred and RN 1's role in the fall.
Based on observation, interview and record review it was determined, for 5 of 33 sampled residents, that the facility did not ensure a resident environment remained as free of accident hazards as was possible; and each resident received adequate supervision and assistive devices to prevent accidents. Specifically, a resident with a history of elopements, eloped from the facility. In addition, resident's experienced repeated falls with no interventions. Another resident experienced a fall during a transfer. Resident identifiers: 24, 36, 30, 31 and 96.
Findings include:
1. Resident 26 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, diabetes mellitus, and hypertension.
Resident 26's medical record was reviewed.
Resident 26's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 5 which indicated severe cognitive impairment. The MDS further revealed resident 26 walked in corridor, walked in room, locomotion on the unit and locomotion off the unit required supervision and setup help only.
Resident 26's care plan dated 8/3/21 with a target date of 5/27/22 revealed The resident requires a safe, secure, environment Elopement risk, Wandering risk. The goal was Resident will remain safe, without feelings of isolation, in the SNU (Special Needs Unit). Interventions initiated on 8/3/21 included Provide activities in the SNU or supervised while outside of the SNU and Provide meals in the dining room in the SNU. An intervention initiated on 7/9/22 Nurse to do the midnight census and check every room. Interventions initiated on 7/10/22 included Continue with [local mental health] case worker and NP (nurse practitioner) for med (medication) mgment (management)/behavior apptments (appointments); Ensure resident [NAME] (sic) all meds. Notify MD of refusal of meds; Frequent patient checks all shifts; Monitor and assess for labs/change of condition if indicated. Report to MD; Monitor for triggers; Provide activities of daily living within the safety of the SNU; and Resident will reside in a room in the SNU.
Resident 26's nursing progress note dated 9/18/21 at 2:50 PM, Resident returned to facility from [local hospital] via facility van accompanied by CNA (Certified Nursing Assistant) at 1330 (1:30 PM).Resident moved to room [ROOM NUMBER] A and reinforcing to stay within the parameters of the facility and not pass the gate in the back. He stated he would needs reinforcement. MD (Medical Doctor) notified of his return and new orders.
A nursing progress note dated 7/10/22 at 2:18 AM by Registered Nurse (RN) 1 revealed, [Resident 26] was discovered missing at about 1930 (7:30 PM). Staff checked every room and the outside around the entire building. Police were called after building and grounds were searched thoroughly, at approximately 2200 (10:00 PM). Police took information, got a copy of his picture, his DOB (date of birth ), his medical problems, etc. They said they would contact us if they found him. Administrator and physician notified as well.
Resident 26's nursing progress note dated 7/10/22 at 1:22 PM revealed, Police returned resident at approx (approximately) 1030 (10:30 AM). Vital signs and BS (blood sugar) WNL (within normal limits). Order obtained to change room to SNU. Resident oriented to room and was happy to see his old roommate. Does not want to smoke today, sleeping at this time.
Resident 26's nursing progress note dated 7/12/22 at 2:03 PM, revealed Resident has adjusted with room change to Memory Lane in RM [ROOM NUMBER]B and understands that he should not attempt leaving the facility d/t (due to) his overall safety. CNA supervises the resident during smoke break.
Review of resident 26's assessments revealed a wander risk scale that was in progress and not completed on 10/19/22.
An initial entity report completed by the Administrator with a fax cover sheet dated 7/10/22 at 3:18 PM revealed the fax was busy/no response. The report revealed that resident 26 went out for the last smoke break at 7:00 PM then returned to his room. Later when doing rounds resident 26 was not in his bed. The report revealed the facility was searched, police were notified, and a sliver alert was sent. The report revealed a former employee texted and notified the facility that resident 26 was at a local convenience store at approximately 9:30 AM. The report revealed police were notified and returned him to the facility about 10:00 AM. There was no other information or investigation into the incident.
On 10/27/22 at 4:15 PM, an interview was conducted with CNA 5. CNA 5 stated she was working when resident 26 eloped. CNA 5 stated she discovered resident 26 was gone. CNA 5 stated that he wandered the facility and was always taking CNA 5's lunch and water bottle and that day her lunch and water bottle were not touched. CNA 5 stated she started checking the facility and outside for him and she was unable to find him. CNA 5 stated that the dinner meal was delivered and there was no tray was delivered so she asked if resident 26 was in the dining room and no one saw him. CNA 5 stated at 8:00 PM, she knew something was up. CNA 5 stated he was not outside smoking, did not eat dinner, he was not in his room and she had not seen him at all. CNA 5 stated staff called the police. CNA 5 stated she told police he had sticky fingers, so they should talk to the local convenience stores. CNA 5 stated he was found at a local convenience store. CNA 5 stated she was working with RN 1 that night, RN 1 was not in her right mind.
On 10/26/22 at 5:28 PM, an interview was conducted with the facility Licensed Clinical Social Worker (LCSW). The LCSW stated she was not notified that resident 26 eloped from the facility. The LCSW stated she was not apart of anything having to do with assessing a resident to determine if the resident should be placed in the memory care unit.
On 10/27/22 at 9:04 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that 7/10/22 was the second time resident 26 eloped. The ADON stated he eloped and was brought back to the facility by the Administrator. The ADON stated the nurse contacted the Medical Director (MD) and she provided a physician's order for him to be placed in Memory Care Unit. The ADON stated the doctor decided a resident needed to reside in the Memory Care Unit. The ADON stated the first time resident 26 left at 7:00 pm in the evening, police found him and brought him back. The ADON stated the second time was in the morning, left and he didn't tell anyone. The ADON stated after the first elopement his room was changed to the memory care unit. The ADON stated when the Administrator brought resident 26 back to the facility but he was still on the premises when she found him.
On 10/26/22 at 4:57 PM, an interview was conducted with the Director of Nursing (DON). The DON stated she was not notified that resident 26 eloped until like a day or 2 later. The DON stated after reviewing the nursing notes and a write up for RN 1, from what she could gather, resident 26 left after the last smoke break. The DON stated she thought she had written up RN 1 because she did not do a midnight census and did not make sure everyone was in the building. The DON stated RN 1 was written up on 8/1/22 for not doing the midnight census. The DON stated it was a few weeks after the incident that RN 1 was written up. The DON stated the ADON documented on 7/10/22 in a nursing progress note that resident 26 returned to the facility on 7/11/22 at 11:00 AM by police. The DON stated the note revealed that a physician's order was obtained to change resident 26's room to the memory care unit. The DON stated resident 26 was taken off the memory care unit because of his relationship with another resident.
2. Resident 31 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, unspecified dementia with behavioral disturbance, and depression.
On 10/21/22 at 12:49 PM, an observation was made of resident 31. Resident 31 was observed in the memory care unit. Resident 31 was observed to have no shoes on and white socks with no grippers on the bottom of them.
Resident 31's medical record was reviewed.
An annual MDS dated [DATE] revealed resident 31 did not have a BIMS because she was rarely/never understood. The MDS further revealed resident 31 had short and long term memory problems. The MDS revealed her cognitive skills for daily decision making was severely impaired. The MDS revealed resident 31 required extensive one person assistance with dressing. The MDS revealed resident 31 had 2 or more falls with no major or minor injury since admission or the prior assessment.
Resident 31's care plan dated 8/25/16 with a target date of 5/27/22 revealed The resident is risk for falls r/t Confusion, Gait/balance problems, Unaware of safety needs , Wandering. The goal was The resident will be free of falls through the review date. Interventions dated 8/25/16 were Anticipate and meet the resident's needs; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; and Follow facility fall protocol. An intervention dated 10/27/21 wear shoes when ambulating or non skid slippers. Another intervention dated 11/2/21 Wear non skid footwear and on 11/19/21 Remove distractions while ambulating. Redirect. An intervention dated 2/18/22 was Lay resident down after meals if tired
An intervention on 5/25/22 Anticipate need for sudden stops. Evaluate VS (vital signs) and on 7/7/22 Keep doorways clear from clutter. Inform Housekeeping to remove cleaning supplies and On 7/17/22 Check resident during rounds and check footwear. [It should be noted that on 10/27/21, 11/2/21 and 7/17/22 involved footwear.]
Resident 31's nursing progress notes and incident reports revealed the following falls:
a. On 1/8/22 at 10:46 AM, resident 31 was found on floor of the hallway. There were no injuries and neurological checks (neuro's) were started. The physician and family were notified.
b. On 5/14/22 at 5:23 AM, resident 31 was found on the floor in her bedroom at about 10:30 PM. Resident was in a partial fetal position and had a large goose egg on top of her forehead. The intervention was for staff to continue to assess her and watch her closely. The physician was notified.
An incident report dated 5/13/22 with no time revealed resident 31 slipped on the floor. The family was notified at 9:25 AM. The intervention was to use shoes with traction.
c. An incident report dated 5/25/22 with no time, revealed resident 31 was ambulating in the hall, then stopped walking and was standing then fell to the floor. There were no injuries. It was documented had proper foot gear on- shoes. The physician was notified. The intervention was to anticipate need for sudden stops.
There was no nursing progress note for 5/25/22.
d. On 7/7/22 at 4:13 PM, resident 31 fell at approximately 4:00 PM. Resident 31 fell over a vacuum in a doorway. There were no injuries and she did not hit her head. The intervention was to keep doorways clear. The physician and family were notified.
An incident report dated 7/7/22 at 4:00 PM revealed resident fell over vacuum in hallway. Resident 31 fell onto left hip and did not sustain any injuries. The intervention was to keep doorways clear.
e. On 7/17/22 at 4:51 PM, resident 31 had a fall at approximately 3:30 PM. There were no injuries and neurological checks were started. Resident 31 continues to ambulate through the hallways. The Family Nurse Practitioner and family were notified.
An incident report dated 7/17/22 at 3:30 PM, revealed resident 31 was found in hallway with no injuries. There was no additional information regarding the fall. The interventions developed were check frequently during rounds.
f. On 10/19/22 at 7:30 AM, Resident 31 was walking towards nurse and the medication cart and was holding on the wall handrails. Resident 31's pants made her lose balance and she held on to the rail and slowly slid to floor. There were no injuries. The physician and family were notified.
There was no incident report provided.
On 10/12/22 at 10:51 AM, an interview was conducted with CNA 2 who was also a family member to resident 31. CNA 2 stated resident 31 wandered and she was unstable when she was walking. CNA 2 stated she was a high fall risk and had falls.
On 10/27/22 at 9:23 AM, an interview was conducted with the ADON. The ADON stated resident 31 had a fall last week on 10/19/22. The ADON stated resident 31 was walking toward the nurse and was holding onto the hand rail. The ADON stated resident 31's pants made her fall and she slowly slid to the floor. The ADON stated resident 31's son was notified. The ADON stated resident 31 fell on 7/17/22 and fell over vacuum on 7/7/22. The ADON stated the intervention was to keep doorways clear. The ADON stated resident 31 fell on 5/14/22 during the night and it was an unwitnessed fall with no injuries. The ADON stated CNA's had been educated to watch her and keep any eye on her when she was up walking all the time because she liked to walk around.
On 10/27/22 at 10:39 AM, an interview was conducted with CNA 3. CNA 3 stated resident 31 was not at risk for falls. CNA 3 stated that she had not been educated or provided information on how to prevent resident 31 from falling. CNA 3 stated that she sat resident 31 on the sofa and put a blanket on her so that she did not pace the hallway all day, get tired and fall. CNA 3 stated she had lots of experience from hospitals that she just thought what the resident would like, for example sitting down with a blanket.
On 10/27/22 at 10:22 AM, an interview was conducted with CNA 4. CNA 4 stated resident 31 was not a fall risk. CNA 4 stated she was not educated regarding interventions to prevent residents from falling. CNA 4 stated that resident 31 had gripper socks on and she tried to put those on her everyday. Resident 31's sock drawer was observed with CNA 4. There were no pairs of socks with grippers and multiple ankle height socks. CNA 4 stated she did not put any of the thin ankle socks on resident 31. CNA 4 stated resident 31 did not wear shoes. CNA 4 stated she saw resident 31 in shoes once when the family put them on her to take her out of the facility.
5. Resident 96 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxemia, permanent atrial fibrillation, diabetes mellitus, and repeated falls.
Resident 96's medical record was reviewed on 10/27/22.
On 7/28/22, a nurses admission note for resident 96 was documented as follows: Hospice 5 day respite . Resident having hip pain from a recent fall, x-ray was done before admit and it is not fractured.
On 7/29/22, a nurses progress note indicated that resident 96 had a Foley catheter.
On 10/27/22 at 4:15 PM, an interview was conducted with CNA 5. CNA 5 stated that she used to work the night shift, but no longer would work that shift because of RN 1. CNA 5 stated that RN 1 would try to help us out, but I don't want her to. She's unsafe when transferring residents. CNA 5 stated that when resident 96 was at the facility during the 5 day respite stay, the exact date she could not recall, she got a call on her personal phone from RN 1 saying come here and help me resident 96 needs to go to the bathroom. CNA 5 stated that she told RN 1 not to take resident 96 to the bathroom because she had a hip fracture and a catheter. CNA 5 stated that she then went to assist RN 1 in resident 96's room and found resident 96 on the floor. CNA 5 stated that RN 1 panicked and she was telling the kitchen worker to come help. CNA 5 stated that she attempted to toilet resident 96, but that the resident had fallen during the transfer. CNA 5 stated that she reported the incident to the oncoming nurse for the next shift, Licensed Practical Nurse (LPN) 1, but was unsure if LPN 1 or RN 1 had filled out an incident report.
No evidence could be located in resident 96's medical record to indicate she had experienced a fall at the facility.
On 10/31/22 at 11:17 AM, a voicemail was left with RN 1, but was not returned prior to the completion of the 2567.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that for 5 of 33 sample residents, the facility did not provide routine ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that for 5 of 33 sample residents, the facility did not provide routine and emergency drugs and biologicals to its residents. The facility did not provide pharmaceutical services to meet the needs of each resident, and did not obtain the services of a licensed pharmacist who consults on all aspects of the provision of pharmacy services in the facility. The facility did not establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation. Specifically, multiple narcotic medications were not documented at the time they were administered. In addition, narcotic medications were not signed as administered in the Medication Administration Record and on the Controlled Drug Record. In addition, a third party did not reconciled narcotic medications monthly. Resident identifiers: 8, 10, 11, 14 and 29.
Findings include:
1. On 10/11/22 at 4:58 AM, Registered Nurse (RN) 1 was observed performing the narcotic reconciliation with RN 3. RN 1 stated that she forgot to sign out narcotics that she had administered overnight. RN 1 was observed to sign out narcotics for residents 8, 10, 11, 29, and three unsampled residents. RN 1 stated that she did not administer any narcotics to resident 10, but one narcotic was missing from resident 10's narcotic medications. RN 1 was observed to sign out the narcotic as having been administered to resident 10 by RN 1.
On 10/17/22 at 2:53 PM, RN 3 was interviewed. RN 3 stated that usually when she performed narcotic reconciliation with RN 1, there were at least two or three narcotics that were not signed out. RN 3 stated that the Director of Nursing (DON) was informed about the discrepancies. RN 3 stated that RN 1 was forgetful.
On 10/20/22 at 10:00 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that RN 1 had illegal drugs in the building, and had multiple complaints about RN 1. LPN 1 stated that RN 1 had told LPN 1 that she did not administer a narcotic but signed it out. LPN 1 stated that he reported to the DON that the narcotic counts were off. LPN 1 stated that RN 1 either did not care or was impaired.
On 10/21/22 at 11:44 AM, the DON was interviewed. The DON stated that staff should always document the narcotics as soon as they were administered. The DON stated that the narcotics should also be signed off in the electronic medical record (EMR) at the same time. The DON stated that RN 1 was written up for missing narcotics multiple times. The DON stated that the nursing standard of practice was to chart the narcotics when they were administered. The DON stated that nurses reported when RN 1 was shaky on shift, but stated that she did not hear that RN 1 was signing out medications that she did not administer. The DON stated that there were previous narcotic diversions related to RN 1, but there did not appear to be any action taken by the facility. The DON stated that she was concerned about the missing narcotics and she had changed the way narcotics were being counted with another nurse. The DON stated that there were sometimes four or five pills in the bottom of the narcotic (narc) drawer, under the cards.
On 10/24/22 at 2:30 PM, a follow-up interview was conducted with the Director of Nursing (DON). The DON stated that the pharmacy reviews go through [the ADM (Administrator) or the previous ADM]. The DON stated that a night nurse identified anomalies in the narcotic records because some residents did not ask for narcotics, but were recorded as being administered by RN 1. The DON stated that she only saw the pharmacy reviews once in a while when they (the ADM or previous ADM) give them to me . it was a hit and miss when I was given them. The DON stated I asked one time what I was supposed to do with them. The DON further stated that she would like to receive the pharmacy reports because they are informative. The DON stated that after last year's annual recertification survey, she had tried to keep a binder with the reviews in them for the nurses, so that they could keep track of medication changes, but that she received very few.
On 10/27/22 at approximately 4:00 PM, an interview was conducted with Employee 6. Employee 6 (E 6) stated that RN 1 was witnessed smoking pot (marijuana) at the facility and that the DON was notified. Employee 6 stated that they were concerned because there were medications in the facility that were not being accounted for.
On 10/27/22 at 4:15 PM, an interview was conducted with CNA 5. CNA 5 stated that she had worked with RN 1 when RN 1 lost medications in the 300 hall. CNA 5 stated that RN 1 instructed the CNAs to look for the missing medications, that were in a small cup. CNA 5 stated that RN 1 had offered her an orange-colored pill when CNA 5 was tired. CNA 5 stated that RN 1 had misplaced pills on more than one occasion, along with the narcotic drawer keys.
On 10/27/22 at 8:52 AM, an interview was conducted with the consulting Pharmacist. The Pharmacist stated that the facility ADM contracted with him for recommendations, but did not have him reconcile the narcotics. The Pharmacist stated that he told the ADM that a third party should reconcile the narcotics.
On 10/25/22 at 1:35 PM, the ADM was interviewed. The ADM stated that she did not have a random drug testing policy. The ADM stated that sometimes there were four or five narcotics in the bottom of the narcotic lock box in the medication cart. The ADM stated that RN 1 had been counseled about missing narcotics on three occasions.
2. On 10/18/22 at 1:20 PM, the Medication Room was observed. There was a bottle of tuberculin administration that was opened on 6/27/22. Tuberculin, multi-dose vials expire after being opened 28 days. The tuberculin would have expired in July, 2022. The ADON was immediately interviewed. The ADON stated that the tuberculin was expired.
On 10/21/22 at 11:44 AM, an interview was conducted with the DON. The DON stated that she had requested a new vial of tuberculin, but had not received one. The DON stated that residents who were admitted after August 1, 2022 received expired tuberculin.
Resident records were reviewed. Three residents were admitted to the facility between August 1, 2022 and 10/31/22. One resident received the expired tuberculin. The other two residents were not tested for tuberculosis.
[Note: There was no reconciliation for expired medications.]
3. Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included cellulitis and abscess of mouth, osteoarthritis in left hip, chronic pain, metabolic encephalopathy, Wernicke's encephalopathy, dementia and psychosis.
On 10/20/22 at 12:00 PM, an interview and observation was made of resident 14. Resident 14 asked why he was in more pain and getting more medication than before he left to the hospital. Resident 14 stated he had pain in legs, hands and spine. Resident 14 stated eating hurt and pain kept him awake at night.
On 10/26/22 at 12:15 PM, an interview was conducted with resident 14. Resident 14 stated he had pain in his right leg and pain from his shoulder to his toes down his leg on his left side. Resident 14 stated he was not in pain at the hospital but since getting back to the facility he had been in pain. Resident 14 stated in the morning he was woken-up by his pain. Resident 14 stated if he gets his pain medication prior to bed, then he was able to sleep. Resident 14 stated without pain killers he did not sleep at all. Resident 14 stated the cold weather made his pain worse. Resident 14 stated he didn't do much because he was in pain. Resident 14 stated if there were activities, he would not go because it hurt for him to walk. Resident 14 stated at the hospital, they were able to control his pain, but he was unable to get the same medications at the facility. At 12:42 PM, resident 14 stated that his back was hurting and he was in pain. Resident 14 stated the pain medication did not last very long.
Resident 14's medical record was reviewed.
Resident 14's physician's orders were reviewed prior to discharging to the hospital. The following medications were ordered:
a. Start date of 9/24/2020, Gabapentin 100 mg by mouth three times a day for low back pain.
b. Start date of 1/5/19, Oxycodone HCL 5 mg. Give 1 tablet by by mouth every 4 hours as needed for pain related to other chronic pain.
c. Start date of 1/5/19, Oxycodone HCL 5 mg. Give 1 tablet by mouth two times a day related to other chronic pain and low back pain. Discontinued on 10/13/22.
Resident 14 returned from the hospital on [DATE] with orders to discontinue the scheduled Oxycodone 5 mg twice daily.
The October 2022 MAR revealed resident 14 was provided Oxycodone 5 mg on the following days:
a. On 10/6/22 at 8:33 PM, with a pain score of 8,
b. On 10/15/22 at 9:58 AM, with a pain score of 7,
c. On 10/16/22 at 3:51 PM, with a pain score of 6,
d. On 10/18/22 at 12:08 PM, with a pain score of 5,
e. On 10/20/22 at 11:56 AM, with a pain score of 5,
f. On 10/21/22 at 12:24 PM, with a pain score of 6 and the medication was ineffective.
g. On 10/21/22 at 7:40 PM, with a pain score of 8,
h. On 10/23/22 at 3:50 PM, with a pain score of 8
i. On 10/24/22 at 10:55 AM, with a pain score of 8,
j. On 10/25/22 at 11:57 AM, with a pain score of 5,
k. On 10/25/22 at 5:22 PM, with a pain score of 5,
l. On 10/26/22 at 11:57 AM, with a pain score of 5.
According to the Controlled Drug Record for the Oxycodone 10 mg take 1/2 tablet by mouth twice daily and 1/2 every four hours as needed were the instructions. Resident 14 was administered a 1/2 tablet on the following days which there were not documented in the MAR entries with pain scores:
a. On 10/13/22 at 9:35 PM
b. On 10/14/22 at 6:00 PM
c. On 10/18/22 at 9:00 AM
d. On 10/15/22 at 6:00 PM
e. On 10/14/22 with no time
f. On 10/17/22 at 9:10 PM
g. On 10/17/22 at 8:30 PM
h. On 10/18/22 at 2:00 AM
i. On 10/18/22 at 11:00 AM
j. On 10/18/22 at 4:30 PM
k. On 10/18/22 at 11:30 PM
l. On 10/19/22 at 8:00 AM
m. On 10/19/22 at 8:00 PM
n. On 10/20/22 at 8:50 AM
o. On 10/22/22 at 3:30 PM
p. On 10/23/22 at 7:00 AM
q. On 10/23/22 at 9:00 PM
r. On 10/26/22 at 8:30 AM
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0775
(Tag F0775)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 4 of 33 sampled residents, that the facility did not file, in the re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 4 of 33 sampled residents, that the facility did not file, in the resident's clinical record, laboratory results that were dated and contained the name and address of the testing laboratory. Specifically, residents did not have laboratory results available to the nursing staff and results were not filed in the medical record. Resident identifiers: 2, 28, 36, and 94.
Findings include:
1. Resident 2 was admitted to the facility on [DATE] with diagnoses which included a cerebral infarction, convulsions and seizures, paranoid schizophrenia, substance use, chronic peptic ulcer, respiratory failure with hypoxia, kidney failure, coagulation deficit, Wernicke's encephalopathy, hypomagnesemia, and hemiplegia.
On 10/13/22 at approximately 9:30 AM, resident 2 was observed to have a seizure. Licensed Practical Nurse (LPN) 1 stated that resident 2 had increased seizure activity when his magnesium was low.
On 10/24/22 at approximately 2:00 PM, a pile of papers approximately three to four inches high was observed in a drawer at the nurses' station. The pile included some labs, incident reports, daily reports, and orders. Additionally, a wire basket was located in another drawer. The Director of Nursing (DON) was immediately interviewed who stated that the wire basket was paper work for the doctor.
On 10/31/22, resident 2's medical record review was completed.
Resident 2's physician orders included the following:
a. On 3/22/22, draw magnesium levels every 2 weeks until further notice.
b. On 1/23/2020, Magnesium oxide, 400 mg tablet, daily
On 10/3/22, a physician's progress note revealed that magnesium levels were to be monitored every two weeks.
Resident 2's electronic record and paper chart did not include magnesium results. The results were in milligrams per deciliter (mg/dL), with a normal range of 1.6 to 2.3. Labs were missing in resident 2's medical record and were requested from the nursing staff. Nursing staff retrieved the results from the laboratory's website. Labs that were missing were for the following dates:
a. 5/31/22, results were 1.7
b. 6/14/22, results were 1.6
c. 7/12/22, results were 1.5 (low)
d. 7/27/22, results were 1.6
e. 8/9/22, results were 1.5 (low)
f. 10/4/22, results were 1.4 (low)
[Note: There was no apparent correlation between low magnesium and seizure activity.]
On 10/24/22 at 2:30 PM, the DON was interviewed. The DON stated that sometimes the nurses did not receive the lab results. The DON stated that when she called the laboratory, she was sometimes told they did not receive the sample. The DON stated that if a lab was ordered STAT (as soon as possible), a Certified Nursing Assistant (CNA) had to take the specimen to the laboratory. The DON stated that at one time, the phlebotomist from the laboratory took a blood sample home overnight by mistake. The DON stated that she received results when she saw the paper laying around. The DON stated that if the laboratory did not fax the result, the nursing staff did not have it.
On 10/25/22 at 1:35 PM, the Administrator (ADM) was interviewed. The ADM stated that labs should have been faxed from the company, but there was no way to determine what labs were sent or what happened to them after they were sent. The ADM stated that she thought she had printed the labs off the computer, but a lot of labs were not in the medical records. The ADM stated that they were revising the system.
2. Resident 28 was admitted to the facility on [DATE] with diagnoses that included Takotsubo syndrome, schizoaffective disorder, respiratory failure with hypoxia, myocardial infarction, diabetes mellitus, hyperlipidemia, insomnia, hypothyroidism, dysphagia, osteoporosis, and rheumatoid arthritis.
On 10/31/22, resident 28's medical record review was completed.
Resident 28 had a physician's order for laboratory work that included:
a. Hemoglobin A1C every 6 months
b. Yearly lipid panel, TSH (thyroid stimulating hormone), and CMP (complete metabolic panel)
c. CBC (complete blood count) with differential, AST, ALT (liver function tests), and Creatinine every 3 months
On 5/5/22, resident 28 had a CMP, lipid panel and TSH completed. Resident 28 had low protein and albumin, high triglycerides, low high-density lipoproteins (HDL), Very-low-density-lipoproteins (VLDL) was high at 45, and the TSH was high at 5.1.
On 5/17/22, resident 28's CBC demonstrated low platelets and a high Hemoglobin A1C of 5.9. Repeat labs were to be obtained in August, 2022.
On 10/26/22 at 5:36 PM, laboratory results were not located in resident 28's chart. The DON was interviewed and assisted in obtaining the laboratory results. Results were obtained on 7/14/22 for the CBC, CMP, AST, ALT and creatinine. On 10/11/22, a hemoglobin A1C was obtained, and on 10/18/22, a CBC, creatinine, AST and ALT were obtained. Resident 28 had a high white blood cell count with high lymphocytes. The DON stated that she had not obtained these results prior.
[Note: High lymphocytes are indicative of a viral infection.]
On 10/17/22 at 11:25 AM, an interview was conducted with LPN 1. LPN 1 stated that labs were sent on the fax machine and the nurses were responsible to contact the physician with the results. LPN 1 stated that the nurse made a note on the laboratory results to document that they had reviewed the results and contacted the physician. LPN 1 stated that the nurse would then place the labs in the doctor's box for the physician to sign. LPN 1 stated that after the physician signed the results, the labs were filed in the resident's charts.
3. Resident 36 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, anxiety, diabetes mellitus, anemia, intellectual disabilities, and depression.
On 10/31/22, resident 36's medical record review was completed.
Resident 36's physician orders included an order to draw a CBC and Clozapine level monthly. This order was initiated on 7/7/2020.
A nursing note revealed that resident 36 had labs drawn on 12/13/21.
On 10/17/22 at 11:38 AM, the Medical Director (MD) was interviewed. The MD stated that not all labs were being obtained.
On 10/26/22 at 5:36 PM, the laboratory results were provided by the DON. It should be noted the results were not in filed in the medical record.
4. Resident 94 was admitted to the facility on [DATE] with diagnoses that included chronic atrial fibrillation, aortic regurgitation and stenosis, pulmonary hypertension, hypertension, and type 2 diabetes mellitus with both diabetic nephropathy and peripheral angiopathy. Resident 94 was discharged from the facility on 9/6/22.
Resident 94's medical record was reviewed from 10/11/22 through 10/31/22.
Physician orders for resident 94 revealed the following:
a. On 6/10/22, resident 94 was prescribed Coumadin 6 milligrams (mg) daily.
b. On 6/16/22, an order was written for resident 94 to have his Prothrombin Time/International Normalized Ratio (PT/INR) checked on 6/21/22. Results for this lab were not able to be located in the resident's medical record.
c. On 7/2/22, an order was written for resident 94 to have his PT/INR checked on 7/12/22. Results for this lab were not able to be located in the resident's medical record.
d. On 7/25/22, an order was written for resident 94 to have his PT/INR checked on 7/26/22. Results for this lab were not able to be located in the resident's medical record.
e. On 8/1/22, an order was written for the resident's Coumadin to be discontinued, and the resident was now to be administered Eliquis 5 mg daily.
On 10/22/22 at 11:20 PM, an interview was conducted with Registered Nurse (RN) 5. RN 5 stated that all lab results were faxed to the facility by the lab company. RN 5 stated that nurses checked the fax machine throughout their shift and then notified the physician of the results. RN 5 stated that after the physician was notified, the lab results were supposed to be placed in the medical record . RN 5 stated that if staff did not have lab results printed out, they could access the lab results directly on the lab's website. However, RN 5 stated that she did not have a username and password for the lab's website.
On 10/18/22 at 1:48 PM, the facility Administrator (ADM) provided the missing lab results as listed above.
On 10/25/22 at 1:35 PM, an interview was conducted with the facility ADM. The ADM confirmed that the labs she provided on 10/18/22 had not previously been placed in resident 94's medical record. The ADM stated that when surveyors had requested the missing labs, she had printed off the results from the lab website. The ADM stated that the labs weren't in the chart. there is a lot of things not in the chart.
On 10/17/22 at 11:38 AM, an interview was conducted with the facility Medical Director (MD). The MD stated that she had been repeatedly writing orders for resident 94's PT/INR to be checked, but that results were not received consistently. The MD stated that on 8/1/22 she decided it wasn't safe for the resident to be on Coumadin, if facility staff were not monitoring the PT/INR appropriately. The MD stated that it was at that time she changed the resident over to Eliquis, as it does not require the same level of monitoring. The MD further stated that when the resident discharged from the facility on 9/6/22, he was admitted to another facility where the MD worked. The MD stated that at the new facility she put resident 94 back on the Coumadin, as she felt it was the better medication for this particular resident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 22 was admitted to the facility on [DATE] and readmitted on [DATE] which diagnoses which include chronic diastolic h...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 22 was admitted to the facility on [DATE] and readmitted on [DATE] which diagnoses which include chronic diastolic heart failure, hyperkalemia, chronic kidney disease, anxiety disorder, difficulty in walking, polyneuropathy, major depressive disorder, cellulitis of lower limb, venous insufficiency, and dysphagia.
On 10/11/22 at 8:37 AM, an observation of resident 22 was made in the dining room. Resident 22 was observed to have grapes on his breakfast tray.
On 10/13/22 resident 22's medical record was reviewed.
A diet order dated 6/25/22 revealed that resident 22 was to receive a mechanical soft diet.
4. Resident 37 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included personal history of covid-19, metabolic encephalopathy, type 2 diabetes mellitus, hypokalemia, systemic lupus erythematosus, chronic pain, muscle weakness, hypercalcemia, and epilepsy.
On 10/11/22 at 7:50 AM, an observation of resident 37 was made during breakfast in the memory care unit's dining room. Resident 37 was observed to have grapes on her breakfast tray. Resident 37 was observed to eat a grape and cough.
On 10/20/22 an observation of resident 37 was made during lunch in the memory care unit's dining room. Resident 37 was observed to have shredded lettuce on her lunch tray.
On 10/13/22 resident 37's medical record was reviewed.
A diet order dated 8/22/18 revealed that resident 37 was to receive on a mechanical soft diet.
5. Resident 9 was admitted to the facility on [DATE] with diagnoses which include major depressive disorder, paranoid schizophrenia, cognitive communication deficit, type 2 diabetes mellitus, low back pain, essential hypertension, epilepsy, and hyperlipidemia.
On 10/20/22 an observation of resident 9 was made during lunch in the locked unit's dining room. Resident 9 was observed to have shredded lettuce on his lunch tray.
On 10/13/22 resident 9's medical record was reviewed.
A diet order dated 12/23/21 revealed that resident 9 was to receive a mechanical soft diet.
On 10/24/22 at 2:08 PM, an interview was conducted with the Medical Director (MD). The MD stated that grapes and hot dog were the worst foods to feed residents with a swallowing problem. The MD stated residents should not be served grapes if the resident required a mechanical soft diet.
On 10/26/22 at 3:51 PM, an interview was conducted with the Dietary Manager (DM). The DM stated grapes were served as the garnish on 10/11/22. The DM stated the grapes were to be cut up for residents on mechanical soft diets. The DM stated residents on mechanical soft diets were able to have shredded lettuce.
According to the International Dysphagia Diet Standardisation Initiative (IDDSI) minced and moist diet revealed biting was not required and minimal chewing was required. The fruit was to be served finely minced or chopped or mashed. The vegetables were to be served finely minced or shopped or mashed. The soft and bite-sized diet revealed that biting was not required and chewing was required before swallowing. The fruit was to be served minced or mashed if cannot be cut to soft and bite-sized pieces. The vegetables were to be steamed or boiled. https://iddsi.org/IDDSI/media/images/Complete_IDDSI_Framework_Final_31July2019.pdf
Based on observation, interview and record review it was determined, for 5 of 33 sampled residents, that the facility did not provide food prepared in a form designed to meet individual needs. Specifically, residents on mechanically altered diets were provided grapes and lettuce. Resident identifiers: 9, 22, 31, 37 and 39.
Findings include:
1. Resident 31 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, dementia with behavioral disturbance, and major depressive disorder.
On 10/11/22 at 7:45 AM, an observation was made of the breakfast meal. Resident 31 was served ground meat, pancake, hot cereal and grapes.
On 10/20/22 at 11:49 AM, an observation was made of the lunch meal. Resident 31 was observed to be served shredded lettuce.
Resident 31's medical record was reviewed.
A diet order dated 9/22/21 revealed regular with minced texture.
Resident 31's meal ticket revealed a minced diet texture.
2. Resident 39 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included atherosclerotic heart disease, diabetes mellitus, vascular dementia, and schizoaffective disorder.
On 10/11/22 at 7:45 AM, an observation was made of the breakfast meal. Resident 39 was served oatmeal, pancake, ground meat and grapes.
On 10/20/22 at 11:49 AM, an observation was made of the lunch meal. Resident 39 was observed to be served shredded lettuce.
Resident 39's medical record was reviewed.
Resident 39's meal ticket revealed a mechanical soft with reduced concentrated sweets diet.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and interview it was determined the facility did not store, prepare and distribute food in accordance with professional standards for food service safety. Specifically, frozen Mig...
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Based on observation and interview it was determined the facility did not store, prepare and distribute food in accordance with professional standards for food service safety. Specifically, frozen Mighty Shakes were observed to be thawing at room temperature.
Findings include:
On 10/27/22 at 2:30 PM, an observation was made of the facility medication room. There were 25 Mighty Shakes on a tray, on the counter, in the medication room. An immediate interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated she had received the Mighty Shakes that morning and had administered a few with the lunch medication pass. The ADON stated the Mighty Shakes were frozen for the morning medication pass. The ADON stated that residents cannot drink the Mighty Shakes when they're frozen, so they were not administered in the morning. The ADON stated that she was thawing the Mighty Shakes on the counter, but they needed to be refrigerated during the thawing process.
According to the United States Department of Agriculture, there are three safe ways to thaw food: in the refrigerator, in cold water, or in the microwave. It's best to plan ahead for slow, safe thawing in the refrigerator. https://www.fsis.usda.gov/food-safety/safe-food-handling-and-preparation/food-safety-basics/freezing-and-food-safety#:~:text=There%20are%20three%20safe%20ways,water%2C%20or%20in%20the%20microwave.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0836
(Tag F0836)
Could have caused harm · This affected multiple residents
Based on observation and interview it was determined that the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations and codes, and...
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Based on observation and interview it was determined that the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. Specifically, resident's medical records were used to block an open door from the memory care unit, preventing egress.
Findings include:
On 10/23/22 at 12:04 AM, an observation was made of Registered Nurse (RN) 5. RN 5 was observed to open the locked door to the memory care unit. RN 5 moved a cart with residents medical records from the memory care unit in front of the open door.
On 10/17/22 at 11:13 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated when she was the only CNA for the facility, the staff opened the door to the memory care unit and placed the medical record cart in front of the open door. CNA 1 stated staff were able to see what was going on in the memory care hallway with the door open. CNA 1 stated she glanced down the memory care unit hallway and then obtained vital signs from residents outside of the locked unit. CNA 1 stated the nurse sometimes watched the hallway.
On 10/17/22 at 2:20 PM, a phone interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated there were not enough CNAs in the facility at times, so staff leave the doors open to the locked unit. LPN 1 stated staff put the cart with medical records in front of the open door. LPN 1 stated that way we can see or hear residents in the locked unit. LPN 1 stated there should always be staff on the locked unit.
On 10/18/22 at 10:55 AM, an interview was conducted with resident 93's family member. Resident 93's family member stated that when she visited her mother, who resided in the facility Memory Care Unit (MCU), the doors to the MCU were often propped open. Resident 93's family member stated that facility staff used a rolling cart that contained resident medical records to prop the doors to the MCU open.
The National Fire Protection Association Life Safety Code 101 requires the following, Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 9 was admitted to the facility on [DATE] with diagnoses which include major depressive disorder, paranoid schizophre...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 9 was admitted to the facility on [DATE] with diagnoses which include major depressive disorder, paranoid schizophrenia, cognitive communication deficit, type 2 diabetes mellitus, low back pain, essential hypertension, epilepsy, and hyperlipidemia.
On 10/26/22 resident 9's medical record was reviewed.
A document titled Hospital ED (emergency department) with a different resident's name was in resident 9's medical record.
On 10/26/22 at 10:51 AM an interview with the Director of Nursing (DON) was conducted. The DON stated that the document with a different resident's name in resident 9's medical record must have been placed there by mistake. The DON stated that the document should be placed in the correct resident's medical record.
4. Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included muscle weakness, schizophrenia, cognitive communication deficit, conversion disorder, anxiety disorder, chronic kidney disease, psychosis, difficulty in walking, and hyperlipidemia.
On 10/13/22 resident 4's medical record was reviewed.
The Behavior Tracking document was reviewed from 10/1/22 to 10/12/22. The Behavior Tracking orders had multiple days with incomplete documentation:
a. An order which stated, Monitor for increased sedation/drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, photosensitivity of skin, excess weight gain had 5 times where it was not charted from 10/1/22 to 10/12/22.
b. An order which stated, Antidepressant target behavior: (lack of interest). 0=did not occur during shift, 1=occurred a few times during shift, 2=occurred often during shift, 3=occurred frequently or constantly during shift every day and night shift had 5 times where it was not charted from 10/1/22 to 10/12/22.
c. An order which stated, Monitor for dry mouth, constipation, blurred vision, disorientation/confusion, difficulty urinating, hypotension, dark urine, yellow skin, N/V [nausea/vomiting], lethargy, drooling, EPS symptoms . had 5 times where it was not charted from 10/1/22 to 10/12/22.
d. An order which stated, Antidepressant target behavior: (distressing delusions). 0=did not occur during shift, 1=occurred a few times during shift, 2=occurred often during shift, 3=occurred frequently or constantly during shift every day and night shift had 5 times where it was not charted from 10/1/22 to 10/12/22.
e. An order which stated, Antidepressant target behavior: (physical aggression). 0=did not occur during shift, 1=occurred a few times during shift, 2=occurred often during shift, 3=occurred frequently or constantly during shift every day and night shift had 5 times where it was not charted from 10/1/22 to 10/12/22.
f. An order which stated, Antidepressant target behavior: (yelling out). 0=did not occur during shift, 1=occurred a few times during shift, 2=occurred often during shift, 3=occurred frequently or constantly during shift every day and night shift had 5 times where it was not charted from 10/1/22 to 10/12/22.
The MAR document was reviewed from 10/1/22 to 10/12/22. The MAR orders had multiple days with incomplete documentation:
a. An order for Atorvastatin Calcium Table 20 milligrams (mg) which started on 12/24/20 was not charted 1 time from 10/1/22 to 10/12/22.
b. An order which stated, Enteral Feed Order, every night shift for prevention of clogging of tube Flush with water 30 milliliters which started on 4/22/22 was not charted 1 time from 10/1/22 to 10/12/22.
c. An order for FLUoxetine HCL Tablet 20 mg which started on 5/14/22 was not charted 1 time from 10/1/22 to 10/12/22.
d. An order for Insulin Glargine Solution 100 unit/ml which started on 12/24/20 was not charted 1 time from 10/1/22 to 10/12/22.
e. An order for Keppra Solution 1000 mg which started on 5/25/22 was not charted 1 time from 10/1/22 to 10/12/22.
f. An order which stated, Enteral Feed Order - every day and night shift NPO (nothing by mouth) was not charted on 1 time from 10/1/22 to 10/12.22.
g. An order which stated, Keep HOB [Head of Bed] elevated for tube feed was not charted 1 time from 10/1/22 to 10/12/22.
h. An order which stated, Pain Scale Assess Pain BID [twice a day] Using Verbal Scale (0-10) or Non-Verbal Scale . was not charted on 1 time from 10/1/22 to 10/12/22.
i. An order for Zyprexa Tablet 15 mg twice a day was not charted 1 time from 10/1/22 to 10/12/22.
j. An order which stated, Enteral Feed Order - every 24 hours Jevity @ 95ml/hr 20hrs/day. Flush 25ml/hr 20hrs/day. Was not charted on 1 time from 10/1/22 to 10/12/22.
k. An order which stated, Flush tube with warm water at least Q[every] 5 hrs was not charted 14 times from 10/1/22 to 10/12/22.
The Treatment Administration Record (TAR) document was reviewed from 10/1/22 to 10/12/22. The TAR orders had multiple days with incomplete documentation:
a. An order which stated, Change syringe and feed bag/tubing with date labeled Q [every] night shift was not charted 6 times from 10/1/22 to 10/12/22.
b. An order which stated, Flush feeding tube night shift every 3 hours .every night shift .to prevent clogging of tube was not charted 6 times from 10/1/22 to 10/12/22.
c. An order which stated, Oxygen via NC [nasal cannula] to keep sats >90% every day and night shift was not charted 6 times from 10/1/22 to 10/12/22.
On 10/18/22 at 10:04 AM, an interview with RN 3 was conducted. RN 3 stated when there were blank areas on the Behavior Tracking document, the MAR, and the TAR, that meant the nurse did not chart whether the order was completed or not.
Based on interview and record review it was determined, for 4 of 33 sampled residents, that the facility did not maintain medical records on each resident that were complete, accurately documented, readily accessible and systematically organized. Additionally, the facility must safeguard medical record information against loss. Specifically, narcotic medications were not reconciled monthly, nursing staff did not sign out narcotic medications, and nursing staff did not document behaviors according to physician's orders. Resident identifiers: 4, 8, 9, and 10.
Findings include:
1. Resident 8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included diabetes, neuropathy, asthma, spinal stenosis, hypertension, anxiety disorder, and dysthymic disorder.
On 10/31/22, resident 8's medical record review was completed.
On 10/25/22, a nursing note revealed that resident 8 was taking antibiotics and was very shaky, some weakness and confusion . and had a fever. Resident 8 was transported to the hospital.
No notes were included in resident 8's medical record that he was admitted to the hospital. Resident 8 returned to the facility on [DATE].
Resident 8's Medication Administration Record (MAR) for October, 2022, revealed that missing data included:
a. Aricept tablet, either administered or refused on 10/2/22.
b. Melatonin tablet, 3 mg, either administered or refused on 10/2/22.
c. Metformin HCl (hydrochloride) extended release, 1000 mg tablet, either administered or refused on 10/2/22.
d. Magnesium, 800 mg tablet, either administered or refused on 10/2/22.
e. Dilaudid on the written narcotic sheet did not match the narcotic record in the electronic medical record (EMR).
The facility did not have pharmacy reviews in the facility for the most recent pharmacist's review. The pharmacist brought the reviews to the facility on [DATE] at 10:00 AM.
On 10/27/22 at 8:52 AM, a consulting Pharmacist was interviewed. The Pharmacist stated that he was not asked to review narcotics for the facility. The Pharmacist stated that he told the Administrator that the best way to ensure accurate accounting of narcotics was to have an outside auditor review the narcotic records.
2. Resident 10 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, vascular dementia, diabetes, asthma, transient ischemic attack, hypertension, fatty liver, and mild intellectual disabilities.
On 10/11/22 at 4:58 AM, Registered Nurse (RN) 1 was observed performing the narcotic reconciliation with RN 3. RN 1 stated that she forgot to sign out narcotics that she had administered overnight. RN 1 was observed to sign out narcotics for residents, including resident 10. RN 1 stated that she did not administer any narcotics to resident 10, but one narcotic was missing from resident 10's narcotic medication card. RN 1 was observed to sign out the narcotic as having been administered to resident 10.
On 10/17/22 at 2:53 PM, RN 3 was interviewed. RN 3 stated that usually when she performed narcotic reconciliation with RN 1, there were at least two or three narcotics that were not signed out. RN 3 stated that the Director of Nursing (DON) was informed about the discrepancies. RN 3 stated that RN 1 was forgetful.
On 10/20/22 at 10:00 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that RN 1 had illegal drugs in the building, and had multiple complaints about RN 1. LPN 1 stated that RN 1 had told LPN 1 that she did not administer a narcotic but signed it out. LPN 1 stated that he reported to the DON that the narcotic counts were off. LPN 1 stated that RN 1 either did not care or was impaired.
On 10/21/22 at 11:44 AM, the DON was interviewed. The DON stated that staff should always chart the narcotics as soon as they were administered. The DON stated that the narcotics should also be signed off in the electronic medical record (EMR). The DON stated that RN 1 was written up for missing narcotics multiple times. The DON stated that the nursing standard of practice was to chart the narcotics when they were administered. The DON stated that nurses reported when RN 1 was shaky on shift, but stated that she did not hear that RN 1 was signing out medications that she did not administer. The DON stated that there were previous narcotic diversions related to RN 1, but there did not appear to be any action taken by the facility. The DON stated that she was concerned about the missing narcotics and changed the way narcotics were counted because of RN 1. The DON stated that there were sometimes four or five pills in the bottom of the narcotic (narc) drawer, under the cards.
On 10/27/22 at 8:52 AM, an interview was conducted with the consulting Pharmacist. The Pharmacist stated that the facility Administrator (ADM) contracted with him for recommendations, but did not have him reconcile the narcotics. The Pharmacist stated that he told the ADM that a third party should reconcile the narcotics.
On 10/25/22 at 1:35 PM, the Administrator (ADM) was interviewed. The ADM stated that she did not have a random drug testing policy. The ADM stated that sometimes there were four or five narcotics in the bottom of the narcotic lock box on the medication cart. The ADM stated that RN 1 had been counseled about missing narcotics on three occasions.
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 interview, observation, and record review, it was determined that the facility did not document the corrective actions ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, it was determined that the facility did not document the corrective actions taken by the facility after it identified incidents under the facility's infection prevention and control program (IPCP), or establish and maintain an IPCP designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, a nurse did not sanitize the glucometer between residents, antibiotics for wounds did not have a corresponding culture, tuberculosis testing was not completed, TB testing was completed with expired tuberculin and staff were observed without a mask. Resident identifiers: 4, 10, 8, 11, 14, 15, 20, 29, 24, 31 and 39.
Findings include:
1. On [DATE] at 4:35 AM, Registered Nurse (RN) 1 was observed obtaining blood glucose readings. RN 1 was observed to not clean the glucometer between residents. Readings were obtained from the following residents:
a. resident 39
b. a resident in room [ROOM NUMBER]
c. resident 4
d. resident 20
e. a resident in room [ROOM NUMBER] bed A
f. resident 10
g. a resident in room [ROOM NUMBER] bed A
h. a resident in room [ROOM NUMBER] bed B
i. resident 34
j. resident 8
k. a resident in room [ROOM NUMBER] bed A
l. resident 11
On [DATE] at 2:25 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the glucometer should be cleaned between residents, allowing for drying time with the disinfectant to ensure cleanliness.
2. Antibiotics were administered to the following residents:
a. Resident 29 had a foot infection. Resident 29 was prescribed Clindamycin, Doxycycline, Bactrim, Ceftriaxone, and Keflex between [DATE] and [DATE] without a culture being obtained. On [DATE], resident 29 was diagnosed with osteomyelitis and subsequently had a toe and metatarsal amputation.
b. Resident 34 had antibiotics prescribed for an eye infection in [DATE] without a culture being obtained.
3. On [DATE] at 4:58 AM, the medication room was observed with Registered Nurse (RN) 3. An opened vial of tuberculin solution was observed with an open date of [DATE]. RN 3 was immediately interviewed. RN 3 stated the tuberculin expired 28 days after being opened.
Three residents were admitted in August, 2022. One unsampled resident received the expired tuberculin solution and two residents were not tested for tuberculosis (TB).
On [DATE] at 11:44 AM, an interview was conducted with the DON. The DON stated that she had requested a new vial of tuberculin, but had not received one. The DON stated that the expired tuberculin vial was the only tuberculin the facility had. The DON stated that residents who were admitted after [DATE] received expired tuberculin.
Resident records were reviewed. Three residents were admitted to the facility between [DATE] and [DATE]. One resident received the expired tuberculin. The other two residents admitted to the facility in August, 2022 were not tested for tuberculosis.
4. On [DATE] at 1:59 PM, an observation was made of Certified Nursing Assistant (CNA) 5. CNA 5 was observed walk through the memory care unit hallway. CNA 5 was observed with her mask below her mouth and nose. CNA 5 was observed to hug resident 15. CNA 5 was observed to talk to resident 14, resident 39 and resident 31 with her mask below her nose and mouth. CNA 5 stated she was recently discharged from the hospital.
On [DATE] at 2:38 PM, an observation was made of CNA 5. CNA 5 was observed walking around nurses station with her mask on chin. CNA 5's mask was not covering her nose or mouth.
On [DATE] at 4:15 PM, an interview was conducted with CNA 5. CNA 5 stated she was recently admitted to the hospital and had discharged the day before.
5. On [DATE] at 11:45 AM, an observation was made of resident 35 in the memory care unit dining room. Resident 35 was observed to drink from his water cup and then was observed to pour his water into the water pitcher on the table.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility did not designate one or more individuals as the infection preventionist who are responsible for the facility's infection control program.
Findings ...
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Based on interview and record review, the facility did not designate one or more individuals as the infection preventionist who are responsible for the facility's infection control program.
Findings include:
On 10/17/22 at 12:33 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that he talked to the Director of Nursing (DON) who would log infections, but there was no infection preventionist in the building.
On 10/18/22, the DON was asked for the IP certificate.
On 10/18/22 at 1:48 PM, an email was provided by the Administrator. The Administrator wrote I do not think that [DON name] finished her certification.
On 10/21/22 at 11:44 AM, the Director of Nursing (DON) was interviewed. The DON stated that she did not have time to do all the responsibilities of the DON because when she was working, she was the nurse on shift (the floor nurse). The DON stated that she had a second nursing job outside the facility, and did not have specific days when she was able to work as the DON at the facility. The DON stated that she found a few minutes during her shift to accomplish her DON tasks. The DON stated that she had not completed the Infection Preventionist (IP) training, and was therefore not an IP.
On 10/24/22 at 12:22 PM, an interview was conducted with the Medical Director (MD). The MD stated that there was no communication about tracking and trending infections currently, because she would obtain the information from the QAPI (Quality Assurance/Process Improvement) meetings, and the meetings had not been held lately. The MD stated that she was not consulted about wounds in the facility, which were handled by an outside agency.
On 10/25/22 at 10:09 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that she was the nurse who was working on Tuesday mornings when the wound care consultants were in the building. The ADON stated that she was not a designated wound person, but was the only nurse who was rounding on the residents with wounds. The ADON stated that she was unable to track and trend the wound infections because she did not have access to the program utilized by the wound care company.
On 10/25/22 at 1:35 PM, an interview was conducted with the Administrator (ADM). The ADM stated that the ADON was responsible for the wounds in the building, ensuring that orders were fulfilled, and that wounds were treated. The ADM stated that the ADON did not have access to the software and reports from the wound care company, and that the ADM was the only staff member with access. The ADM stated that she had not been able to log into the wound care site for a while. The ADM stated she had not followed-up to ensure staff were completing infection control processes.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0886
(Tag F0886)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to test facility staff who were not fully vacci...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to test facility staff who were not fully vaccinated based on the current parameters. Specifically, there was no documentation that COVID-19 testing was completed and the results of the testing were available.
Findings include:
In September, 2022, staff who were not fully vaccinated were required to complete COVID-19 testing twice weekly. A list of eleven staff members who were not fully vaccinated was provided. The following testing forms were observed:
a. Speech Therapist (ST) 1 tested on [DATE], 9/7/22, 9/15/22, 9/19/22, and 9/29/22
b. [NAME] 2 worked on Fridays, Saturdays, Sundays and Mondays. [NAME] 2 tested on [DATE] and 9/30/22.
c. [NAME] 3 worked on Tuesdays, Thursdays, Fridays and Saturdays, and tested on [DATE] and 9/22/22.
d. [NAME] 4 worked on Sundays, Tuesdays, Wednesdays and Thursdays. [NAME] 4 tested on [DATE], 9/9/22, 9/14/22, and 9/18/22.
e. Registered Nurse (RN) 6 tested on [DATE].
f. RN 7 worked part time and did not test in September.
g. Certified Nursing Assistant (CNA) 9 worked part time and did not test in September.
h. CNA 8 tested on ce in September, with a date of 9/12/22-9/13/22.
i. Physical Therapist (PT) 1 tested on [DATE].
j. CNA 10 tested on [DATE].
k. Housekeeper (HK) 1 did not test.
On 10/27/22 at 10:52 AM, an observation was made of COVID-19 testing forms with the Administrator (ADM). The ADM verified that they were the only COVID-19 tests that were completed.
On 10/26/22 at 10:55 AM, the Director of Nursing (DON) was interviewed. The DON stated that she was not responsible for the COVID-19 testing of staff in the building.
On 10/27/22 at 12:26 PM, RN 3 stated that she did not know when staff who were not fully vaccinated needed to test. RN 3 stated that she was not involved in COVID-19 testing.
On 10/27/22 at 2:00 PM, an interview was conducted with the ADM. The ADM stated that she was responsible for the COVID-19 testing, and the ADM stated she thought they were doing it. The ADM stated she had not followed-up to ensure staff were completing COVID-19 testing. The ADM stated that she saw people through her window doing testing.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0923
(Tag F0923)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined the facility did not have adequate ventilation by means of windows, or mech...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined the facility did not have adequate ventilation by means of windows, or mechanical ventilation, or a combination of the two. Specifically, there were observations of urine and bowel movement odor throughout the facilty throughout the survey.
Findings include:
1. On 10/11/22 at 4:22 AM, an observation was made in the memory care unit. There was a strong urine odor in the hallway. At 5:52 AM, the strong urine odor continued to linger in the hallway.
2. On 10/11/22 at 4:25 AM, an observation was made in the 200 hall. There were strong urine and bowel movement odors in the hallway outside rooms [ROOM NUMBERS].
3. On 10/11/22 at 4:51 AM, an observation was made of the 200 hall. There was a strong bowel movement and urine odor. A follow-up observation was conducted, and the strong bowel movement and urine odor was lingering at 7:21 AM.
4. On 10/11/22 at 4:54 AM, a strong urine smell was observed in the 300 hall.
5. On 10/12/22 at 9:53 AM, an observation was made in the memory care unit. There was a strong urine and bowel movement odor. At 11:50 AM, the strong urine and bowel movement odor lingered. At 2:46 PM, there was a strong urine odor.
6. On 10/13/22 at 10:09 AM, an observation was made in the memory care unit. There was a strong urine odor in the hallway. At 11:09 AM, the strong urine odor was lingering in the hallway.
7. On 10/13/22 at 1:16 PM, a strong bowel movement and urine odor was observed in the memory care unit.
8. On 10/13/22 at 2:05 PM, an observation was made in the memory care unit dining room. There was a strong bowel movement and body odor.
9. On 10/17/22 at 2:21 PM, a strong bowel movement and urine odor was observed in the memory care unit.
10. On 10/18/22 at 12:14 PM, an observation was made at the nurses station. There was a bowel movement odor. At 1:36 PM, there bowel movement odor was lingering.
11. On 10/18/22 at 12:15 PM, an observation was made of the memory care unit. There was a bowel movement and urine odor.
12. On 10/20/22 at 12:15 PM, an observation was made of the memory care unit. There was a bowel movement odor. The bowel movement odor was observed at the nurses station.
13. On 10/21/22 at 12:50 PM, an observation was made in the memory care unit. There was a strong urine odor in the hallway.
14. On 10/26/22 at 11:04 AM, an observation was made in the 200 hall. There were strong urine and bowel movement odor in the hallway outside room [ROOM NUMBER].
15. On 10/26/22 from 1:45 PM until 2:36 PM, an observation was made of resident 31 in the memory care unit. Resident 31 was observed to have a bowel movement odor. Resident 31 was not changed for 46 minutes and was observed to wander the memory care unit.
16. On 10/26/22 at 1:58 PM, a strong bowel movement and urine odor was observed in the 200 hall. A follow-up observation was conducted, and the strong bowel movement and urine odor lingered in the memory care unit at 2:31 PM.
On 10/12/22 at 10:17 AM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated the whole facility reeks of bowel movement and pee.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 10/27/22, the maintenance log book was observed. Issues were included that started on 11/11/21 through 8/7/22. There was no m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 10/27/22, the maintenance log book was observed. Issues were included that started on 11/11/21 through 8/7/22. There was no mention of bugs in the facility.
On 10/27/22 at 9:10 AM, an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated that the only issues she put on the maintenance log were for clogged showers and toilets.
On 10/27/22 at 9:35 AM, an interview was conducted with CNA 4. CNA 4 stated that broken light bulbs or clocks, clogged sinks or call lights that would not turn off would go into the maintenance log. CNA 4 stated that any issue that could be handled immediately would not be logged. CNA 4 stated that she did not look for any bugs or damaged furniture in the rooms.
On 10/27/22 at 10:19 AM, Registered Nurse (RN) 3 was interviewed. RN 3 stated that issues for maintenance were call lights, toilets and sinks. RN 3 stated that she was not instructed to look for issues with insects or spiders.
On 10/27/22 at approximately 10:30 AM, an interview was conducted with the Administrator (ADM). The ADM stated that the maintenance worker was not in the facility that week.
Based on observation and interview it was determined the facility did not maintain an effective pest control program so that the facility was free of pests and rodents. Specifically, a resident had a swollen eye from a bug bite, another resident collected pests in a small cup, and residents were observed with flies around them. Resident identifiers: 9, 14 and 39.
Findings include:
1. On 10/11/22 at 7:00 AM, an observation was made of resident 39. Resident 39 was observed to have a swollen right eye. CNA 2 stated it was reported to her by another CNA that resident 39 had a bug bite on her eye.
2. On 10/11/22 at 6:23 AM, an interview was conducted with resident 9. Resident 9 stated he was being bitten by bugs and had scabs on his head and arms from the bites. Resident 9 showed a small cup with black spots in it. Resident 9 stated they were in his bed.
On 10/20/22 at 12:15 PM, an interview was conducted with resident 9. Resident 9 stated he was waiting for his skin test results. Resident 9 stated he had bug bites on his head and arms.
On 10/21/22 at 12:50 PM, an observation was made in the memory care unit. There was a brown spider observed in the hallway outside of room [ROOM NUMBER]. An interview was conducted with resident 9. Resident 9 stated that he observed bugs in the unit regularly, and kept a cup of them in his room to prove that he had an infestation.
On 10/24/22 at 5:15 PM, an interview was conducted with resident 9. Resident 9 stated he was being bitten by bugs in his room. Resident 9 showed a small cup with black spots and a dead spider in it. Resident 9 stated that he was getting bit by bugs in his room.
3. On 10/31/22 at 11:01 AM, an observation was made of resident 14. Resident 14 was observed in bed with flies around his head, feet, and food at his bedside.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. Resident 5 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia, type 2 diabetes mellitu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. Resident 5 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia, type 2 diabetes mellitus, essential hypertension, hyperlipidemia, major depressive disorder, and unspecified osteoarthritis.
On 10/13/22 at 3:14 PM, an interview with resident 5 was conducted. Resident 5 stated, If there are activities going on, I don't know about them. Nobody comes to ask me about activities. All I can do here is watch television. Resident 5 stated that he would enjoy doing some activities. Resident 5 stated that he used to do leather work and he enjoyed playing pool, so having activities like that would be enjoyable for him.
On 10/14/22 resident 5's care plan was reviewed.
An annual MDS dated [DATE] revealed it was very important for resident 5 to keep up with the news, do things with people, do his favorite activities, and go outside to get fresh air when the weather was good.
Resident 5 had a care plan for activities/diversionary which was initiated on 10/14/21. The goal was use of 1:1 activities with resident, movies, puzzles. The interventions included, Entertain and encourage resident about the availability and use of activities. Additionally, resident 5 had a care plan with the focus being, resident has an alteration in through process and potential for social isolation r/t resident has a severe thought process impairment. Resident has a d/x of Dementia. Resident has a short attention span and difficulties with recall and orientation skill. Resident will isolate in room. The goal was, Resident will accept 1x1 visits weekly to check on leisure needs, socialize and to encourage group activity participation by next review. Resident will participate in 1 group activity weekly by next review. The interventions included, Provide resident with a calendar of group activities so he choose what I want to attend. Invite resident to diversionary activities of voiced interest of those you think might be of interest and hold his attention when they are available such as: music, word games, trivia. Resident will participate in independent activities daily such as: watch t.v, movies, watch the news, socialize, get fresh air on a good day. Help resident to have involvement with the church. when available. Resident will wear a mask and social distance himself when in common areas when required to do so. Help me get recreation supplies when I request them. 1x1 visits 1 x per week to check on my leisure needs, encourage group activity participation and or to socialize by next review.
On 10/12/22 at 10:17 AM, an interview with CNA 2 was conducted. CNA 2 stated that there were never activities on the locked unit, where resident 5 resided. CNA 2 stated that residents in the locked unit wander the halls, sit around, or lay in their beds all day.
On 10/20/22 at 12:17 PM, an observation of the activities calendar in the locked unit was made. The activities calendar stated the activities on 10/20/22 were Fresh air, music and relaxation, and 1x1's. An interview with Licensed Practical Nurse (LPN) 1 was conducted. LPN 1 stated that he did not know what the activity Fresh air was. LPN 1 stated that the activities department needed help. LPN 1 stated that the resident need more to do because boredom was not good for the residents. LPN 1 stated that sometimes singers came in to perform for the residents, but the residents needed activities to do daily.
Based on observation, interview and record review it was determined, for 10 of 33 sampled residents, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community were not provided. Specifically, residents in the memory care unit did not receive activities in the unit and activities were not provided during the day. Resident identifiers: 5, 7, 9, 13, 26, 31, 32, 35, 36, and 37.
Findings include:
The facility activity calendar was reviewed for October 2022. The calendar revealed the following activities:
a. On 10/11/22: 5:15 PM Travel Bug, 5:45 PM Reminiscing, and 6:15 PM Sensory
b. On 10/12/22: 10:00 AM Relief Society, 5:15 PM Banking, 5:45 PM, Current Events, 6:15 PM, Trivia, 7:00 PM Family Home Evening. There was an activity added at 2:30 PM called Honey Bun Folk Music
c. On 10/13/22: 10:00 AM Fresh Air, 5:15 PM Music and Relaxation, 6:00 PM 1x1's (one on ones)
d. On 10/17/22: 5:15 PM Banking, 5:30 PM Exercises, 5:45 PM Word Games, 6:15 PM Self-Esteem
e. On 10/18/22 same as 10/11/22 and 10/25/22.
f. On 10/19/22 was the same as 10/12/22 except for no Family Home Evening or Honey Bun Folk Music. On 10/26/22 the activities were the same as 10/19/22 except for the Honey Bun Folk Music
g. On 10/20/22 was the same as 10/13/22 and 10/27/22.
The memory care unit was observed to not have activities offered during the following times:
a. On 10/12/22 at 2:46 PM, an observation was made of the memory care unit. There were no activities observed.
b. On 10/13/22 at 2:05 PM, an observation was made of the memory care unit. There were no activities observed.
c. On 10/24/22 at 11:12 AM, an observation was made of the memory care unit. There were no activities observed.
d. On 10/28/22 at 10:00 AM, an observation was made of the memory care unit. There were no activities observed.
On 10/11/22 at 6:24 AM an interview with resident 9 was conducted. Resident 9 stated that the only activity in the facility was BINGO on Fridays.
1. Resident 36 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, anxiety, diabetes mellitus, anemia, intellectual disabilities, and depression.
On 10/11/22 at 4:00 AM, resident 36 was observed wandering the memory care unit.
On 10/11/22 at 5:05 AM, Registered Nurse (RN) 1 stated that resident 36 wandered all night.
On 10/11/22 from 4:22 AM until 6:04 AM, resident 36 was observed wandering the memory care unit.
On 10/12/22 at 2:38 PM, an activity was held in the activity room, near the main dining room. Four residents from the locked unit were observed going to the activity. Resident 36 was observed to not go to the activity.
On 10/22/22 at 10:40 PM until 12:37 AM, resident 36 was observed wandering the hallway in the locked unit.
On 10/24/22 at 11:12 AM, resident 36 was observed wandering the hallway in the locked unit. Resident 36 was observed to ask Certified Nursing Assistant (CNA) 4 and CNA 8 for scissors because there were wires on his bed. Resident 36 was observed to sit down in the dining room at a table at 11:36 AM for approximately three minutes. Resident 36 continued to ask for clippers or scissors while walking in the hallway from staff and residents at 11:50 AM.
Resident 36's medical record was reviewed.
An annual Minimum Data Set (MDS) dated [DATE] revealed resident 36 was rarely/never understood so an activity preference interview was not conducted. According to the staff assessment of daily activity preferences revealed resident 36 preferred participating in favorite activities.
2. Resident 37 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, diabetes mellitus, hypokalemia, chronic pain, epilepsy, delusional disorder, dementia, osteoporosis, atherosclerotic heart disease, systemic lupus erythematosus, hypertension, and schizophrenia.
On 10/11/22 at 10:17 AM, resident 37 was observed sitting in her wheelchair in the memory care unit, looking at the door. Resident 37 stated, They won't let me out, I have a hair appointment. CNA 2 overheard the conversation and stated that resident 37 always thought she had appointments. Resident 37 then responded to CNA 2 with expletives.
On 10/27/22 from 1:30 PM until 2:30 PM, resident 37 was observed in a wheelchair, next to the nursing station. Staff walked past resident without engaging her in conversation. Resident 37 was facing the door to the medication room. Staff were observed to walk past resident 37 without engaging in conversation or offering an activity.
On 10/28/22 from 10:10 AM until 12:00 PM, resident 37 was observed to be sitting in a wheelchair, near the nursing station, facing the closed doors of the memory care unit. Staff were observed to walk past resident 37 without engaging in conversation or offering an activity.
Resident 37's record review was completed on 10/31/22.
An annual MDS dated [DATE] revealed it was very important for resident 37 to do her favorite activities. It was somewhat important for resident 37 to keep up with the news, do things with groups of people, and participate in religious services or practices.
Resident 37's care plan stated:
a. On 8/3/21, an intervention to help resident 37 feel safe was initiated and was to Provide activities in the SNU (Skilled Nursing Unit) or supervised while outside of the SNU.
b. On 6/2/22, I will participate in independent activities daily such as: watch t.v, socialize, watch the news
c. I will participate in diversionary activities prn (as needed).
d. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: [blank]
e. Give the resident as many choices as possible about care and activities
On 6/15/22 at 6:43 PM, a recreation therapy note revealed that resident 37 stated that activities that were somewhat important to her were .keeping up on news and doing things with a group and religious activities .
On 10/26/22 at 11:30 AM, CNA 1 was interviewed. CNA 1 stated that residents in the locked unit liked to watch movies, but the DVD player had been broken for about a month.
On 10/28/22 at 10:55 AM, a follow-up interview was conducted with CNA 1. CNA 1 stated that resident 37 wanted to go to the store and to have her hair done, and wanted to go buy shoes. CNA 1 stated that the CNAs brought resident 37 out of the memory care unit because resident 37 focused on leaving the facility when she was near her room. CNA 1 stated that resident 37 frequently tried to get out, so it was easier for staff to just let her out of the unit. CNA 1 stated that resident 37 was not taken to activities because resident 37 just wanted to leave. CNA 1 stated that resident 37 wheeled herself down the 200 and 300 hallways, but staff didn't have time to talk with resident 37. CNA stated that resident 37 would wheel herself around every day for a few hours and then staff would take her to her room after she tired herself out.
3. Resident 7 was admitted to the facility on [DATE] with diagnoses which included Schizoaffective disorder, dementia with behavioral disturbance, anxiety and type 2 diabetes mellitus.
On 10/12/22 at 11:51 AM, an observation was made of resident 7. Resident 7 was observed in his room. There were no activities observed in the memory care unit. On 10/12/22 there were no activities provided.
Resident 7's medical record was reviewed.
An annual MDS dated [DATE] revealed it was important for resident 7 to read, listen to music, do things with groups of people, do favorite activities, get fresh air when the weather was good and participate in religious services. The MDS revealed that it was somewhat important to resident 7 to be around animals and keep up on the news.
A care plan dated 5/19/22 revealed Resident has a potential for social isolation. He prefers in room activities but has some interest in group activities. The goal was I will accept 2 short 1x1 (one on one) visits weekly by next review. The interventions developed were 1x1 visits 2 [times] weekly to check on leisure needs and to socialize; Invite me to activities of voiced interest such as: Trivia and Word games; I will participate in independent activities daily such as: watch t.v, movies, keep up on the news, get fresh air on a good day, socialize; Support me in my desire to have involvement with the church .; I will wear a mask and social distance myself when in common areas when required to do so; I will participate in independent / diversionary activities daily such as: watching t.v., movies, socialize, t.v., music; and Help me to obtain recreation supplies as I request them.
A form titled Recreation Therapy Assessment 1 dated 11/11/21 revealed [Resident 7] likes to stay in room. States he likes to watch TV. [Resident 7] does come to some music and accepts short 1x1 visits.
On 10/26/22 at 3:20 PM, an interview was conducted with Therapeutic Recreational Technician (TRT). The TRT stated resident 7 usually preferred one on one visits or small groups in the dining room. The TRT stated resident 7 enjoyed trivia, board games, and short one on one visit.
On 10/26/22 at 11:30 AM, an interview was conducted with CNA 1. CNA 1 stated that sometimes the activities staff provided coloring sheets or word searches for resident. CNA 1 stated not many residents participate in the coloring sheets or word searches. CNA 1 stated resident 7 did not participate in coloring. CNA 1 stated she had not had any sheets for a couple of weeks to hand out. CNA 1 stated yesterday there was a movie activity but most of the resident's did not go. CNA 1 stated sometimes she put a movie on for the residents in the dining room, but the DVD player had been broken for about a month. CNA 1 stated there were no activities during the day in the memory care unit.
4. Resident 13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included encephalopathy, atrial fibrillation, muscle weakness, dementia with behavioral disturbance and Schizophrenia.
On 10/12/22 at 11:43 AM, an observation was made of the memory care unit. There were no activities observed. Resident 13 was observed wandering the hallway.
On 10/24/22 at 11:38 AM, an observation was made of resident 13. Resident 13 was observed to be walking behind his wheelchair in the hallway. Resident 13 was observed to invite staff into his room.
Resident 13's medical record was reviewed.
An annual MDS dated [DATE] revealed it was very important resident 13 to have books, newspapers and magazines to read; listen to music; to be around animals; keeping up with the news; do things with groups of people; favorite activities; get outside to get fresh air when the weather was good; and to participate in religious services or practice.
A care plan dated 5/17/22 revealed resident 13 had Alteration in thought process r/t I have a
severe thought process impairment. I (sic) difficulties with recall skills and orientation. The goal was I will participate in 2 group activities of interest weekly that fit with my current cognitive level
by next review. The interventions were Invite me to activities of appropriate cognitive level such as: Music, special events, current events, travel bug, socials; I will participate in independent activities daily such as: watch t.v, movies, keep up on the news, get fresh air on a good day, socialize; and Support me in my desire to have involvement with the church. as Covid precautions allow.
A Recreation Therapy Assessment 1 dated 1/31/22 revealed [Resident 13] likes activities of interest and comes to most of them.
On 10/26/22 at 11:30 AM, an interview was conducted with CNA 1. CNA 1 stated resident 13 did not do coloring or word searches when they were provided by activities. CNA 1 stated resident 13 went to church events, social events, and depending on the type of music he went. CNA 1 stated he went to the music sing along on 10/12/22.
On 10/26/22 at 3:30 PM, a phone interview was conducted with the TRT. The TRT stated resident 13 was good about going to different activities. The TRT stated resident 13 liked bingo, trivia and sensory activities. The TRT stated resident 13 liked to go to a lot activities.
5. Resident 26 was admitted to the facility on [DATE] with diagnoses which included schizophrenia, diabetes mellitus, and epilepsy.
On 10/11/22 at 8:25 AM, an interview was conducted with resident 26. Resident 26 stated there were no outings form the facility. Resident 26 stated the only thing to do was sleep all day. Resident 26 stated there was nothing to read or write on.
On 10/12/22 at 11:28 AM, an observation was made of resident 26. Resident 26 was observed wandering the memory care unit hallway.
Resident 26's medical record was reviewed.
An annual MDS dated [DATE] revealed it was very important for resident 26 to read, listen to music, be around animals, keep up with the news, do things in groups of people, do his favorite activities, go outside when the weather is good and participate in religious services or practices.
A care plan dated 10/14/21 revealed Activities/Diversionary. The goal was Decrease wandering behaviors that impact other residents. The intervention included Redirect and provide activity such as coloring, music, movies;
Another care plan dated 5/17/22 revealed Alteration in thought process. Resident
has a severe thought process impairment. He has interest in group and independent
activities. He has identified activities of interest. The goal developed was I will participate in 2 group activities of interest weekly that fit with my current cognitive level
by next review. The interventions developed were Invite me to activities of appropriate cognitive level such as: Music, special events, bingo, socials, word games, cooking; I will participate in independent activities daily such as: watch t.v, movies, keep up on
the news, get fresh air on a good day, socialize; Support me in my desire to have involvement with the any church I choose; I will wear a mask and social distance myself when in common areas when required to do so; I will participate in diversionary activities prn; and Help me to obtain recreation supplies as I request them.
A form titled Recreation Therapy Assessment 1 dated 4/18/22 revealed [Resident 26] participates in word games and current events.
On 10/26/22 at 11:30 AM, an interview was conducted with CNA 1. CNA 1 stated resident 26 went to activities, but he tried to sneak out to try and go outside or get a coffee when he went to activities. CNA 1 stated if resident 26 went to an activity, he had to be monitored by a staff member so he did not leave the facility. CNA 1 stated resident 26 had colored with staff, so he probably liked that activity.
On 10/26/22 at 3:30 PM, a phone interview was conducted with the TRT. The TRT stated resident 26 liked to participate in activities, word games, travel bug and bingo.
6. Resident 31 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, hyperlipidemia, dementia with behavioral disturbance and major depressive disorder.
On 10/12/22 at 10:00 AM, an observation was made of resident 31. Resident 31 was observed wandering the memory care unit. Resident 31 was observed to wander in the dining room and out and into the hallway. Resident 31 was not offered activities.
On 10/12/2022 at 2:51 PM, an observation was made of resident 31. Resident 31 was wandering the memory care unit hallway. Resident 31 was observed trying to open the back door to the outside.
On 10/26/22 at 11:12 AM, an observation was made of resident 31. Resident 31 was observed to be sitting at a table in the memory care unit dining room. The meal was not observed to be served until 11:46 AM. There were no activities offered. At 1:59 PM, resident 31 were observed sitting on the sofa in the hallway of the memory care unit. There were no activities offered.
On 10/28/22 at 10:12 AM, an observation was made of the memory care unit. Resident 31 was observed to be sitting on the sofa in the hallway with a blanket over her.
Resident 31's medical record was reviewed.
An annual MDS dated [DATE] revealed an interview was not conducted regarding resident 31's activity preference.
A care plan dated 10/14/21 revealed Activities/Diversionary. The goal was to decrease wandering behaviors. The interventions was turn on music and have her sit and enjoy music.
Another care plan dated 5/19/22 revealed Alteration in thought process. Resident has STM (short term memory) and LTM (long term memory) loss. She has impaired decision-making skills and inattention. She has a d/x (diagnosis) of Alzheimer?s (sic) and Dementia. The goals were I will accept 2 sensory 1x1 visits weekly by next review and Explore meaning/purpose of behavior r/t removing clothing. The interventions were 1x1 Sensory visits 2 [times] weekly; Invite and escort resident to diversionary activities of appropriate cognitive level that might hold my attention where I can be a passive onlooker as they are available such as: Music, special events; Support me in my desire to have involvement with the . church when they are available; Resident will wear a mask and social distance herself when in common areas when required to do so; Refocus me to the task at hand when I or my mind tends to wander; Escort me to and from activities as needed and; Invite me to diversionary activities PRN (as needed).
A form titled Recreation Therapy Assessment 1 dated 10/14/21 revealed [Resident 31] is a passive onlooker in activities such as music, religious, socials. [Resident 31] is very confused and usually wanders and doesn't like to stay still, activities does 1x1 with residents.
On 10/26/22 at 11:30 AM, an interview was conducted with CNA 1. CNA 1 stated resident 31 sometimes colored but it depends on the day. CNA 1 stated there were no coloring sheets provided for a while.
On 10/26/22 at 3:37 PM, a phone interview was conducted with the TRT. The TRT stated resident 31 was a passive onlooker but she participated in sensory activities. The TRT stated resident 31 liked to wander so I would walk with her and talk to her. The TRT stated she helped feed resident 31 as an activity.
7. Resident 35 was admitted to the facility on [DATE] with diagnoses which included schizophrenia, cognitive communication deficit, muscle weakness and chronic foot ulcer.
Resident 35's medical record was reviewed.
An admission MDS dated [DATE] revealed it was somewhat important for resident 35 to read books, newspapers, and magazines; listen to music; be around animals; keep up with the news; do things with groups of people; do his favorite activity; got outside to get fresh air when the weather was good; and participate in religious services or practices.
There were no comprehensive care plans in resident 35's medical record.
On 10/12/22 at 10:05 AM, an interview was conducted with resident 35. Resident 35 stated he did not have anything to do and would like things to do.
On 10/12/22 at 2:30 PM, an observation was made of resident 35. Resident 35 was at an activity in the dining room. Resident 35 was observed to be smiling.
On 10/26/22 at 3:30 PM, a phone interview was conducted with the TRT. The TRT stated resident 35 admitted to the facility a few weeks ago. The TRT stated resident 35 came out to activities hosted by volunteers. The TRT stated she was unable to do assessment because she had not been at the facility.
On 10/26/22 at 11:30 AM, an interview was conducted with CNA 1. CNA 1 stated resident 35 liked to stay in his room. CNA 1 stated resident 35 had chewing Tobacco for his activity. CNA 1 stated when activities were offered he did not go. CNA 1 stated resident 35 might enjoy a word search or coloring sheet, but could not remember if she had offered him one or not.
9. Resident 32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia, chronic obstructive pyelonephritis, severe sepsis, aspiration pneumonitus, supraventricular tachycardia, acute kidney failure, bipolar disorder, epilepsy, thyrotoxicosis and osteoarthritis.
On 10/12/22 at 11:20 AM, an interview was conducted with resident 32. At the time of the interview, resident 32 was laying in bed in the dark with his eyes closed. Resident 32 stated he did not get out of bed to participate in group activities. Resident 32 stated that he could not watch televeision in his room because it broke a year ago so I just live with it. Resident 32 stated that no activities were provided for him and he spent his days laying in bed and sleeping.
On 10/26/22 resident 32 was observed in his room laying in bed in the dark with his eyes closed.
On 10/23/22 at 12:49 AM, an interview was conducted with CNA 7. CNA 7 stated that she did not recall ever seeing resident 32's TV on.
Resident 32's medical records were reviewed between 10/11/22 and 10/31/22.
A 5 day MDS assessment dated [DATE] revealed that it was somewhat important for resident 32 to have books, newspapers, and magazines to read; listen to music; be around animals, keep up with the news; do things with groups of people; do his favorite activites; go outside and get fresh aire; and participate in religious services.
On 1/31/22, a Recreation Therapy assessment 1 was completed by the TRT. The TRT documented that resident 32 would often isolate in his room, but did have activity preferences of 1 on 1, small groups, or independent leisure. The TRT documented that resident 32 enjoyed watching TV in his room, and listening to music in a group setting.
On 2/20/22 a Therapeutic Recreation Assessment 2 was completed for resident 32 by the Certified Therapeutic Recreation Specialist (CTRS). The CTRS documented that resident 32 reported having interest and pleasure in doing things, but that staff noted him to be angry, sad and pessimistic. The CTRS documented that the resident enjoyed music and television. The CTRS determined that the resident was able to identify his activities of interest, and that the resident liked select groups, independent activities and 1 on 1 visits.
On 10/26/22 at 3:30 PM, a phone interview was conducted with the TRT regarding resident 32. The TRT stated that resident 32 did not like to leave his room, so she tried to do 1 on 1 visits with him. The TRT could not provide any documentation of the activities she had provided for any of the residents, including 1 on 1 visits for resident 32.
On 10/11/22 at 8:22 AM, Ombudsman (OM) 2 sent an email to the surveyors stating that she was concerned about the lack of activities at the facilty. OM 2 stated that she had brought this to the Administrator's (ADM) attention multiple times.
On 10/24/22 at 2:30 PM, an interview was conducted with the DON. The DON stated that resdients need the stimulation of being outside, and if they don't have it they are just here to die or get in a fight. The DON stated that there were a couple of activities provided in the evening, but those occurred when residents are ready to go to bed or during dinner. The DON stated that the TRT comes in once in a while, but not every day. The DON stated that dinner was served at 6:00 PM in the main dining room, and the activities person came in from 5:15 PM to 6:45 PM, so the activities scheduled would be occurring in the middle of dining. The DON stated there were not activities scheduled everyday.
On 10/26/22 at 5:46 PM, an interview was conducted with the facility Social Services Worker (SSW). The SSW stated that she was in the building Monday through Friday from 5:30 PM to 9:30 PM. The SSW stated that while she was at work she would walk around the dining room during dinner and provide socializations, paint the residents' nails, read newspapers, talk about current events, provide banking access, and count cigarettes. The SSW stated counting cigarettes took up a lot of her time. The SSW stated she did not run the resident council meetings. The SSW stated I just want to work here and come and spend time with the residents.
On 10/26/22 at 3:30 PM, a phone interview was conducted with the TRT. When asked about her work schedule, the TRT stated that she worked when I can make it in there. The TRT stated that between June and October 2022, she did not come in to the building to do activities with the residents. The TRT stated she used to come to the facility some evenings, but then her husband's work schedule changed, so the TRT couldn't work in the evenings anymore. The TRT stated that she was going to try to come to the facility a few weeks ago, but became ill. The TRT stated it had been at least 3 weeks since she had been in the facility. The TRT stated that she was at the facility on 10/24/22 for an hour and a half. The TRT stated she did crafts with a couple residents but with how late she was at the facility most residents were sleeping or getting ready for bed. The TRT stated she did not have an assistant and the facility had tried to get her an assistant but they did not work out. The TRT stated she tried to get volunteers for a reading club with cookies but the residents did not attend so the volunteers did not come back. The TRT stated since she had not been at the facility the assessments had not been completed. The TRT stated the fresh air activity was something she put on the calendar because she was not there. The TRT stated the residents went outside but with it being cold now, she was going to take that activity off the calendar for November. The TRT stated the memory care unit was served dinner between 5:30 PM and 6:00 PM. The TRT stated she tried to do activities in the main hall before their dinner and then the memory care unit after dinner. The TRT stated she felt bad for the residents because they needed a full time Activity Director.
On 10/26/22 at 6:11 PM, an interview was conducted with the CTRS. The CTRS stated that the last time she had spoken with the TRT was in July 2022. The CTRS stated that she usually tried to come to the facility monthly, but she had not been able to do this because there wasn't a TRT consistently in the building, and so there is no one to consult with. The CTRS stated that she thought there was a TRT in the building 2 hours per day, 4 days a week. The CTRS then stated that she just found out that the TRT wasn't coming in to the building to do activities on a regular basis. The CTRS stated that when there was a TRT in the building, she was attempting to work on[TRUNCATED]
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0680
(Tag F0680)
Could have caused harm · This affected most or all residents
Based on record review and interview, the facility did not have an activities program that was directed by a qualified professional who is a qualified therapeutic recreation specialist. Specifically, ...
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Based on record review and interview, the facility did not have an activities program that was directed by a qualified professional who is a qualified therapeutic recreation specialist. Specifically, the facility did not employ a Certified Therapeutic Recreation Specialist.
Findings include:
The facility Administrator (ADM) was asked to provide the most recent notes from the Certified Therapeutic Recreation Specialist (CTRS).
Review of the notes revealed that the CTRS provided feedback to the facility in October and November 2021. There were no notes for December 2021. The notes also revealed that the CTRS provided feedback to the facility from January 2022 through April 2022, but not in May 2022. The CTRS also provided feedback in June and July of 2022.
On 10/25/22 at 1:35 PM, an interview was conducted with the ADM. The ADM confirmed that the last time the CTRS provided feedback to the facility was in July of 2022 because the Therapeutic Recreation Specialist (TRT) had been sick.
On 10/26/22 at 3:30 PM, a phone interview was conducted with the TRT. When asked about her work schedule, the TRT stated that she worked when I can make it in there. The TRT stated that between June and October 2022, she did not come in to the building to do activities with the residents. The TRT stated she used to come to the facility some evenings, but then her husband's work schedule changed, so the TRT couldn't work in the evenings anymore. The TRT stated that she was going to try to come to the facility a few weeks ago, but became ill. The TRT stated it had been at least 3 weeks since she had been in the facility. The TRT stated that she was at the facility on 10/24/22 for an hour and a half. The TRT stated she did crafts with a couple residents but with how late she was at the facility most residents were sleeping or getting ready for bed. The TRT stated she did not have an assistant and the facility had tried to get her an assistant but they did not work out. The TRT stated she tried to get volunteers for a reading club with cookies but the residents did not attend so the volunteers did not come back. The TRT stated since she had not been at the facility the assessments had not been completed. The TRT stated the fresh air activity was something she put on the calendar because she was not there. The TRT stated the residents went outside but with it being cold now, she was going to take that activity off the calendar for November. The TRT stated the memory care unit was served dinner between 5:30 PM and 6:00 PM. The TRT stated she tried to do activities in the main hall before their dinner and then the memory care unit after dinner. The TRT stated she felt bad for the residents because they needed a full time Activity Director.
On 10/26/22 at 6:11 PM, an interview was conducted with the CTRS. The CTRS stated that the last time she had spoken with the TRT was in July 2022. The CTRS stated that she usually tried to come to the facility monthly, but she had not been able to do this because there wasn't a TRT consistently in the building, and so there is no one to consult with. The CTRS stated that she thought there was a TRT in the building 2 hours per day, 4 days a week. The CTRS then stated that she just found out that the TRT wasn't coming in to the building to do activities on a regular basis. The CTRS stated that when there was a TRT in the building, she was attempting to work on the sensory activities because those have to be done. The CTRS stated she was unaware that resident council was not happening. The CTRS stated that after the previous recertification survey, she was contracted to be the CTRS, but then after a few months, was not working for the facility anymore. The CTRS stated she had repeatedly talked to the Administrator about the lack of activities in the building, but was told they were trying to find a full time TRT. The CTRS stated that in order for an activity to be considered therapeutic, it has to be run by a TRT. The CTRS then stated that if the Social Services Worker (SSW) was coming to to paint fingernails for example, that would only be considered a diversionary activity.
[Note: It should be noted that this deficiency was cited during the previous annual recertification survey completed on 9/1/21.]
[Cross refer to F679]
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected most or all residents
Based on record review, the facility did not conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day ope...
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Based on record review, the facility did not conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there was, or the facility plans for, any change that would require a substantial modification to any part of this assessment. Specifically, the facility did not accurately assess the residents' needs.
Findings include:
The Facility Assessment (FA) was requested from the facility Administrator (ADM) on 10/11/22.
The FA provided by the ADM was reviewed.
1. The FA did not address the care required by the resident population with regard to the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population. Areas of the FA entitled Common diagnoses, Major RUG-IV Categories, Assistance with Activities of Daily Living, and General Care were all left blank.
2. The FA did not address the number of residents and the facility's resident capacity.
3. The FA did not address staff competencies that are necessary to provide the level and types of care needed for the resident population.
4. The FA did not address any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services.
5. The FA did not address services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies.
6. The FA did not address all personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care.
7. The FA did not address contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies.
8. The FA did not address health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations.
9. The FA indicated that 10 Certified Nurse Assistants (CNAs) were required to provide care for the resident population. However, based on interview, observation and record review, the number of CNAs ranged from 1 to 6 depending on the day. [Cross refer to F725].
10. The FA indicated that 3 licensed nurses were required to provide care for the resident population. Based on interview, observation and record review, the number of licensed nurses ranged from 2 to 3 depending on the day [Cross refer to F725].
On 10/25/22 at 1:35 PM, an interview was conducted with the facility ADM. The ADM stated that it was the previous ADM who had completed the FA, and that I didn't even look at it before I sent it. It needs to be better, huh?
Sept 2021
30 deficiencies
2 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0688
(Tag F0688)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review it was determined the facility did not ensure a resident with limited range ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review it was determined the facility did not ensure a resident with limited range of motion received appropriate treatment and services to increase their range of motion and to prevent further decrease in range of motion. Specifically, a resident with documentation of a contracture to the right and left hand was not provided with treatment and services to increase their range of motion or to prevent further decrease in range of motion. This finding resulted in a harm deficiency. Resident identifier: 28.
Findings include:
Resident 28 was originally admitted to the facility on [DATE], with medical diagnoses that included, but not limited to, Alzheimer's disease with dementia, restlessness and agitation, dizziness and giddiness, repeated falls, diarrhea, polyneuropathy, hyperlipidemia, hypothyroidism, chronic leukemia, history of urinary tract infection, pleural effusion, depressive episodes and chronic respiratory failure with hypoxia.
On 8/30/21 at 8:19 AM, resident 28 was observed at breakfast attempting to hold a cup with her left hand. After three attempts at grasping the cup resident 28 was able to grasp the cup in order to bring it to her mouth. At this time resident 28's right hand was closed and kept close to her body.
On 8/30/21 at 11:39 AM, resident 28 was again observed to be able to grab a cup of water independently with the left hand.
On 8/30/21 at 11:30 AM, Certified Nursing Assistant (CNA) 2 reported resident 28 was independent with eating meals, but resident 28 needed help in other areas like zipping things or completing tasks that needed fine motor skills. CNA 2 reported she was unaware if resident 28 had any contracture issues to the right or left hands. CNA 2 also reported staff did not use any splints or interventions for preventing contractures with resident 28's hands.
On 8/30/21 at 11:38 AM, resident 28's room was examined. No splints or range of motion devices were noted.
On 9/1/21 at 12:00 PM, resident 28 was observed at lunch to be unable to grasp a fork with the left hand. Resident 28 placed the fork back onto the table and then using her left hand, resident 28 grasped the meat patty and brought the food to her mouth.
On 9/1/21 at 9:20 AM, Licensed Practical Nurse (LPN) 1 stated resident 28 had a contracture to both the left and right hands. LPN 1 stated since starting employment at the facility in January 2021, LPN 1 had noticed resident 28 was suffering from a contracture to the left hand. LPN 1 also stated the contracture to resident 28's right hand had gotten worse and resident 28 was not able to use the right hand at all now. LPN 1 stated in the past he tried to place a rolled up towel within resident 28's right hand, but resident 28's right hand would not open. LPN 1 stated there were no consistent interventions in place to help prevent worsening contracture to resident 28's right or left hands.
On 9/1/21 at 11:59 AM, CNA 4 stated they had seen LPN 1 try to place a towel in resident 28's right hand in the past. CNA 4 stated the CNA staff were not doing anything with resident 28's hands to prevent further contracture to the left or right hand.
On 9/1/21 a review of resident 28's medical record was completed. The following observations were made within resident 28's medical record:
a. A Weekly Note from 5/13/21 stated, Resident . Uses w/c [wheelchair] for mobility, has contractures in both hands.
b. A Weekly Note from 7/15/21 stated, Rt. [Right] hand fully closed d/t [due to] contractures and Lt. [left] hand is partially contracted.
c. A Weekly Note from 7/22/21 stated, Resident has hand contractures and right hand completely closed.
d. A Weekly Note from 8/5/21 stated, Resident has contractures to both hands and Right (sic) hand contracture is completely closed.
e. A Weekly Note from 8/26/21 stated, Contractures to both hands and left hand [resident] is still able to use and right hand is completely closed (sic).
f. Resident 28's Minimum Data Set (MDS) assessment history was reviewed regarding functional status and Functional Limitation in Range of Motion. MDS records from 6/30/21 indicate, Upper Extremity (shoulder, elbow, wrist, hand) . Impairment on one side. [Note: per nursing documentation resident with contracture to both hands].
g. Occupational Therapy (OT) documentation from therapy services present from 12/10/19 to 3/8/20. OT documentation indicates resident was seen for Contracture; right hand.
h. On 08/30/21 at 12:08 PM, resident 28's care plan was reviewed. Within resident 28's electronic care plan, no care plan related to contractures was noted.
On 9/1/21 at 9:33 AM, the Director of Nursing (DON) reported having noticed resident 28's left hand contracture seemed worse the other day. The DON reported because of working as a floor nurse the DON was not always able to observe how all the residents were doing, unless they were on the DON's workload that day. The DON reported there were no interventions being done with resident 28's left or right hands to prevent the contractures from getting worse. The DON also stated being unaware if resident 28 had received any OT services for the hand contractures at this time.
On 9/1/21 at 12:47 PM, an OT therapist for the facility was interviewed. The OT therapist stated resident 28 had not received therapy services in, quite a while. The OT therapist reported around the 1st of August 2021, the OT department had received a referral to look into resident 28's contractures. The OT therapist reported resident 28 had not been added to the therapy case load following receipt of the referral around 8/1/21 because one of the OT therapists was on vacation.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
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 did not ensure that 1 of 30 sample residents maintained acceptable parameters...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that 1 of 30 sample residents maintained acceptable parameters of nutritional status. Specifically, a resident who was exclusively tube fed lost weight without timely interventions to prevent further weight loss. The findings were cited at a harm level. Resident identifier: 24.
Findings include:
Resident 24 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included COVID-19, schizophrenia, anxiety disorder, conversion disorder, chronic kidney disease, and cognitive communication deficit.
Resident 24's medical record was reviewed on 8/29/21.
Resident 24's Nutritional Assessment was reviewed. The Nutritional Assessment indicated that the facility Dietary Manager (DM) completed the assessment on 12/28/20, which was 4 days after resident 24 was readmitted . The Assessment further indicated that the facility Registered Dietitian (RD) did not review the Assessment until 1/15/21, approximately 3 weeks after resident 24 was readmitted . The Assessment indicated that resident 24 weighed 161.6 pounds (lbs). The Assessment indicated that resident 24 was receiving an enteral tube feeding of Replete with Fiber for 65 milliliters (ml) an hour for 24 hours a day. The Assessment also indicated that resident 24 had experienced a recent significant weight change. The Assessment indicated that resident 24 was not eating any food by mouth, and was exclusively tube fed due to a swallowing difficulty. The Assessment indicated that resident 24's estimated calorie needs to be between 1470 and 1838 calories a day. The Assessment indicated that resident 24's tube feeding formula would provide 1560 calories a day.
Resident 24's care plan was reviewed. Review of the care plan indicated that it was not developed until 1/15/21, approximately 3 weeks after resident 24 was admitted . The care plan indicated that the facility was to monitor resident 24's weights every week.
Review of resident 24's graphed weight records revealed the following weights:
a. 1/3/21 - 157.1 lbs.
b. 2/7/21 - 155.8
c. 3/7/21 - 157.6
d. 4/4/21 - 150.8
e. 5/2/21 - 150.4
f. 6/6/21 - 148.2
g. 7/4/21 - 146.2
On 8/31/21 at 1:30 PM, an interview was conducted with the DM. The DM stated that weights were taken and recorded on a graph the first Sunday of every month.
Review of resident 24's physician orders revealed that despite weight loss from January 2021 through July 2021, the resident's tube feeding was not changed until 7/5/21. On 7/5/21, resident 24's tube feeding rate was increased to 75 ml an hour for 24 hours. It should be noted that between 1/3/21 and 7/4/21, resident 24 had lost approximately 11 lbs.
On 7/3/21, the RD documented that resident 24's weight was overall trending downward, although no acute significant loss. Resident weight upon initiation of TF (tube feeding) Jan (January) 2021 161.6 [lbs], currently 144 [lbs], [decrease] 10.9 [percent] [in] 7 months. RD to cont (continue) to watch [and] f/u (follow up)PRN (as needed). The RD recommended that resident 24's tube feeding rate be increased to 75 ml an hour for 24 hours.
Review of weekly weights provided by the DM revealed the following weights:
a. 7/11/21 - 146.0
b. 7/18/21 - 143.8
c. 7/25/21 - 143.0
d. 8/1/21 - 142.8
e. 8/8/21 - 142.0
f. 8/15/21 - 141.8
g. 8/22/21 - 139.8
Review of resident 24's physician orders revealed that despite weight loss from 7/4/21 through 8/22/21, the resident's tube feeding was not changed until 8/30/21. On 8/30/21, resident 24's tube feeding rate was increased to 85 ml an hour for 24 hours. It should be noted that between 7/4/21 and 8/22/21, resident 24 had lost approximately 6.4 lbs.
On 8/29/21, the RD documented that resident 24's weight was dropping, and that the trend downward not desired. The RD also documented that resident 24 had lost 2.2 percent of his body weight in one month. The RD recommended that resident 24's tube feeding rate be increased to 85 ml an hour for 24 hours.
Resident 24's care plan revealed that despite resident 24's weight loss and multiple changes in tube feeding rate, the care plan was not updated after 4/15/21.
Review of resident 24's August 2021 Medication Administration Record (MAR) revealed that facility staff were to administer the tube feeding formula twice a day. The MAR indicated that facility staff did not document that resident 24 received his evening enteral feedings on the following dates: 8/4/21, 8/12/21, 8/15/21, 8/18/21, and 8/24/21.
On 8/31/21 at 1:00 PM, an interview was conducted with the DM. The DM stated that she was aware of resident 24's weight loss, and that the RD had recently increased the rate of resident 24's tube feeding. The DM stated that she did not know why resident 24 was losing weight. The DM further stated that she was not involved in making decisions about tube feeding recommendations.
On 9/1/21 at 8:42 AM, an interview was conducted with the facility RD. The RD stated that she participated in the skin and weight meetings, and that she was in weekly communication with the DM. The
RD stated that she was responsible for evaluating the residents receiving tube feedings to determine if their needs were being met. The RD stated that resident 24 had experienced a general change of condition. The RD stated that she thought that resident 24 was receiving some of his calories by mouth, and that there were other things happening. The RD stated that she had recently increased the tube feeding rate for resident 24, and that she was thinking about changing the formula to a 1.1 or 1.2 calorie formula. The RD stated that she was going to wait to change the resident's formula to correct his weight loss until after the survey was over so that she didn't shake things up for facility staff.
On 9/1/21 at 9:30 AM, an interview was conducted with the facility Director of Nursing (DON). The DON confirmed that resident 24 was not receiving any food by mouth. When asked about resident 24's tube feeding, the DON stated we are aware that he is losing weight. My assumption would be that the RD may not be coming in because of COVID.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
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 did not ensure that 2 of 30 sample residents had the right to request, refuse...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that 2 of 30 sample residents had the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Resident identifiers: 5 and 32.
Findings include:
1. Resident 5 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus, coronary artery disease, hyperlipidemia, hemiplegia, and cerebral infarction.
Resident 5's medical record was reviewed on 8/29/21.
No documentation could be located to indicate that resident 5 had a Physicians Order of Life Sustaining Treatment (POLST).
On 8/31/21 at 4:27 PM, an interview was conducted with Registered Nurse (RN) 4. RN 4 confirmed that resident 5 did not have a POLST in his medical record.
On 9/1/21 at 2:10 PM, an interview was conducted with resident 5. Resident 5 stated that if his heart stopped beating, he did not want to be resuscitated. Resident 5 stated that he had filled out his advance directives at the hospital already.
2. Resident 32 was readmitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia, major depressive disorder, cognitive communication deficit, and diabetes mellitus.
Resident 32's medical record was reviewed on 8/29/21.
No documentation could be located to indicate that resident 32 had a POLST.
On 9/1/21 at 1:00 PM an interview was conducted with resident 32. Resident 32 stated that if his heart stopped beating, he did not want to be resuscitated, stating just let me die.
On 9/1/21, an interview was conducted with the facility Director of Nursing (DON). The DON confirmed that resident 5 and 32 did not have a POLST in their medical record. The DON stated that if a POLST was not in the medical record, and the resident stopped breathing, the facility would initiate resuscitation efforts.
CONCERN
(D)
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 record review and interview, it was determined that the facility did not ensure that all alleged violations involving a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility did not ensure that 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 24 hours if the event that caused the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency. Specifically, an entity report of an abuse allegation was not submitted to the State Survey Agency until approximately 73 hours after the incident occurred. Resident identifiers: 1 and 17.
Findings include:
Resident 1 was admitted to the facility on [DATE] with diagnoses that included, but not limited to, schizophrenia, type 2 diabetes, hypertension and idiopathic epilepsy and epileptic syndromes with seizures.
Resident 17 was originally admitted to the facility on [DATE] with medical diagnoses that included, but not limited to, Alzheimer's disease with dementia, hyperlipidemia, hypertension, major depressive disorder and history of Coronavirus disease 2019 (COVID-19).
On 8/29/21 at 8:50 AM, an observation was made of resident 1 and resident 17 in an open bathroom on the 100 hallway (memory care unit). Resident 17 was observed to have her back to the wall by the sink and resident 1 was standing directly in front of her. Resident 1 was observed to turn his head toward the surveyor, and then took a step backwards. Resident 17 was observed to walk around resident 1 and leave the room. Resident 17 was observed to be fully clothed. Resident 1 was observed to turn around and face the doorway, while still standing by the sink. Resident 1 was observed to have his penis exposed and turned on the water and began splashing his penis with water.
On 8/29/21 at 9:09 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 was informed about the observation made by the surveyor that morning.
On 8/29/21 at approximately 10:00 AM an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that he had been notified by CNA 1 about the incident between resident 1 and resident 17. LPN 1 stated he had not observed that behavior from resident 1 before.
On 9/1/21 at 1:17 PM, an interview was conducted with LPN 1. LPN 1 stated that CNA 1 told him that a surveyor had reported to her that resident 1 was with resident 17 and resident 1 was doing up his pants, or his pants were coming down. LPN 1 stated he asked CNA 1 where both residents were and instructed CNA 1 to check on resident 17. LPN 1 stated he then went and reported the incident to the administrator.
On 8/31/21 at approximately 3:50 PM, an interview was conducted with the facility administrator (ADM). The ADM stated he was told by LPN 1 about the incident between resident 1 and resident 17 on 8/29/21. The ADM stated he was told that resident 1 was observed in the bathroom with his pants down and his penis exposed. The ADM stated he was unaware that resident 1 and resident 17 were in the bathroom together with resident 1 in close proximity to resident 17 while exposed.
On 9/1/21 at 1:13 PM, an interview was conducted with the facility ADM. The ADM stated he sent a fax to the State Survey Agency at 10:34 AM that day regarding resident 1 and resident 17. The ADM stated he had also notified the ombudsman, resident 1's mental health provider and adult protective services (APS). The ADM stated he did not call the police. The ADM stated that after the interview conducted on the previous day he realized it was more than just [resident 1] seen getting up from the toilet with his pants down so he filed a report.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not develop a baseline care plan for 1 of 30 sample residents within 48 h...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not develop a baseline care plan for 1 of 30 sample residents within 48 hours of the resident's admission. Resident identifier: 98.
Findings include:
Resident 98 was admitted to the facility on [DATE] with diagnoses that included sepsis, viral pneumonia, chronic obstructive pulmonary disease, acute respiratory failure, congestive heart failure, protein-calorie malnutrition, and dementia.
Resident 98's medical record was reviewed on 8/29/21.
No baseline or comprehensive care plan could be located for resident 98 in his medical record.
Resident progress notes dated 8/18/21 indicated that resident 98 was admitted to the facility on hospice services.
On 9/1/21 at 9:30 AM, an interview was conducted with the facility Director of Nursing (DON). The DON stated that resident 98's hospice nurses should have developed a care plan for resident 98 and placed it in his medical record. The DON confirmed that resident 98 did not have a baseline or comprehensive care plan in his medical record.
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** 2. Resident 1 was admitted to the facility on [DATE] with diagnoses that included, but not limited to, schizophrenia, type 2 dia...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 1 was admitted to the facility on [DATE] with diagnoses that included, but not limited to, schizophrenia, type 2 diabetes, hypertension and idiopathic epilepsy and epileptic syndromes with seizures.
Resident 1's medical record was reviewed on 8/30/21.
On 8/19/21 a quarterly Minimum Data Set (MDS) was completed for resident 1. The MDS documented that wandering behaviors were not exhibited, that resident 1 rejected evaluation or care necessary to achieve goals for health and well-being on 1-3 days, that resident did not exhibit any behavioral symptoms including behaviors that impacted other residents. The MDS documented that resident 1 had symptoms of hallucinations and delusions. The MDS also documented that resident 1 did not have scheduled pain medications, but did receive as needed (PRN) pain medication. Non-medications interventions were documented as being received.
Resident 1's care plan was documented as being initiated on 8/3/21. Resident 1's care plan, documented that resident 1 had behavior problems related to schizophrenia. Interventions/tasks included to prevent behaviors were Caregivers to provided opportunity for positive interaction, attention. Stop and talk with him/her as passing by .If reasonable discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident .Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situation. Document behavior and potential causes. There was no care plan development addressing pain, or inappropriate behaviors with other residents.
Resident 1's medication administration record (MAR) was reviewed. The July MAR documented resident 1 received pain medication on 7/28/21 and on 8/3/21.
Resident 1's progress notes included documentation on 8/14/21 Licensed Practical Nurse (LPN) 1 documented Resident has been frequently touching staff and other residents without consent, On 8/25/21 that the Director of Nursing (DON) documented Spoke with [name of local mental health provider] about residents being sexually inappropriate. States she will see him today.
Based on interview and record review, the facility did not ensure that resident care plnas were developed within 7 days after completion of the comprehensive assessment for 2 of 30 sample residents. Resident identifiers: 1 and 24.
Findings include:
1. Resident 24 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included COVID-19, schizophrenia, anxiety disorder, conversion disorder, chronic kidney disease, and cognitive communication deficit.
Resident 24's medical record was reviewed on 8/29/21.
On 12/31/20, the facility completed an annual Minimum Data Set (MDS) for resident 24. The MDS indicated that a care plan for activities should have been developed.
Review of resident 24's medical record indicated that neither an assessment of resident 24's activity needs, nor an activities care plan had been developed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
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, it was determined the facility did not ensure residents received treatmen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, it was determined the facility did not ensure residents received treatment and care in accordance with professional standards of practice. Specifically, for 2 of 30 sample residents, the facility did not ensure standards of care were met regarding treatment and care of a resident's edema or treatment and care of a resident's facial rash. Resident identifiers: 44 and 99.
Findings include:
1. Resident 44 was originally admitted to the facility on [DATE] with medical diagnoses that included, but not limited to, paranoid schizophrenia, major depressive disorder, hypertension, heart failure, chronic obstructive pulmonary disease, gastro-esophageal reflux disease, diverticulosis, hypoxemia, urinary incontinence, morbid obesity, type 2 diabetes mellitus, pulmonary edema, asthma, adenoviral pneumonia, acute and chronic respiratory failure, obstructive sleep apnea, chronic kidney disease, anemia in chronic kidney disease, history of urinary tract infection, osteoarthritis, chronic pain and history of Coronavirus disease 2019 (COVID-19).
On 8/29/21 at 2:47 PM, resident 44 was observed to have a facial rash with red, peeling, flaky skin. When asked if the rash was itchy or painful, resident 44 responded, Yes.
On 8/30/21 at 12:03 PM, resident 44 was observed to still have a red facial rash which was flaky and peeling. When resident 44 was asked if the rash was painful, resident 44 responded, Yes.
On 8/31/21 at 10:30 AM, resident 44 was observed to still have a facial rash with red, flaky skin. When asked if the rash hurt, resident 44 responded, Yes.
On 9/1/21 at 11:09 AM, resident 44 was observed to continue having a red, peeling facial rash present.
On 8/30/21 at 12:55 PM, Certified Nursing Assistant (CNA) 2 reported resident 44's facial rash was the same rash that resident 44 had on her breast area. CNA 2 reported the CNAs were not providing any treatment to the facial rash, but the nurse may be providing her a cream. CNA 2 reported when working last week resident 44 did not have the facial rash, and CNA 2 reported, That is new.
On 8/30/21 at 2:35 PM, CNA 3 reported if a resident has a skin issue the CNAs would have documented this on the skin check sheets which the CNAs completed when providing a resident a shower. CNA 3 stated these skin check sheets were placed in a binder for the nurses to review, and CNA 3 was unsure what the nurses did with the skin check sheets once they had reviewed them.
On 8/30/21 at 3:34 PM, Registered Nurse (RN) 2 reported the best way nurses learned about skin issues was through reviewing the shower skin check sheets for information or learning about the skin issue during report.
On 8/31/21 at 10:39 AM, RN 3 stated resident 44's facial rash, is off and on. When asked what treatment the nurses had been providing for resident 44's facial rash RN 3 reported, I do not know, and stated, I guess I should give her something. RN 3 stated when resident 44 was provided with a treatment or lotion for the facial rash it would be documented on the Medication Administration Record (MAR).
On 9/1/21 at 8:11 AM, Licensed Practical Nurse (LPN) 1 reported the triamcinolone medication lotion would be the best choice to apply to resident 44's facial rash. LPN 1 reported when resident 44 was provided with the triamcinolone lotion it cleared up the facial rash. LPN 1 reported, if a nurse was to provide resident 44 with the triamcinolone lotion the nurse would document this within the MAR.
On 9/1/21 at 10:21 AM, the Director of Nursing (DON) reported resident 44 did get the facial rash, every once in a while. The DON reported resident 44 will have triamcinolone lotion applied to the facial rash. The DON reported the hydrocortisone cream could be used in addition to the triamcinolone lotion. The DON reported the facial rash had begun, .within the last couple days. About last Monday, which would have been around 8/23/21. The DON reported if a nurse did apply lotion to resident 44's facial rash it would be coded within the resident's MAR. When the DON was asked about whether hydrocortisone or triamcinolone lotion should be used she reported, the triamcinolone works best and reported, the nurses need to be a little more educated about what to provide.
On 9/9/21, a review of resident 44's medical record was completed. The following documentation regarding resident 44's facial rash was present:
a. Skin check sheets:
i. Skin check sheet from 8/2/21 with no skin issues noted.
ii. Skin check sheet from 8/6/21 stated, Redness on face and right arm.
iii. Skin check sheet from 8/11/21 stated, Sore redness under breasts.
iv. Skin check sheet from 8/25/21 stated, Redness under stomach and breast.
v. Skin check sheet from 8/30/21 stated, Red under breast.
b. A Weekly Note from 8/7/21 stated, Also has facial rash/redness and dermatitis cream is used PRN (as needed).
c. A Weekly Note from 8/21/21 stated, Redness rash on face and Triamcilone (sic) cream applied PRN.
d. On 8/31/21, following conversation with RN 3 about resident 44's facial rash, RN 3 documented 8/31/2021 10:48, Orders - Administration Note Note Text: Hydrocortisone Lotion 1 % Apply to face topically as needed for skin; Given for facial rash.
e. On 08/31/21 at 10:53 AM, resident 44's MAR was reviewed for August 2021. An order was noted for, Triamcinolone Acetonide Cream 0.1 %. Apply to rash on face topically every 12 hours as needed for facial rash Apply BID (twice daily) prn. No documentation was present that resident 44 was provided with the Triamcinolone Acetonide Cream in August 2021.
2. Resident 99 was admitted to the facility on [DATE] with diagnoses that included localized swelling, mass and lump, lower limb, bilateral; paranoid schizophrenia; and lymphedema.
On 8/29/21 at 8:38 AM, resident 99 was observed. Resident 99 had large edematous legs. No wraps were present. This observation was made throughout the day on 8/30/21, 8/31/21, and 9/1/21.
Resident 99's medical record was reviewed on 8/29/21.
Resident 99's discharge orders from the hospital dated 8/5/21 revealed that resident 99 was to have leg wraps placed for management of his lymphedema.
Resident 99's care plan dated 8/17/21 documented that resident 99 had edema in both lower extremities due to lymphedema. The interventions included to apply compression as ordered and encourage resident to elevate legs while in room.
Resident 99's initial nursing evaluation dated 8/6/21 revealed that resident 99 had edema to his bilateral lower extremities.
Resident 99's Preadmission Screening and Resident Review (PASRR) dated 8/5/21. The PASRR evaluator indicated that on 6/10/21, resident 99's doctor reported significant swelling in [resident 99's] lower extremities. The evaluator also documented that resident 99 was experiencing a lot of leg pain and fatigue with ambulation, and that the resident could not apply compression stockings independently.
Progress notes for resident 99 revealed the following:
a. On 8/6/21, staff indicated that resident 99 has lymphydema (sic) wraps to his legs bilaterally upon arrival to the facility from the hospital.
b. On 8/6/21, staff indicated that resident 99 had 4 plus edema to bilateral legs, his left leg is larger than his right leg.
c. On 8/8/21, staff indicated that ted hose were applied to resident 99's legs for lymphedema.
No progress notes were located in resident 99's chart after 8/9/21.
Review of resident 99's physician orders revealed that resident 99 did not have an order for compression wraps to be applied.
On 9/1/21 at 9:30 AM, an interview was conducted with the facility Director of Nursing (DON) . The DON stated that she was the nurse who had admitted resident 99 to the facility, and was not aware that there was a discharge order from the hospital for resident 99 to have wraps applied to his legs for lymphedema management.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and observation, the facility did not ensure that 1 of 30 sample residents received proper tre...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and observation, the facility did not ensure that 1 of 30 sample residents received proper treatment and care to maintain mobility and good foot health. Specifically, a resident had an open wound on his foot that was not being treated by facility staff or a physician. Resident identifier: 33.
Findings include:
Resident 33 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included schizoaffective disorder, COVID-19, benign prostatic hyperplasia, vascular dementia, and diabetes mellitus.
Resident 33's medical record was reviewed on 8/29/21.
Resident 33's care plan dated 11/1/18 was reviewed. The care plan indicated that resident 33 was at risk for developing pressure ulcers. The interventions included to monitor, document and report any changes in skin status.
A note from a wound healing company for resident 33 dated 5/13/21 was reviewed. The note indicated that resident 33 had a diabetic ulcer on the plantar surface of his left foot. The note also indicated that This wound looks significantly better today. There is a small area of eschar that is residual on the bottom of his foot. We will have the facility apply lotion to his foot every day. We will evaluate this foot 1 more week and if everything is still okay, we will discharge the patient .
On 7/21/21 a podiatrist note indicated that resident 33 had been seen by the podiatrist. The podiatrist documented that resident 33 had a callus on his left plantar foot that was debrided.
Resident 33's progress notes indicated the following:
a. On 8/13/21, facility staff documented that the resident has been repeatedly asking for tums for heartburn and Tylenol for pain on wound right (sic) foot. put name on pediatrist (sic) appointment. Right (sic) foot does look like it is causing pain.
b. On 8/27/21, facility staff documented that resident 33 has an ulcer on bottom of left foot, name written in appointment book.
[Note: There were no progress notes for resident 33 between 8/13/21 and 8/27/21. In addition, the facility staff did not document that they had notified the facility physician to obtain orders, treatments and/or referrals. No physician notes regarding the wound in August 2021 could be located.]
Resident 33's physician orders were reviewed. No orders could be located to indicate that resident 33 had any orders for dressing or treatment of the wound on the resident's left foot since he had complained of pain on 8/13/21.
A list placed at the nurses station entitled Residents to be seen by the podiatrist was reviewed. Facility staff documented that resident 33 had a foot callus on his left foot on 7/3/21. The resident was also listed later on the list after 7/20/21, although no date was documented.
On 8/30/21 at 9:21 AM, an observation was made of resident 33. Resident 33 was observed to be laying in his bed with his shoes on. Resident 33 stated that he had a sore on his left foot, but that there were no dressings on it.
On 8/30/21 at 3:10 PM, an observation was made of the resident's left foot with the Director of Nursing (DON). The DON removed resident 33's left shoe and sock. Resident 33's left foot had an open wound on the upper plantar area. The DON observed the wound on the left foot and stated it appeared to be an open plantar wart. The DON also stated that because the wound was open, it should have a dressing on it because its starting to crack, and is bleeding. The DON stated that she did not know why a dressing had not been placed on the wound prior to this. The DON stated that the resident would be placed on the podiatrist list. The DON also stated that Registered Nurse (RN) 4 was the wound nurse, and would know more about the wound.
On 8/31/21 at 4:27 PM, an interview was conducted with RN 4. RN 4 stated that resident 33 had been being seen by a wound specialist, for a reoccurring callus, but had been discharged from their services. RN 4 stated she was unaware that resident 33 had an open wound on his left foot, and that she had last seen the resident's feet approximately one month prior. RN 4 stated that the wound specialist would be coming to the facility on 9/1/21, and she would put resident 33 on the list of residents to be seen.
On 9/1/21, a follow up interview was conducted with the DON. The DON stated that the podiatrist came to the facility every two months, so if a resident was placed on the podiatrist list to be seen for an issue, it could be up to two months before the resident was seen. The DON stated she would contact the physician about resident 33's foot wound, so the appropriate referrals could be made. The DON stated that on 8/30/21 she placed a padded pink dressing on the resident's foot, but had not contacted the physician, or received orders for a dressing or treatment. The DON stated we need to get in and fix it. When asked why the resident's foot was not treated for approximately two weeks even though he was complaining of pain, and facility staff were aware of the wound, the DON stated it should have been taken care of. It can't go that long.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review it was determined the facility did not ensure that the residents' environme...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review it was determined the facility did not ensure that the residents' environment remained free of accident hazards as possible, or that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 2 of 30 sampled residents, interventions regarding fall prevention were observed to not be followed; these included, proper footwear was not provided or utilized with a resident, and wheels on a resident's wheelchair were not locked with transfers. Resident identifiers: 25 and 44.
Findings include:
1. Resident 25 was originally admitted to the facility on [DATE] with medical diagnoses that included, but not limited to, Alzheimer's disease, major depressive disorder, hyperlipidemia, history of urinary tract infection, and history of Coronavirus disease 2019 (COVID-19).
On 8/29/21 at 10:18 AM, resident 25 was observed to be seated on a sofa in the 100 hall, communal dining area. At this time, resident 25's wheelchair was left behind the sofa. While wearing regular tube socks resident 25 was observed to stand from the sofa, walk by shuffling her feet and head toward her wheelchair. Certified Nursing Assistant (CNA) 1 was then seen to assist the resident to take several more steps toward resident 25's wheelchair. With the wheelchair wheels unlocked, and CNA 1 standing on the left side of the wheelchair, CNA 1 assisted resident 25 to sit in the wheelchair. As resident 25 began to sit, the wheelchair rolled slightly backward and CNA 1 was able to stop the wheelchair from rolling backward too far, and the resident sat in the wheelchair without falling.
On 9/1/21 at 8:01 AM, when attempting to turn on the light within resident 25's room, it was observed the overhead lighting in the resident's room was not working when utilizing the light switch near the door to the room entrance.
On 8/30/21 at 1:49 PM, CNA 2 was interviewed regarding residents with fall prevention interventions. CNA 2 stated being unaware of any interventions in place with resident 25 for prevention of falls. CNA 2 stated residents who had recent falls were discussed in report, and that was when CNA 2 learned about fall prevention interventions.
Resident 25's medical record review was completed on 9/1/21. The following documentation regarding past falls and interventions were noted:
a. Incident/Accident Report from 3/3/21 read, Res (Resident] was sitting in her w/c (wheelchair) went to the bed (sic), w/c was not lock (sic), bed was higher than w/c. CNA went to help roommate and [resident 25] transferred herself and slid down to the floor. [Resident 25] did not hit her head per CNA .Additional comments and/or steps taken to prevent recurrence: Lock w/c [wheelchair]. [Note: Observation made of resident having been transferred to her wheelchair with wheels unlocked.]
b. Incident/ Accident Report from 6/17/21 read, Resident was sitting on couch and slid on to floor (sic). Unsure if she hit her head, however will implement neuros .Additional comments and/or steps taken to prevent recurrence: Frequent room checks.
c. Incident/Accident Report from 7/23/21 read, FOF [Found on floor] in dining room, alert, non [NAME] [non-cooperative], regular confusion (sic) .Additional comments and/or steps taken to prevent recurrence: ensure socks on.
d. Actual Fall Care Plan from resident 25's hard chart read, Interventions: .Keep environment clear of obstructions, floors dry, well lit, etc . Toilet q [every] 2 hours PRN [as needed] .Lock w/c [wheelchair]. [Note: Observations were made of wheelchair unlocked during a transfer and overhead lighting within resident 25's room was not functioning.]
2. Resident 44 was originally admitted to the facility on [DATE] with medical diagnoses that included, but not limited to, paranoid schizophrenia, major depressive disorder, hypertension, heart failure, chronic obstructive pulmonary disease, gastro-esophageal reflux disease, diverticulosis, hypoxemia, urinary incontinence, morbid obesity, type 2 diabetes mellitus, pulmonary edema, asthma, adenoviral pneumonia, acute and chronic respiratory failure, obstructive sleep apnea, chronic kidney disease, anemia in chronic kidney disease, history of urinary tract infection, osteoarthritis, chronic pain and history of COVID-19.
On 8/29/21 at 11:18 AM, resident 44 was observed to be walking from a bedroom to the dining room, using a four-wheel walker, wearing regular tube socks and wearing a skirt which hung over resident 44's socks in the front. As resident 44 was walking a CNA came by and raised resident 44's skirt which then fell down below the front of her tube socks again.
On 8/31/21 at 9:00 AM resident 44's medical record was reviewed. A General Note from 8/30/2021 read, Note Text: Resident was found on her bum after slipping out of w/c. Her socks on her left foot was found half on. No apparent injury, abrasions, contusions. Unwitnessed fall, neuros started. MD notified and family notified.
On 8/31/21 at 10:32 AM, CNA 6 reported resident 44 had not had any recent falls. During a follow-up interview on 8/31/21 at 11:16 AM, CNA 6 reported she was never told during report about resident 44's fall the previous day. CNA 6 reported no neurological checks had been initiated or were being completed by the CNAs.
On 8/31/21 at 11:03 AM, Registered Nurse (RN) 3 reported during morning report she was not informed resident 44 had fallen the previous day. RN 3 was able to find out resident 44 had a fall on 8/30/21 because of an order to complete alert charting during the shift.
On 8/31/21 at 12:32 PM, resident 44 was observed in the dining room wearing regular tube socks, no non-skid material on the bottom and no shoes were being worn.
A review of resident 44's medical record was completed on 9/1/21. The following documentation regarding falls was noted:
a. An Incident/Accident Report from a fall on 6/29/21 read, Resident got up from chair in dining room and slipped on floor it was just mopped (sic) and she bumped left (sic) side of her head on dining table . Additional comments and/or steps taken to prevent recurrence: Ensure residents are out of a room that is being mopped until floor is dry.
b. An Incident/Accident Report from a fall on 7/15/21 read, Pt [Patient] was found sitting on floor facing toilet one sock on one sock off (sic) . Pt. was on the way to bathroom did not use walker (sic) . Additional comments and/or steps taken to prevent recurrence: bed in low position, walker by bedside, toilet regularly.
c. An 'Incident/Accident Report from a fall on 8/30/21 read, Resident slipped out of w/c [wheelchair] onto bottom. Right side of socks were on half way and cause for slipping (sic) .Additional comments and/or steps taken to prevent recurrence: Ensure socks/footwear is on properly.
On 8/31/21 at 11:07 AM, RN 3 reported an intervention put in place for resident 44 to prevent further falls was to ensure resident 44 was wearing proper footwear. RN 2 stated proper footwear would include, that the resident should, not be wearing just socks.
On 9/1/21 at 1:20 PM, the Director of Nursing (DON) stated proper footwear would include, shoes or non skid slipper socks. When asked why residents were wearing regular socks, the DON reported, We do not have any non-skid slippers in stock.
On 8/29/21 at 9:23 AM, CNA 1 was asked about staffing of the 100 hall. CNA 1 reported the facility had one CNA not come in for her shift, so another CNA was rotating all units today. CNA 1 reported feeling rushed and reported difficulty with monitoring a lot of people who wandered.
On 9/1/21 at 11:07 AM CNA 4 stated resident 44 wanted to walk a lot so the CNA staff tried to keep resident 44 busy, but that could be tough because the memory care unit did not have a lot of planned activities.
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 it was determined, for 1 of 30 sample residents, that the facility did not en...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 1 of 30 sample residents, that the facility did not ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents goals and preferences. Specifically, a resident that did not require oxygen therapy was provided an oxygen concentrator without a physician's order for oxygen therapy. Resident identifier: 4.
Findings include:
On 8/29/21 at 12:32 PM, an interview was conducted with resident 4. Resident 4 stated she wore oxygen and recently had to turn up the oxygen due to shortness of breath. Resident 4 was observed to have an oxygen concentrator in her room and the nasal cannula tubing was observed not to be dated.
Resident 4 was admitted to the facility on [DATE] with diagnoses which included but not limited to major depressive disorder, post-traumatic stress disorder, generalized anxiety, chronic migraine, conversion disorder with seizures or convulsions, personal history of traumatic brain injury, and bradycardia.
Resident 4's medical record was observed on 9/1/21.
A Care Plan Focus initiated on 8/2/21, documented The resident has oxygen therapy. A Goal initiated on 8/2/21, documented The resident will have no s/sx (signs or symptoms) of poor oxygen absorption through the review date. An Intervention initiated on 8/2/21, documented Monitor for s/sx of respiratory distress and report to MD (Medical Director) PRN (as needed): Respirations, Pulse oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis, Cough, Pleuritic pain, Accessory muscle usage, Skin color.
The Oxygen Summary was reviewed from February 2021 to current. Resident 4's oxygen saturation was documented on room air and averaged 94.1 percent. Resident 4's oxygen saturation was not documented below 90 percent.
The Order Summary Report was reviewed. A physician's order for oxygen therapy was unable to be located.
On 9/1/21 at 12:47 PM, an interview was conducted with resident 4. Resident 4 stated the staff did not fill the humidifier bottle on her oxygen. The humidifier bottle attached to the oxygen concentrator was observed to be empty. The oxygen concentrator was observed to be set between 3 to 3.5 liters of oxygen. Resident 4 stated she would adjust the oxygen level on her own if she was feeling shortness of breath. Resident 4 stated the staff have never changed the oxygen tubing.
On 9/1/21 at 12:52 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated the oxygen tubing should be changed weekly. LPN 1 stated the oxygen concentrator humidifier bottles were filled by the Certified Nursing Assistants (CNAs).
On 9/1/21 at 12:57 PM, an interview was conducted with CNA 5. CNA 5 stated she filled the oxygen concentrator humidifier bottles for the residents. CNA 5 stated she would glance at the humidifier bottle when she was in the resident room and fill the bottle if necessary.
On 9/1/21 at 1:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated if a resident had oxygen therapy there should be a physician's order. The DON stated the oxygen tubing should be changed every 2 to 3 weeks on Sundays. The DON stated if the oxygen tubing was changed the nursing staff would document the change on the Treatment Administration Record. The DON stated she was told to have a physician's order for the oxygen concentrator humidifier bottles. The DON was informed that resident 4 had an oxygen concentrator in her room without a physician's order. The DON asked why does the resident have oxygen. The DON was informed resident 4 was observed wearing the oxygen. The DON asked why was the resident wearing the oxygen. The DON stated the oxygen concentrator might belong to resident 4's roommate.
On 9/1/21 at 1:06 PM, an observation of resident 4's room was conducted. An oxygen concentrator was observed at the foot end of resident 4's bed and an additional oxygen concentrator was observed at the foot end of the roommates bed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 of 30 sample residents, that the irregularities noted by the pharm...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 of 30 sample residents, that the irregularities noted by the pharmacist during the drug regimen review were not reported to the attending physician and the facility's Medical Director (MD). Specifically, irregularities were not documented on a separate written report that includes the resident name and the irregularity the pharmacist identified. In addition, the attending physician did not document in the resident's medical record that the identified irregularities had been reviewed and what action, if any, had been taken to address the irregularities. Resident identifiers: 7 and 41.
Findings include:
1. Resident 7 was admitted to the facility on [DATE] with diagnoses which included but not limited to type 2 diabetes mellitus without complications, mood disorder, essential hypertension, atherosclerotic heart disease, and chronic kidney disease.
Resident 7's medical record was reviewed on 8/30/21.
The Consultant Pharmacist's Medication Regimen Review dated 4/2/21, documented This resident takes medications that requires periodic monitoring of an A1c (glycated hemoglobin), CBC (complete blood count) and CMP (comprehensive metabolic panel) every six months. A review of the chart shows that these labs have not been drawn since September of 2020. This was discussed with the medical director and the following has been approved: 1. Draw A1c, CBC and CMP on the next convenient lab date, then every six months thereafter.
[Note: The Consultant Pharmacist's Medication Regimen Review included recommendations for other residents that resided at the facility.]
A separate written report documenting the pharmacist recommendation was unable to be located in the medical record. In addition, no documentation was located that the attending physician documented in resident 7's medical record that the identified recommendations had been reviewed.
2. Resident 41 was admitted to the facility on [DATE] with diagnoses which included but not limited to Wernicke's encephalopathy, psychosis, alcohol use, chronic pain, and encephalopathy.
Resident 41's medical record was reviewed on 8/30/21.
The Consultant Pharmacist's Medication Regimen Review dated 6/3/21, documented This resident has an order for Seroquel, Depakote and Duloxetine for psychosis and encephalopathy. These medications do not carry a labeled indication for this diagnosis. This was discussed with the medical director, and it was confirmed there is sufficient evidence that symptoms of depression, agitation and mood instability are common behavioral symptoms of psychosis and encephalopathy, and that these medications are effective in treating these symptoms. Prior attempts with other agents have resulted poorly in managing the patients behaviors. As a result the medical director feels that the benefits of treatment with these medications for this diagnosis currently outweigh any potential risks at this time.
[Note: The Consultant Pharmacist's Medication Regimen Review included recommendations for other residents that resided at the facility.]
A separate written report documenting the pharmacist recommendation was unable to be located in the medical record. In addition, no documentation was located that the attending physician documented in resident 41's medical record that the identified recommendations had been reviewed.
On 9/1/21 at 9:29 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the Consultant Pharmacist's Medication Regimen Review reports were sent to the Administrator and Business Manager. The DON stated she had asked the Administrator and Business Manager to forward a copy of the reports to her so she could write the necessary physician's orders and include the reports in the book so things were not missed. The DON stated that individualized resident forms were completed and signed by the MD. The DON stated If the pharmacist recommended labs she would go ahead and do the labs. The DON stated the reports were a process that needed to be fixed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
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 did not ensure that 1 of 30 sample residents was free of significant medicati...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that 1 of 30 sample residents was free of significant medication errors. Specifically, a resident was not administered pain and anxiety medication as prescribed to assist in comfort during the dying process. Resident identifier: 98.
Findings include:
Resident 98 was admitted to the facility on [DATE] with diagnoses that included sepsis, viral pneumonia, chronic obstructive pulmonary disease, acute respiratory failure, congestive heart failure, protein-calorie malnutrition, and dementia.
Resident 98's medical record was reviewed on 8/29/21 and again on 8/31/21.
Resident 98's physician orders were reviewed. Resident 98 had the following medications prescribed:
A. On 8/22/21, Lorazepam 2 milligrams per milliliter (mg/ml) 0.5 ml by mouth every 8 hours for anxiety and restlessness. [Note: Lorazepam is an anti-anxiety medication.]
Resident 98's August 2021 Medication Administration Record (MAR) was reviewed.
a. On 8/24/21, the resident was not administered Lorazepam at 12:00 AM. Review of the narcotic record revealed that the Lorazepam was not administered at 12:00 AM.
b. On 8/27/21, the resident was not administered Lorazepam at 12:00 AM. Review of the narcotic record revealed that the Lorazepam was not administered at 12:00 AM as scheduled.
c. On 8/28/21, the resident was not administered Lorazepam at 12:00 AM or 8:00 AM. Review of the narcotic record revealed that the Lorazepam was not administered at 12:00 AM.
d. On 8/29/21, the resident was not administered Lorazepam at 12:00 AM. Review of the narcotic record revealed that the Lorazepam was not administered at 12:00 AM or 8:00 AM.
e. On 8/31/21, the resident was not administered Lorazepam at 12:00 AM. Review of the narcotic record revealed that the Lorazepam was not administered at 12:00 AM as scheduled.
B. On 8/22/21, Dilaudid 1 mg/ml 0.5 ml by mouth every 4 hours for pain of shortness of breath. [Note: Dilaudid is a narcotic pain medication.]
Resident 98's August 2021 MAR was reviewed.
a. On 8/23/21, the Dilaudid was not administered at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, or 8:00 PM. Review of the narcotic record revealed that the Dilaudid was not administered at noon, 4:00 PM, or 8:00 PM.
b. On 8/24/21, the Dilaudid was not administered at 12:00 AM or 4:00 AM. Review of the narcotic record revealed that the Dilaudid was not administered at 12:00 AM, 4:00 AM, 12:00 PM or 8:00 PM.
c. On 8/25/21, the Dilaudid was not administered at 12:00 AM or 4:00 AM. The narcotic sheets did not indicate that Dilaudid was administered on this date.
d. On 8/26/21, the Dilaudid was not administered at 12:00 AM or 4:00 AM. The narcotic sheets did not indicate that Dilaudid was administered on this date.
e. On 8/27/21, the Dilaudid was not administered at 12:00 AM, 4:00 AM or 12:00 PM. The narcotic sheets did not indicate that Dilaudid was administered on this date.
f. On 8/28/21, the Dilaudid was not administered at 12:00 AM, 4:00 AM, or 8:00 AM. The narcotic sheets did not indicate that Dilaudid was administered on this date.
g. On 8/29/21, the Dilaudid was not administered at 12:00 AM, 4:00 AM, or 8:00 AM. The narcotic sheets did not indicate that Dilaudid was administered on this date.
h. On 8/30/21, the Dilaudid was not administered at 12:00 AM or 4:00 AM. The narcotic sheets did not indicate that Dilaudid was administered on this date.
i. On 8/31/21, the Dilaudid was not administered at 12:00 AM or 4:00 AM. Review of the narcotic record revealed that the Dilaudid was not administered at 12:00 AM or 4:00 AM.
On 8/31/21 at 4:20 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that she had held resident 98's Lorazepam and Dilaudid on 8/28/21 at 8:00 AM because the daughter did not want the nurse to administer the medications at that time. RN 1 stated she did not know why the other documentation was missing for the Lorazepam and Dilaudid doses, and had no way of knowing if the medications were administered.
On 9/1/21 at 9:30 AM, an interview was conducted with the Director of Nursing (DON). The DON stated she did not know why resident 98 was not administered his Lorazepam and Dilaudid as prescribed by the physician.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0776
(Tag F0776)
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 did not provide or obtain radiology and other diagnostic services to meet the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not provide or obtain radiology and other diagnostic services to meet the needs of 1 of 30 sample residents. Specifically, a resident did not have timely imaging completed of his cervical and lumbar areas, nor of his gallbladder/liver area as prescribed by physicians. Resident identifier: 22.
Findings include:
Resident 22 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, benign prostatic hyperplasia, intervertebral disc degeneration, aortic valve stenosis, and major depressive disorder.
On 8/30/21 at 8:53 AM, an interview was conducted with resident 22. Resident 22 stated that he was supposed to have a Magnetic Resonance Imaging (MRI) scan completed on his back, but that the facility had not followed through and scheduled it. The resident also stated that the MRI was supposed to help his back specialist determine if the resident required surgery on his back. Resident 22 stated that he had been experiencing abdominal pain and had been seeing a gastroenterologist, who recommended he have certain procedures such as a colonoscopy, endoscopy, etc. to determine the cause of the pain. The resident stated that the Administrator (ADM) and Business Office Manager (BOM) keep telling me I can't go to those appointments and that the ADM controls the appointments. Resident 22 stated that the ADM had accused him of setting up his own appointments, but it was the nurses that did it.
Resident 22's medical record was reviewed on 8/29/21.
Resident 22's progress notes indicated the following:
a. On 4/1/21, Pain level at 4 at lumbar area from degenerative disc.
b. On 4/27/21, Resident informed about making his own appointment's (sic) and if he does then he is responsible for transportation .
c. On 5/6/21, a Nurse Practitioner (NP) documented that resident 22 had chronic low back pain - continue current regimen of tramadol, cyclobenzaprine, and gabapentin .
d. On 5/24/21, He complains of back pain level 8, he takes tramadol for the pain.
e. On 6/16/21, the resident was seen in the local emergency room (ER) for abdominal pain. The resident had a diagnosis of a compression fracture of Lumbar (L) 4 vertebra, and compression deformities at L1, L2, and L3. The resident was to have a follow up at a Spine Clinic, and a follow up with a gastroenterologist.
f. On 6/17/21, resident 22 saw a gastroenterologist for abdominal pain. The gastroenterologist recommended a Hepatobiliary Imminodiacetic Acid (HIDA) scan be completed.
g. On 6/23/21, the Spine clinic appointment was made for resident 22, and was scheduled for 7/15/21.
h. On 6/23/21, the facility Medical Director documented that the resident had a compression fracture, and would continue receiving Morphine as needed for the pain.
i. On 7/15/21, Resident went to spine clinic. Physician ordered cervical and lumbar MRIs. Follow up after imaging.
j. On 7/19/21, the Medical Director documented that the resident says he still has intermittent abdominal pain. He saw GI (gastroenterologist) and is supposed to be scheduled for a HIDA scan. He saw the spine specialist who has ordered MRIs of cervical and lumbar spine .
k. On 8/5/21, the resident complains of back pain and abdominal pain daily.
l. On 8/16/21, the Medical Director documented that the resident had not yet had a HIDA scan, and that management is arranging his follow up appts (appointments) as ordered by GI doctor.
m. On 8/31/21, staff documented that the resident had a HIDA scan performed that day. [Note: This was approximately 2.5 months after the gastroenterologist recommended it be completed.]
No documentation could be located to indicate that resident 22 had an MRI of his neck and back completed as recommended in July 2021 by the spine clinic.
On 9/1/21 at 9:30 AM, an interview was conducted with the facility Director of Nursing (DON). The DON stated she was unaware if resident 22's MRI had been scheduled because the ADM and BOM scheduled those appointments, so they could make sure the insurance would cover the procedures.
On 9/1/21 at 1:25 PM, the BOM was asked to provide documentation that resident 22 had the MRI scheduled or completed. The BOM was unable to provide documentation of this.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined for 1 of 30 sample residents that the facility did not ensure that the h...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined for 1 of 30 sample residents that the facility did not ensure that the hospice services met professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services. Specifically, a resident who was admitted to the facility on hospice, did not have cares coordinated between hospice and the facility, and information was not conveyed between providers. Resident identifier: 98.
Findings include:
Resident 98 was admitted to the facility on [DATE] with diagnoses that included sepsis, viral pneumonia, chronic obstructive pulmonary disease, acute respiratory failure, congestive heart failure, protein-calorie malnutrition, and dementia.
Resident 98's medical record was reviewed on 8/29/21.
Resident progress notes dated 8/18/21 indicated that resident 98 was admitted to the facility on hospice services.
No baseline or comprehensive care plan could be located for resident 98 in his medical record. No hospice notes from the hospice provider could be located in the resident's medical record.
On 9/1/21 at 1:00 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that when a hospice provider saw a resident in the facility, the providers would typically write up a note and place it in the resident's medical record. LPN 1 stated that sometimes the hospice providers would tell us verbally when they leave so we know what's happening with the resident.
On 9/1/21 at 9:30 AM, an interview was conducted with the facility Director of Nursing (DON). The DON stated that resident 98's hospice nurses should have developed a care plan for resident 98 and placed it in his medical record. The DON confirmed that resident 98 did not have a baseline or comprehensive care plan in his medical record. The DON also confirmed that no notes from the hospice providers were in the resident's medical record. The DON stated that hospice providers were supposed to document their visits and then place them in the resident's medical record. The DON stated that she had brought the lack of communication between the facility and the hospice providers to the attention of the facility Administrator (ADM) on previous occasions.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 8/29/21 at 10:53 AM, an interview was conducted with resident 4. Resident 4 stated the call light response time was an iss...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On 8/29/21 at 10:53 AM, an interview was conducted with resident 4. Resident 4 stated the call light response time was an issue. Resident 4 stated she did a lot for herself because staff did not respond timely.
5. On 8/29/21 at 1:16 PM, an interview was conducted with resident 2. Resident 2 stated the staff did not respond to her call light timely and she had wet herself. Resident 2 stated that she could not help it.
6. On 8/29/21 at 11:49 AM, an interview was conducted with resident 32. Resident 32 stated that the night shift did not answer call lights. Resident 32 stated that he had his call light on that day to request a pain pill, and I don't know how long I sat there before they came.
7. On 8/29/21 at 8:26 AM, the call light for resident room [ROOM NUMBER] was activated. At 8:43 AM, staff were observed to respond to the call light. The call light was activated for 17 minutes.
8. On 8/29/21 at 2:15 PM, the call light for resident room [ROOM NUMBER] was activated. At 2:36 PM, staff were observed to respond to the call light. The call light was activated for 21 minutes.
9. On 8/30/21 at 11:52 AM, the call light for resident room [ROOM NUMBER] was activated. At 12:23 PM, staff were observed to respond to the call light. The call light was activated for 31 minutes.
10. On 8/30/21 at 12:45 PM, the call light for resident room [ROOM NUMBER] was activated. At 12:57 PM, staff were observed to respond to the call light. The call light was activated for 12 minutes.
Based on interview and observation, the facility did not treat each resident with respect and dignity and care for 8 of 30 sample residents in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, residents voiced concerns with call light response times, and long call light response times were observed. Resident identifiers: 2, 4, 9, 15, 22, 28, 32, and 42.
Findings include:
1. On 8/31/21 at 10:00 AM, an interview was conducted with six residents from the resident council. Residents were asked about call light response times, and had the following concerns:
a. Resident 9 stated that he waited at least 10 minutes for his call light to be answered.
b. Resident 15 stated that she did not wait for staff to answer her call lights because it took too long. Resident 15 stated I just yell.
c. Resident 28 stated that she usually waited for approximately an hour for staff to respond to her call light. Resident 28 further stated that she has brought up the issue in resident council, but that call light response times were still an hour sometimes.
2. On 8/30/21 at 8:53 AM, an interview was conducted with resident 22. When asked about call light response times, resident 22 stated I don't even bother to use call lights because of the long wait times. Resident 22 stated that there was one occasion when he waited approximately one hour for his call light to be answered.
3. On 8/29/21 at 11:00 AM, an interview was conducted with resident 42. Resident 42 stated that he would push his call light for help, and still they don't come . I have to go out and find someone to help me. Resident 42 stated that 90 percent of the time, call lights took about 45 minutes or more to be answered. Resident 42 further stated that when staff did answer his call light, they would say things like, What do you want? in a rude tone. Resident 42 stated that he has been left on the toilet for 45 to 60 minutes before staff returned, and its not comfortable. During the interview, a staff member entered the resident's room without knocking.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0559
(Tag F0559)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 1 was admitted to the facility on [DATE] with diagnoses which included but not limited to type 2 diabetes, schizophr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 1 was admitted to the facility on [DATE] with diagnoses which included but not limited to type 2 diabetes, schizophrenia, hypertension, and polymyalgia.
On 8/29/21 at 9:09 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated resident 1 had been moved to a room closer to the nursing cart and where the CNAs could observe resident 1 more closely due to inappropriate behaviors.
On 8/29/21 at approximately 10:00 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated resident 1 was moved closer to where staff could keep a closer eye on him.
Resident 1's medical record was reviewed on 9/1/21.
On 8/10/21 at 1:46 PM, a general progress note documented Resident is moving to room [ROOM NUMBER]B today, all his belongings and T.V. is moved with resident. Resident is oriented to his room-mate as well room. Resident has adjusted to RM (room) 111B this shift.
Written notification informing resident 1 and his representative of the room change and the reason for the change was unable to be located in the medical record.
4. Resident 9 was admitted to the facility on [DATE] with diagnoses which included but not limited to schizoaffective disorder, dementia, anxiety disorder, chronic obstructive pulmonary disease, and type 2 diabetes.
Resident 9's medical record was reviewed on 9/1/21.
Written notification informing resident 9 of the roommate change and the reason for the change was unable to be located in the medical record.
On 8/31/21 at 11:56 AM, an interview was conducted with the Administrator and the Business Manager. The Administrator stated when a resident was moved to a different room in the facility either he or the Resident Advocate would show the resident what rooms were available and the resident would choose which room they wanted. The Administrator stated staff would help the resident move and the resident's family members and the new roommate would be notified. The Administrator stated families were notified by a telephone call. The Administrator stated information about room changes were kept in the resident's progress notes.
Based on interview and record review it was determined, for 5 of 30 sample residents, that the facility did not provide written notice, including the reason for the change, before the resident's room or roommate in the facility was changed. Specifically, residents did not receive written notice prior to a roommate change, and other residents did not receive written notice prior to a room change. Resident identifiers: 1, 2, 9, 14, and 22.
Findings include:
1. Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included schizoaffective disorder, type 2 diabetes mellitus without complications, rheumatoid arthritis, muscle wasting and atrophy, and insomnia.
On 8/29/21 at 1:29 PM, an interview was conducted with resident 2. Resident 2 stated she did not like her roommate and her roommate bothered her. Resident 2 stated she had told staff but the staff told her to ignore her roommate. Resident 2 further stated the staff told her they would not move her roommate.
Residents 2's medical record was reviewed on 8/30/21.
Written notification informing resident 2 of the roommate change and the reason for the change was unable to be located in the medical record.
2. Resident 14 was admitted to the facility on [DATE] with diagnoses which included but not limited to dementia without behavioral disturbance, Alzheimer's disease late onset, major depressive disorder, and history of falling.
Resident 14's medical record was reviewed on 8/30/21.
On 7/21/21 at 5:34 PM, a General progress note documented [Resident 14] has a new room and new roommate. I tried to introduce the 2 of them but they said they already know each other. Family notified.
On 7/21/21 at 5:35 PM, a General progress note documented Notified clients and her daughter about room change. Client was excited to meet her new roommate, and is agreeable to the room change. Admin (Administrator) and nursing and social work notified.
Resident 14's census report was reviewed and documented that resident 14 was moved to resident 2's room on 7/23/21.
Written notification informing resident 14 of the room change and the reason for the change was unable to be located in the medical record.
On 9/1/21 at 11:00 AM, an interview was conducted with the Administrator. The Administrator stated a progress note would be completed by himself or the Resident Advocate Trainee prior to a resident room change or roommate change. The Administrator stated the resident family would be notified by telephone. The Administrator stated the facility was not providing written notices to residents prior to a room change or a roommate change.
5. Resident 22 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, benign prostatic hyperplasia, intervertebral disc degeneration, aortic valve stenosis, and major depressive disorder.
Resident 22's medical record was reviewed on 8/29/21.
Resident 22's progress notes indicated that on 7/29/21, resident 22 was moved to a different room.
Written notification informing resident 22 and/or his representative of the room change was unable to be located in the medical record.
On 8/30/21 at 8:53 AM an interview was conducted with resident 22. Resident 22 stated that he had requested a roommate or room change because he was not getting along with his previous roommate. Resident 22 stated that he had since changed rooms, but did not receive written notice that this was going to occur.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility did not ensure that residents maintained their right to organize and participate in resident groups in the facility. Specifically, resident council w...
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Based on interview and record review, the facility did not ensure that residents maintained their right to organize and participate in resident groups in the facility. Specifically, resident council was not conducted at regular intervals. Resident identifiers: 13 and 28.
Findings include:
1. On 8/31/21 at 10:00 AM, an interview was conducted with six residents from the resident council.
Multiple residents stated that they had not had resident council meetings regularly for several months, and that they missed having the council meetings.
Resident 28 stated that there was a long time that the facility was not conducting resident council meetings. Resident 28 further stated that the facility activities director usually conducted the meetings, but that the facility did not currently have an activities director.
Resident 13 stated that there was nothing to do at the facility, including participate in resident council meetings.
2. Resident council meeting notes were reviewed. Review of the notes revealed that resident council was conducted on 11/5/20, 4/22/21, 5/27/2, 6/25/21, and 7/23/21. Review of the notes also revealed that during time when clients were not having group activities, Resident Advocate staff conducted individual 'resident council interviews' to document residents (sic) issues, and reviewed with council president. The resident council notes revealed that multiple individual interviews were done during November 2020, but not after that. Review of the notes also revealed that in-person resident council meetings resumed in April 2021.
3. On 8/31/21 at 1:12 PM, an interview was conducted with the facility Administrator (ADM). The ADM confirmed that no group or individual resident council meetings were conducted between November 2020 and April 2021. The ADM stated that the facility did not conduct resident council meetings for a few months because he misunderstood the requirements for visitation and group activities during the COVID-19 pandemic.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0567
(Tag F0567)
Could have caused harm · This affected multiple residents
Based on interview and record review it was determined, for 2 of 30 sampled residents, that the facility did not provide the residents the right to manage his or her financial affairs. Specifically, r...
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Based on interview and record review it was determined, for 2 of 30 sampled residents, that the facility did not provide the residents the right to manage his or her financial affairs. Specifically, residents who had authorized the facility to manage any personal funds did not have ready and reasonable access to those funds. Resident identifiers: 4 and 28.
Findings include:
On 8/29/21 at 10:49 AM, an interview was conducted with Resident 4. Resident 4 stated she could only get money from her personal funds account on Mondays, Wednesdays, and Fridays. Resident 4 stated if she needed money on a Tuesday she would have to wait until Wednesday.
On 8/31/21 at 10:00 AM, an interview was conducted with six residents from the resident council. The residents were asked about banking hours and resident funds. Resident 28 stated that there were specific banking hours and you could not access your money unless it was within those timeframes. Resident 28 stated that banking hours were only for part of the day on Mondays, Wednesdays, and Fridays. Resident 28 stated that she had attempted to withdraw money from her account, but they told me I had to wait until banking hours to access her money. All of the residents stated that they did not have access to their money on the weekends.
On 8/30/21 at 2:53 PM, a Resident Banking Access sign was observed to be posted in the 300 hall. The sign documented that resident banking access was at 3:00 PM, in the ice cream bistro on Monday, Wednesday, and Friday. All other days, residents could obtain petty cash from the charge nurse.
On 8/31/21 at 11:57 AM, an interview was conducted with Registered Nurse (RN) 4. RN 4 stated she was the charge nurse for the day. RN 4 stated the medication carts did not ever have money in them for resident access. RN 4 stated it had been years since the medication carts had a money box. RN 4 stated if it was off hours for banking the resident could ask the front office but on the weekends there was no way to access resident money.
On 8/31/21 at 12:19 PM, an interview was conducted with the Business Manager. The Business Manager stated the routine banking hours for residents were Monday, Wednesday, and Friday between 3:30 PM or 4:00 PM. The Business Manager stated she was not strict on the banking hour times. The Business Manager stated she would usually have a money box that was locked and available in the nursing medication carts. The Business Manager stated if a resident requested money on the weekends the money box would be available in the nursing medication carts.
On 8/31/21 at 12:38 PM, an interview was conducted with RN 3. RN 3 stated the medication carts in the past had a money box in them but it had been a couple months or longer since the medication carts had a money box. RN 3 stated resident banking hours were Mondays, Tuesdays, and Fridays. RN 3 stated if a resident requested money outside of the banking hours the resident would have to request from the Administrator or the Business Manager. RN 3 stated if a resident requested money on the weekend the resident would have to wait because she did not have access to the money.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0568
(Tag F0568)
Could have caused harm · This affected multiple residents
Based on interview, the facility did not ensure that residents had their individual financial records available through quarterly statements and upon request. Resident identifier: 42.
Findings includ...
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Based on interview, the facility did not ensure that residents had their individual financial records available through quarterly statements and upon request. Resident identifier: 42.
Findings include:
1. On 8/31/21 at 10:00 AM, an interview was conducted with six residents from the resident council. The residents were asked about resident funds. All of the residents stated that they were not receiving quarterly statements regarding their financial records.
2. On 8/29/21 at 11:00 AM, an interview was conducted with resident 42. Resident 42 stated that he had never received a quarterly statement regarding his financial records.
3. On 8/31/21 at 12:19 PM, an interview was conducted with the Business Manager and the Administrator. The Administrator stated he thought the residents were receiving quarterly statements regarding personal funds. The Business Manager stated she could not remember when the last statements were issued and to which residents she had issued the statements to. The Business Manager stated the statements were not completed electronically or quarterly.
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 observations and interviews, it was determined the facility did not provide residents with a safe, clean, comfortable, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, it was determined the facility did not provide residents with a safe, clean, comfortable, and homelike environment. Specifically, wheelchairs were observed to be dirty and soiled, walls had holes with drywall exposed, baseboard trim was peeling from walls in resident rooms, on multiple occasions halls were observed to have extended periods of urine and feces smells, and blinds in residents' rooms were broken and unable to be retracted. Resident identifier: 5.
Findings include:
1. On 8/29/21 at 9:23 AM, in room [ROOM NUMBER], the baseboard trim lining the bottom of the resident's wall was observed to be peeling away from the dry wall.
2. On 8/29/21 at 9:25 AM, in room [ROOM NUMBER], a hole in the drywall was observed in the resident's bathroom.
3. On 8/29/21 at 9:37 AM, in room [ROOM NUMBER], the baseboard trim on a wall near bathroom was observed to be peeling from the wall.
4. On 8/29/21 at 9:42 AM, in room [ROOM NUMBER], a metal privacy curtain hanger was observed to be hanging off the ceiling with the sharp metal edge exposed. The privacy curtain was observed to be on the ground. On observation, Certified Nursing Assistant (CNA) 1 then stated, I did not know that was like that. On 8/29/21 at 10:32 AM, room [ROOM NUMBER] was observed to have the door closed with yellow and black Caution tape placed over the door.
5. On 8/29/21 at 10:40 AM, in room [ROOM NUMBER], the window blinds were observed to have several broken slats and the blinds were unable to be retracted or opened.
6. On 8/29/21 at 10:42 AM, in room [ROOM NUMBER], the window blinds were observed to have several broken slats and the blinds were unable to be retracted or opened.
7. On 8/30/21 at 10:32 AM, a strong urine smell was observed when entering the 100 hall, memory care unit. This was still present at 11:24 AM.
8. On 8/30/21 at 11:20 AM, the outdoor area adjacent to the 100 hall was observed. A pile of large, used fence posts with peeling paint were observed to be laying along the fence in the resident outdoor area.
9. On 8/29/21 at 1:06 PM, in the resident communal/dining area of the 100 hall, a box filled with trash was observed to be left on the resident counter space next to a bowl filled with bananas.
10. On 8/31/21 at 8:27 AM, when entering the 100 hall, memory care unit, a strong urine smell was observed.
11. On 9/1/21 at 8:00 AM, two large, 55 Gallon, gray plastic trash bins were observed to be stored within the resident bathroom that adjoined rooms [ROOM NUMBERS]; one bin was labeled Laundry and the other was labeled Trash.
12. On 9/1/21 at 8:02 AM, an unused bed in room [ROOM NUMBER] was observed to have no linens and the mattress was observed to be torn in multiple areas. At this time, the blinds in room [ROOM NUMBER] were also observed to have several broken slats and were unable to be opened or retracted.
13. On 9/1/21 at 8:01 AM, the switch for overhead lighting within room [ROOM NUMBER] was observed to not turn on any lighting within the room.
14. On 9/1/21 at 8:03 AM, in room [ROOM NUMBER], the baseboard trim lining the wall was observed peeling away from the wall with dry wall in that area cracked and exposing insulation.
15. On 9/1/21 at 8:05 AM, within the communal dining area of the 100 hall, a curtain hanger above the window was observed to be broken and was hanging off of the wall.
16. On 8/29/21 during the lunch meal, resident 5's electric wheelchair was observed. The wheelchair was observed to be soiled with dried spills and debris on the foot and side areas.
17. On 8/29/21 at 9:07 AM, room [ROOM NUMBER] had what appeared to be feces on the floor.
18. On 8/29/21 at 9:35 AM , in room [ROOM NUMBER], paint patches were observed on the walls and paint was peeling and worn off of the chair guards along the wall.
19. On 8/29/21 at 9:36 AM, in room [ROOM NUMBER], window blinds were bent and broken.
20. On 8/29/21 at 9:54 AM, in room [ROOM NUMBER], a strong smell of feces was observed when entering the room.
21. On 8/31/21 at 12:38 PM, a strong smell of urine was observed when entering the 100 hallway, memory unit.
22. On 8/31/21 at 3:18 PM, a strong smell of urine was observed when entering the 100 hallway, memory unit.
On 8/30/21 at 1:44 PM, CNA 2 stated they noticed maintenance would take about one week to fix major maintenance issues. CNA 2 stated the maintenance worker was somewhat responsive. CNA 2 also stated when there was a maintenance issue that needed to be addressed staff would communicate that to the maintenance person by writing it within the maintenance book located at the nurses' station. On 8/30/21 at 2:20 PM, the maintenance log was examined. There were no issues from the 100 hall listed on the maintenance log. The Maintenance Log Book read, 8/12; Fan in S1 (sic) not working,, 8/22; Sprinkler by shed broken,, 8/22; sink in room [ROOM NUMBER] is pulling away from wall, and, 8/25; [name of resident] needs her air conditioner fixed; Date Completed 8/27/21.
On 9/1/21 at 8:10 AM, Licensed Practical Nurse (LPN) 1 reported maintenance could be a little slow at addressing issues. LPN 1 reported when someone tried to find the maintenance person they never can because the maintenance person came late in the day. LPN 1 stated, There are definitely a lot of things that need repairs.
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** 4. Resident 24 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included COVID-19, schizo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident 24 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included COVID-19, schizophrenia, anxiety disorder, conversion disorder, chronic kidney disease, and cognitive communication deficit.
Resident 24's medical record was reviewed on 8/29/21.
Resident 24's care plan was reviewed. Review of the care plan indicated that it was not developed until 1/15/21, approximately 3 weeks after resident 24 was admitted . The care plan indicated that the facility was to monitor resident 24's weights every week.
Review of resident 24's graphed weight records revealed the following weights:
a. 1/3/21 - 157.1 lbs.
b. 2/7/21 - 155.8
c. 3/7/21 - 157.6
d. 4/4/21 - 150.8
e. 5/2/21 - 150.4
f. 6/6/21 - 148.2
g. 7/4/21 - 146.2
On 7/3/21, the RD documented that resident 24's weight was overall trending downward, although no acute significant loss. Resident weight upon initiation of TF (tube feeding) Jan (January) 2021 161.6 [lbs], currently 144 [lbs], [decrease] 10.9 [percent] [in] 7 months. RD to cont (continue) to watch [and] f/u (follow up)PRN (as needed). The RD recommended that resident 24's tube feeding rate be increased to 75 ml an hour for 24 hours.
Review of weekly weights provided by the DM revealed the following weights:
a. 7/11/21 - 146.0
b. 7/18/21 - 143.8
c. 7/25/21 - 143.0
d. 8/1/21 - 142.8
e. 8/8/21 - 142.0
f. 8/15/21 - 141.8
g. 8/22/21 - 139.8
Review of resident 24's physician orders revealed that despite weight loss from 7/4/21 through 8/22/21, the resident's tube feeding was not changed until 8/30/21. On 8/30/21, resident 24's tube feeding rate was increased to 85 ml an hour for 24 hours. It should be noted that between 7/4/21 and 8/22/21, resident 24 had lost approximately 6.4 lbs.
On 8/29/21, the RD documented that resident 24's weight was dropping, and that the trend downward not desired. The RD also documented that resident 24 had lost 2.2 percent of his body weight in one month. The RD recommended that resident 24's tube feeding rate be increased to 85 ml an hour for 24 hours.
Resident 24's care plan revealed that despite resident 24's weight loss and multiple changes in tube feeding rate, the care plan was not updated after 4/15/21.
Based on observations, interviews and record reviews, it was determined the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs as identified in the comprehensive assessment. Specifically, for 6 of 30 sample residents, residents did not have updated fall care plans or implementations of fall interventions, a resident did not have a care plan and interventions initiated for contractures, residents with activities care plans did not have interventions implemented, and a resident with unplanned weight loss did not have care plan interventions reviewed. Resident identifiers: 17, 24, 25, 27, 28, and 44.
Findings included:
1. Residents 17 and 27 had activities care plan with interventions not in place.
a. Resident 17 was originally admitted to the facility on [DATE] with medical diagnoses that included, but not limited to, Alzheimer's disease with dementia, hyperlipidemia, hypertension, major depressive disorder and history of Coronavirus disease 2019 (COVID-19).
On 8/29/21 at 1:45 PM, resident 17 was observed wandering in the 100 hall, entering residents rooms, and trying to open the doors at the front and back of the 100 hall.
Resident 17's record review was completed on 9/01/21. The following documentation was noted:
i. A care plan was noted with the focus of Resident is at potential risk for changes to mood, behavior, and psychosocial well being related to recent COVID-19 restrictions as dictated by the CDC [Centers for Disease Control and Prevention]. These restrictions make changes to visitation from resident's friends and family . Interventions/ Tasks: Offer supportive and in room activities that are of interest to resident.
ii. Within resident 17's paper chart was a care plan titled, Socially Inappropriate Behavioral Care Plan with an intervention Encourage increased socialization and participation in activities as a therapeutic use of distraction.
iii. Within resident 17's paper chart was a care plan titled, Altered Thought Process; Recreational Therapy had a Problem noted as, I have STM [Short Term Memory] and LTM [Long Term Memory] loss, I have difficulties with recall skills and orientation. I am easily distracted and have a short attention pan. I wander. Approaches were noted as, Involve me activities of appropriate cognitive level that might hold my attention, such as: music, manicure, special events, current events, exercise, cookouts, socials, outings, active games, crafts, reminisce, trivia, flower arranging.
On 08/30/21 at 1:25 PM, Certified Nursing Assistant (CNA) 2 stated the facility was not doing any in room activities at this time. CNA 2 also reported activities that are held included bingo, which was held on Wednesdays. CNA 2 reported, Since covid started [the facility] hasn't been doing anything. CNA 2 also reported the residents do not appear to have enough activities in the memory care unit, and the residents, seem to get bored.
On 08/31/21 at 3:30 PM, the Administrator was interviewed. The administrator expressed the staff are encouraged to do activities with the residents in the memory care unit, and the facility has had trouble following the posted activities schedule because they do not have the staff to hold activities.
On 9/1/21 at 11:07 AM, CNA 4 reported residents on the memory care unit wander a lot and staff try to keep residents busy, but that can be tough because the memory care unit does not have a lot of planned activities.
On 9/1/21 at 9:15 AM, Licensed Practical Nurse (LPN) 1 reported, There are not a lot of activities in the memory care unit. LPN 1 also stated the memory care unit does keep a movie playing at most times, and in the past, the unit did provide female residents with a nail painting activity. LPN 1 stated, It has been a while since we have done that.
b. Resident 27 was admitted to the facility on [DATE] with diagnoses which included, but not limited to, dementia, type 2 diabetes, chronic viral hepatitis C, hypertension, major depressive disorder, and osteoarthritis.
On 8/30/21 at 9:01 AM an observation was made of resident 27 laying on his bed. An interview was conducted. Resident 27 stated there were no activities when asked if he participated in facility activities.
Resident 27's medical record was reviewed on 8/30/21.
i. Resident 27's care plan revealed a focus of Resident is at potential risk for changes to mood, behavior, and psychosocial well-being related to recent COVID-19 restrictions as dictated by the [Centers for Disease Control and Prevention] CDC. These restrictions make changes to visitation from resident's friends and family. Interventions/tasks documented Offer supportive and in room activities that are of interest to resident.
ii. An activity assessment initiated on 3/21/19 revealed resident 27's activity preferences were 1:1, independent and small group activities. Activities of interest a were documented as being music, TV, Movies, social activities and cookouts. The activities assessment was reviewed on 7/1/19, 12/30/19, and 5/19/20.
iii. Resident 27's MDS documents were reviewed. On 3/30/21 the MDS documents keeping up with the news, doing things with groups of people, doing favorite activities, and going outside to get fresh air when the weather is good were very important.
On 8/30/21 at 2:53 PM, an observation was made of a Weekend Activity Book in the kitchen area. Inside the book were instructions for activities that could be held. The top of the first page was titled March Saturday Activities. Activities that were listed included an ice cream activity with instructions for staff to take the resident to the ice cream room to eat ice cream. A daily chronicle and word packet were included with instructions to pass it out to residents. Other activities that were listed were give out a deck of cards or a board game. A list of residents was included in the book with instructions to mark the residents that participated in the activities. There were no markings by any of the resident's names in the book.
On 8/31/21 at 3:19 PM, an interview with Certified Nursing Assistant (CNA) 3. CNA 3 stated the facility had not had an activities director for about 2 months. CNA 3 stated bingo was offered in the facility in the main part of the facility if residents wanted to go. CNA 3 stated a staff member would take the residents from the memory unit if they wanted to go. CNA 3 stated only 2 residents wanted to participate in bingo. CNA stated bingo was held on Tuesday afternoons. CNA 3 stated some days the residents colored and it helps them relax. CNA 3 stated when the virus hit activities were stopped completely. CNA 3 stated the facility resident advocate (RA) was in the facility 2-3 times per week and would visit with residents on a 1:1 basis.
2. Several residents (residents 25 and 44) had care plans without post-fall reviews or implementation of interventions per care plan documentation.
a. Resident 25 was originally admitted to the facility on [DATE] with medical diagnoses that included, but not limited to, Alzheimer's disease, major depressive disorder, hyperlipidemia, history of urinary tract infection, and history of COVID-19.
On 08/29/21 at 10:18 AM, resident 25 was observed seated on a sofa in the communal dining area. While wearing regular tube socks, resident 25 was then observed to attempt walking independently toward her wheelchair, through shuffling of her feet. CNA 1 was then observed to notice resident 25 attempting to walk independently toward her wheelchair located at the back of the sofa, and CNA 1 assisted resident 25 several more steps toward her wheelchair. Without locking the wheels of the wheelchair, CNA 1 helped to transfer resident 25 into her wheelchair. With CNA 1 standing to the left of the wheelchair, the wheelchair began to slightly roll backward as resident 25 went to sit and CNA 1 was able to stop the wheelchair from rolling away, enough that resident 25 was was able to transfer into the wheelchair without falling.
A review of resident 25's medical record was completed on 09/01/21. The following documentation regarding falls was noted:
i. Per resident 25's August 2021 Minimum Data Set (MDS) assessment, resident 25 was coded as having had two or more falls since the previous assessment.
ii. A Health Status Note following a fall on 3/3/2021 read, Note Text: Resident was left sitting in [wheelchair] next to [the] bed. The CNA went to go assist her roommate and [resident 25] tried to transfer herself into her bed. [Resident 25's] bed was higher than the [wheelchair], and she slid down onto the floor onto her buttocks. The fall was witnessed by the CNA whom was assisting her roommate. She was assisted into bed. [Moves all extremities] without pain. No injuries noted. MD [Medical Doctor] notified of fall at 1335, family at 1345 and administrator at 1350. Vital signs taken .
iii. A Health Status Note following a fall on 4/16/2021 read, Note Text: CNA's reported [resident 25] fell this morning and hit her head. Saw [resident 25] during my shift, awake and alert, no signs of being in pain, took med, will continue to monitor.
iii. A Health Status Note following a fall on 6/17/21 read, Note Text: Resident was on the couch in the dining room/TV area and slid off couch, unsure if she hit her head and no head injury noted, no bruises or open wounds, Neuro checks started/implemented. Neuros WNL [within normal limits], .Resident was assisted off the floor and able to stand and answer to yes/no questions. MD [name] notified. Will continue to monitor. Awaiting for UA [urine analysis] results from lab as UA was collected last night.
iv. A Health Status Note following a fall on 7/23/21 read, Note Text: at 19:38 this evening, resident found on floor in dining room by wheelchair, possible fall, alert, nonverbal but cooperative, no injuries noted, vitals taken by CNA . MD notified and family notified will continue to monitor.
v. Within resident 25's medical record, post-fall completed neuro reports were unable to be found. On 09/01/21 at 2:13 PM, the Director of Nursing (DON) stated completed neuro reports are kept after completion, and the facility staff will have them sent via email. On 09/01/21 at 2:00 PM, an email with completed neuro reports from resident 25's falls was received. Neuro reports dated 4/16/21 through 4/17/21 were provided. No other neuro reports were sent via email. The missing post fall neuro reports were from falls occurring on 6/17/21 and 7/23/21. [Note: Per interviews with facility staff, the fall policy specifies, if a fall is witnessed and the resident does not hit their head neuro checks are not initiated].
vi. Resident 25's care plans titled, Actual Fall Care Plan initiated on 12/16/20 was reviewed. Per care plan new intervention and review of Actual Fall Care Plan was completed on 12/16/20 and 3/3/21. Interventions per care plan included, Follow facility fall protocol for post fall interventions, and, Lock w/c [wheelchair]. [Note: Fall documentation was present from falls on 3/3/21, 4/16/21, 6/17/21, and 7/23/21. No care plan updates noted on 4/16/21, 6/17/21 or 7/23/21 per Actual Fall Care Plan within resident 25's medical record.]
b. Resident 44 was originally admitted to the facility on [DATE] with medical diagnoses that included, but not limited to, paranoid schizophrenia, major depressive disorder, hypertension, heart failure, chronic obstructive pulmonary disease, gastro-esophageal reflux disease, diverticulosis, hypoxemia, urinary incontinence, morbid obesity, type 2 diabetes mellitus, pulmonary edema, asthma, adenoviral pneumonia, acute and chronic respiratory failure, obstructive sleep apnea, chronic kidney disease, anemia in chronic kidney disease, history of urinary tract infection, osteoarthritis, chronic pain and history of COVID-19.
On 8/29/21 at 11:18 AM, resident 44 was observed ambulating, with a shuffle gait, wearing regular tube socks, while wearing a skirt with a length that cause the skirt to wrap underneath the front of resident 44's feet. A CNA was observed to attempt raising the skirt, which did subsequently wrap around the front of resident 44's feet again.
A review of resident 44's medical record was completed on 09/01/21. The following documentation regarding falls was noted:
i. A Health Status Note from 6/29/2021 read, Note Text: Resident had a fall in the memory hall dining room at 10:45a.m. no injuries noted. Resident stated she got up from the chair and slipped on the floor because it was just mopped and bumped her [left] side of her head on the dining table . Neuro checks implemented . Informed MD [Medical Doctor] and family. Will continue to monitor.
ii. A General Note from 7/15/2021 read, Note Text: [Resident] was found siting on the floor facing the toilet with one sock on and one sock off ppt [patient] is c/o [complaining of] bottom hurting and states that she hit her head MD notified Will (sic) pass on to next shift to call the family . WCTM [Will continue to monitor].
iii. A Health Status Note from 7/23/2021 read, Note Text: [Resident 44] was a little sore walking today but no sign of difficulty walking around . Fell yesterday was not reported to nurse, unable to assess for pain but no verbal complaints of pain given to nurse.
iv. A General Note from 8/30/21 read, Note Text: Resident was found on her bum after slipping out of w/c. Her socks on her left foot was found half on. No apparent injury, abrasions, contusions. Unwitnessed fall, neuros started. MD notified and family notified.
v. Within resident 44's medical record, post-fall completed neuro reports were unable to be found. On 09/01/21 at 2:13 PM, the Director of Nursing (DON) stated completed neuro check reports are kept after completion, and the facility staff will have them sent via email. On 09/01/21 at 2:00 PM, an email with completed neuro reports from resident 44's falls was received. Neuro reports dated from 6/29/21 through 07/02/21 were provided. No other neuro reports were sent via email. The missing post fall neuro reports were from falls occurring on 7/15/21, 7/23/21 and 8/30/21. [Note: Per interviews with facility staff, the fall policy specifies, neuro checks would be initiated if a fall is unwitnessed or the resident hits their head].
v. Incident/Accident Reports from falls on 6/29/21, 7/15/21, and 8/30/21 were provided. Per Incident/Accident Report from 8/30/21, Additional comments and/or steps taken to prevent recurrence: Ensure socks/footwear is (sic) on properly.
vi. Within resident 44's electronic medical record was a Care Plan with the focus of, The resident is Low risk for falls r/t unsteadiness fall 2/2018, and an intervention/task written as, Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c. The most recent time this care plan was revised was on 05/10/2018.
vii. Within resident 44's paper chart was a document entitled Actual Fall Care Plan. Per the Actual Fall Care Plan, adjustments and review of the fall related care plan interventions was completed on 12/25/20, 7/15/21 and 7/22/21. Per the Actual Fall Care Plan, an intervention included, Follow facility fall protocol for post fall interventions. [Note: Review of resident 44's fall care plan was not evident post fall on 6/29/21 or 8/30/21.]
Following resident 44's fall on 8/30/21 staff working in the Memory Care Unit were interviewed on 08/31/21. The following information was gathered:
i. On 08/31/21 at 10:32 AM, CNA 6 reported being unaware resident 44 had fallen yesterday. CNA 6 stated when a resident has a fall the CNA's will be provided the information during report at the beginning of their shift. This helps the CNA's to know which residents they have to complete neuro check reports on. CNA 6 reported she was not provided a neuro check report for resident 44 and had not been checking her vitals per the facility's fall protocol.
ii. On 08/31/21 at 11:03 AM, RN 3 reported not being informed of resident 44's fall during report at the beginning of her shift. RN 3 reported she had just found out resident 44 had a fall because of an alert on resident 44's electronic medical record that indicated RN 3 needed to complete a post-fall note during her shift. RN 3 stated the neuro check report should have been started following resident 44's fall on 8/30/21, but RN 3 was unsure where the neuro check report would be kept or if the neuro check report had been initiated post-fall. RN 3 also stated following this fall an intervention to prevent further falls would include, to ensure resident 44 was wearing proper footwear. RN 3 stated, [Resident 44] should not be wearing just socks.
On 08/30/21 at 1:49 PM, CNA 2 was interviewed regarding the facility's fall protocol. CNA 2 stated following identification of a fall the CNA would call the nurse or radio for help, take the resident's vitals, help the resident to get up, and then the nurse would contact the family and the doctor. Following a fall, the CNA staff are to complete a neuro check report for a certain time frame if the resident hit their head during the fall or if the fall was unwitnessed. Once the neuro check report was completed it was provided to the nurse, and CNA 2 was unsure what happened to the information after it was provided to the nurse.
On 09/01/21 at 10:20 AM, the DON reported when a fall is unwitnessed the fall would be treated by gathering vitals, assessing the resident, and then contacting the doctor and family. The DON reported if the fall is unwitnessed, staff can not know if the resident hit their head, so the CNA's do the vitals and neuros as specified on the neuro check reports. When asked about updating care plans post-falls, the DON stated she had tried to train all the nurses on how to update the care plans. The DON stated, I try to put the monkey on their back. The DON stated it can be hard for her to follow-up on all falls to ensure the care plans were updated, but the DON reported trying to audit the resident care plans once having received the incident/accident reports. The DON stated when reviewing the care plans she looked to see what interventions were in place and how the fall interventions could be adjusted.
On 09/01/21 at 01:20 PM, the DON was interviewed regarding footwear of the residents. When asked what would constitute appropriate footwear, as specified in resident 44's care plan, the DON stated proper footwear was shoes or non-skid slippers. The DON also stated, We do not have any non-skid slippers in stock, and then elaborated, hopefully this gets us some.
3. A resident (resident 28) was identified to have contractures, per documentation within resident 28's medical record, but did not have a care plan or interventions in place for treatment or prevention of worsening contractures.
a. Resident 28 was originally admitted to the facility on [DATE], with medical diagnoses that included, but not limited to, Alzheimer's disease with dementia, restlessness and agitation, dizziness and giddiness, repeated falls, diarrhea, polyneuropathy, hyperlipidemia, hypothyroidism, chronic leukemia, history of urinary tract infection, pleural effusion, depressive episodes and chronic respiratory failure with hypoxia.
On 08/30/21 at 08:19 AM, resident 28 was observed at breakfast attempting to hold a cup with her left hand. After three attempts at grasping the cup, resident 28 was able to grasp the cup in order to bring it to her mouth. At this time, resident 28's right hand was closed and kept close to her body.
On 08/30/21 at 11:38 AM, there were no splints or assistive devices to prevent contractures present at resident 28's bedside.
On 09/01/21 at 12:00 PM, resident 28 was observed at lunch. After attempting to use a fork to eat the meal, resident 28 was unable to grasp the fork with her left hand, and resident 28 ended up putting the fork back down on the table. Using her left hand, resident 28 was then observed to grasp the meat patty from her plate and was able to bring it to her mouth.
A review of resident 28's medical record was completed on 09/01/21. The following documentation regarding contractures was present:
i. A Weekly Note from 5/13/21 stated, Resident . Uses w/c [wheelchair] for mobility, has contractures in both hands.
ii. A Weekly Note from 7/15/21 stated, Rt. [Right] hand fully closed d/t [due to] contractures and Lt. [left] hand is partially contracted.
iii. A Weekly Note from 7/22/21 stated, Resident has hand contractures and right hand completely closed.
iv. A Weekly Note from 8/5/21 stated, Resident has contractures to both hands and Right (sic) hand contracture is completely closed.
v. A Weekly Note from 8/26/21 stated, Contractures to both hands and left hand [resident] is still able to use and right hand is completely closed (sic).
vi. Resident 28's MDS assessment history was reviewed regarding functional status and Functional Limitation in Range of Motion. MDS records from 12/28/20, 3/30/21, and 6/30/21 indicated, Upper Extremity (shoulder, elbow, wrist, hand) . Impairment on one side. [Note: per nursing documentation resident with contractures to both hands].
vii. Occupational Therapy (OT) documentation from therapy services was present from 12/10/19 to 3/8/20. OT documentation indicated resident 28 was seen for Contracture; right hand.
viii. On 08/30/21 at 12:08 PM, resident 28's care plan was reviewed. Within resident 28's electronic care plan, no care plan related to contractures was noted.
On 08/30/21 at 11:30 AM, CNA 2 reported being unaware if resident 28 had any contractures, and CNA 2 reported staff are not doing anything to prevent or treat any contractures resident 28 is suffering from.
On 09/01/21 at 9:20 AM, LPN 1 reported being aware of resident 28's contractures. LPN 1 stated, in the past, LPN 1 had tried to place a rolled cloth into resident 28's right hand, which is fully contracted, but he was unable to open the right hand. LPN 1 also stated there are no consistent interventions in place to help prevent further contracture to resident 28's left or right hand. LPN 1 stated, resident 28 can currently use her left hand for some activities like eating.
On 09/01/21 at 9:33 AM, the DON stated at this time there are no interventions in place to prevent further contracture to resident 28's left hand.
On 09/01/21 at 11:59 AM, CNA 4 stated in the past CNA 4 had observed LPN 1 trying to place a towel in resident 28's right hand, but LPN 1 was not able to get the towel inside of resident 28's right hand. CNA 4 stated, at this time, the CNA staff are not doing anything to prevent further contractures to resident 28's left or right hand.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0680
(Tag F0680)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility did not have an activities program that was directed by a qualified professional who is a qualified therapeutic recreation specialist. Specifically, ...
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Based on record review and interview, the facility did not have an activities program that was directed by a qualified professional who is a qualified therapeutic recreation specialist. Specifically, the facility did not employ a Certified Therapeutic Recreation Specialist.
Findings include:
On 8/31/21, the facility Business Office Manager (BOM) provided the consultant notes from the facility Certified Therapeutic Recreation Specialist (CTRS) for the previous 10 months. The consultant notes indicated that the CTRS had not provided oversight from 11/30/20 until 5/25/21. The notes also indicated that the CTRS did not provide oversight in June 2021.
On 8/31/21, an interview was conducted with the facility Administrator (ADM). The ADM confirmed that the CTRS did not provide oversight from 11/30/20 to 5/25/21.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected multiple residents
Based on observation and interview, it was determined that the facility did not have the nurse staffing information posted. The facility must post the following information on a daily basis: Facility ...
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Based on observation and interview, it was determined that the facility did not have the nurse staffing information posted. The facility must post the following information on a daily basis: Facility name, the current date, the resident census, and the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered nurses, Licensed practical nurses, and Certified nurse aides. The facility must post the nurse staffing data on a daily basis at the beginning of each shift. Specifically, the nurse staffing data was not posted on a daily basis and the daily resident census was not accurate.
Findings include:
On 8/29/21 at 8:21 AM, an interview was conducted with Registered Nurse (RN) 3. RN 3 stated she was not sure what the resident census was for the day but information could be located on the nurse staffing post located by the medication storage room.
On 8/29/21 at 8:21 AM, the nurse staffing post was observed. The nurse staffing post was dated 8/26/21, and the current census was documented as 47.
On 8/30/21 at 8:00 AM, the nurse staffing post was observed. The nurse staffing post was dated 8/26/21, and the current census was documented as 47.
On 8/31/21 at 8:00 AM, the nurse staffing post was observed. The nurse staffing post was dated 8/26/21, and the current census was documented as 47.
On 9/1/21 at 7:23 AM, the nurse staffing post was observed. The nurse staffing post was dated 8/26/21, and the current census was documented as 47.
On 9/1/21 at 9:29 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the nurse staffing post was being completed by the Administrator and the Business Manager. The DON stated that recently she given the assignment of the nurse staffing post and she would have one of the Certified Nursing Assistants complete the posting. The DON further stated the night nurse that was in the facility after 11:00 PM, would complete the nurse staffing post every night. The DON stated that she relied on the night nurse to post the nurse staffing post every night.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation and interview it was determined that the facility did not ensure that all drugs and biologicals were labeled in accordance with currently accepted professional principles and incl...
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Based on observation and interview it was determined that the facility did not ensure that all drugs and biologicals were labeled in accordance with currently accepted professional principles and included the expiration date when applicable. In addition, drugs and biologicals must be stored in locked compartments and permit only authorized personnel to have access to the keys. Specifically, medications and multi-dose vials of insulin and Tubersol were opened, expired, and available for use. An unidentified medication cup with an unidentified substance was not labeled in the medication cart. In addition, the treatment cart was observed on two separate occasions unlocked and unattended.
Findings include:
1. On 8/29/21 at 8:14 AM, an initial tour was conducted of the facility. The treatment cart located in the central area of the facility next to the medication storage room was observed to be unlocked. The two nurses on shift were passing morning resident medications and the other staff present were assisting residents. The treatment cart was observed to be unattended by staff. At 9:08 AM, a staff member locked the treatment cart.
On 8/31/21 at 10:18 AM, the treatment cart was inspected and contained the following items:
a. The top drawer contained: bandage scissors, paper scissors, 13 non-safety scalpels, pocidone-iodine swabsticks, lubricating jelly, alcohol prep pads, safety hypodermic needles, toenail clippers, woven gauze sponges, and skin barrier film non sting wipes.
b. The second drawer from the top contained: skin closure strips reinforced, abdominal pads sterile, suture removal kit, powder free synthetic gloves, antifungal powder, moisturizing body lotion, wound dressing ointment, stomahesive protective powder, clotrimazole, hydrocortizone cream 1% tube, 2 terbinafine hydrochloride cream 1%, hydro gel, venelex ointment, A&D ointment, 3 jars of silver sulfadiazone cream, hydrocortisone cream 2.5%, Medihoney, Medihoney 80% gel, Silver sulfadiazine 1% cream, and Santyl 250 unit/gram ointment. [Note: The Santyl 250 unit/gram ointment was labeled with a resident name, available for use in the treatment cart, and had an expiration date of 6/20.]
c. The third and fourth drawer from the top contained: bandages.
d. The fifth drawer from the top contained: a bottle of hydrogen peroxide, Eucerin creams, dermal wound cleaner, nystatin cream, hydrocortisone creams, diclofenca sodium gel 1%, Nyamyc nystatin topical powder, triamcinolone cream, Prep H (hemorrhoid cream), muscle rub, triple antibiotic, bengay, and powder.
On 9/1/21 at 8:39 AM, the treatment cart located in the central area of the facility next to the medication storage room was observed to be unlocked. The treatment cart was observed to be unattended by staff. At 9:30 AM, the treatment cart was observed to still be unlocked.
2. On 8/31/21 at 7:14 AM, the medication administration task was being conducted. Registered Nurse (RN) 3 was observed preparing medications for a resident. An unidentified medication cup with an unidentified substance and a spoon was observed in the top drawer of the medication cart. The medication cup was not labeled.
On 8/31/21 at 7:46 AM, an interview was conducted with RN 3. RN 3 stated she had prepared the medications for a resident and the staff took the resident to the shower room. RN 3 stated the cup was not labeled with resident information. RN 3 stated if more than one resident medication cup was in the drawer she would label the cup with the resident name. RN 3 stated she did not like to prepare resident medications without administering them.
3. On 8/31/21 at 10:08 AM, RN 3's medication cart was inspected and the following items were expired and available for use: [Note: Multi-dose vials of insulin should be discarded within 28 days after opened or accessed.]
a. A multi-dose vial of Novolog insulin had an open date of 7/27/21, and an expiration date of 8/25/21. [Note: The Novolog insulin should have been discarded on 8/23/21.]
b. A multi-dose vial of Novolog insulin had an open date of 8/1/21. [Note: The Novolog insulin should have been discarded on 8/28/21.]
c. A multi-dose vial of Novolog insulin had an open date of 7/27/21, and an expiration date of 8/25/21. [Note: The Novolog insulin should have been discarded on 8/23/21.]
d. A Humalog Kwikpen was not labeled with an open date or an expiration date.
e. A Lantus pen was not labeled with an open date or an expiration date.
On 8/31/21 at 10:16 AM, an interview was conducted with RN 3. RN 3 stated multi-dose vials of insulin should be disposed of 28 days after opening.
4. On 8/31/21 at 10:48 AM, the medication fridge within the storage room was inspected and the following items were expired and available for use:
a. A multi-dose vial of Tubersol had an open date of 11/5/2020. [Note: Multi-dose vials of Tubersol should be discarded within 30 days after opening.]
b. A bottle of Magic mouth wash suspension had an expiration date of 6/21/21.
On 8/31/21 at 11:00 AM, an interview was conducted with RN 4. RN 4 stated there was not a system for pulling expired medications from the medication carts. RN 4 stated she would write open dates on items and would pay attention to the dates.
On 8/31/21 at 11:15 AM, an interview was conducted with RN 3. RN 3 stated she was usually good at keeping the treatment cart locked but she could get distracted. RN 3 stated it was especially important to keep the treatment cart locked on the memory care unit because they had residents that liked to get into the cart. RN 3 stated she tried to keep the treatment cart locked.
On 9/1/21 at 9:29 AM, an interview was conducted with the Director of Nursing (DON). The DON stated medications should be labeled and there was a sheet on the medication fridge indicating when medications were expired. The DON stated the night shift nurses should be doing medication fridge and medication cart checks for expired medications. The DON stated there should be no excuses because she had been going over the expired medications since July. The DON stated she went by the Tubersol expiration date on the vial and she was not aware the Tubersol had to be discarded 30 days after opening. The DON stated the medication carts, treatment carts, and medication storage room should be locked at all times. The DON stated she had told the staff on numerous occasions to make sure those items are always locked. The DON stated she needed to meet with the staff and charge nurses and provide additional education.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations and interviews, it was determined the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, ...
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Based on observations and interviews, it was determined the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, prepared food items were stored within the kitchen's walk-in fridge for longer than the facilities 7-day policy, expired dairy products were stored within the kitchen's walk-in refrigerator, an item was stored open to air within the kitchen's walk-in freezer, and mighty shakes with packaging that was labeled Store Frozen were stored in the facility's unit refrigerator without a date when the items left the facility's freezer.
Findings include:
1. On 8/29/21 at 8:39 AM, during an initial tour of the kitchen, the facility's walk-in refrigerator was examined.
a. Buttermilk stored in the walk-in fridge was observed to have separated, and the packaging was labeled with a best by date of 8/18/21.
b. Heavy whipping cream that was stored in the walk-in fridge was labeled with an open date of 8/3/21, and a best by date of 8/9/21.
c. Prepared tuna salad was stored in a container and covered with plastic wrap with prepared date of 8/19/21. [Note: 11 days have passed from 8/19/21 until observation date on 8/29/21.]
On 08/29/21 at 8:42 AM, the kitchen cook was interviewed. The kitchen cook reported all the kitchen employees shared responsibility in cleaning the fridge. It is the kitchen's policy that prepared items should get thrown away after 7 days. Also, any expired items should be thrown away when the fridge was cleaned.
2. On 8/31/21 at 7:30 AM, during a follow-up visit to the kitchen, the walk-in freezer was observed. Within the freezer was a box of orange juice concentrate stored on the floor of the freezer. Also, a package of hashbrowns was observed stored open to air.
3. On 8/31/21 at 10:57 AM, the memory care unit refrigerator was examined. Within the unit refrigerator, 26 Mighty Shakes were stored. The packaging read Store Frozen. The Mighty Shakes were not labeled with a date they left storage in the freezer and were placed in the unit fridge. [Note: Recommendations for storage and use of Mighty Shakes published by the manufacturer read, Once opened, shelf life is 14 days, when kept refrigerated.]
On 8/31/21 at 1:28 PM, the Dietary Manager (DM) was interviewed. The DM reported she was unaware of what the stock of Mighty Shakes was within the unit fridge. The DM reported the kitchen staff did not date the Mighty Shakes when they were taken from the freezer and placed in the unit fridge.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility did not ensure that medical records were complete and accurate for 6 of 30 s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility did not ensure that medical records were complete and accurate for 6 of 30 sample residents. Specifically, documentation was not complete in residents' Medication Administration Records, and resident documents were located in the wrong resident's medical record. Resident identifiers: 4, 7, 14, 24, 41, and 98.
Findings include:
1. Resident 24 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included COVID-19, schizophrenia, anxiety disorder, conversion disorder, chronic kidney disease, and cognitive communication deficit.
Resident 24's medical record was reviewed on 8/29/21.
Review of resident 24's physician orders revealed that as of 7/5/21 resident 24 was to receive a tube feeding, Replete with fiber 75 milliliters an hour for 24 hours.
Review of resident 24's August 2021 Medication Administration Record (MAR) revealed that facility staff were to hang a tube feeding formula twice a day. The MAR indicated that facility staff did not document that resident 24 received his evening enteral feedings on the following dates: 8/4/21, 8/12/21, 8/15/21, 8/18/21, and 8/24/21.
2. Resident 14 was admitted on [DATE] with diagnoses that included dementia and major depressive disorder.
Resident 14's medical record was reviewed on 8/31/21.
A document entitled Skin/Hydration/Weight Meeting for resident 42 was located in resident 14's medical record.
On 8/31/21 at 1:00 PM, an interview was conducted with Registered Nurse (RN) 4. RN 4 confirmed that resident 42's Skin/Hydration/Weight notes were incorrectly placed in resident 14's medical record.
3. Resident 41 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included Wernicke's encephalopathy, psychosis, alcohol-induced persisting dementia, and chronic pain.
Resident 41's medical record was reviewed on 8/31/21.
Resident 41's July and August 2021 MAR was reviewed. The following treatments and medications were not documented as having been administered:
a. ANTIANXIETY MEDICATION -MONITOR FOR DROWSINESS, SLURRED SPEECH, DIZZINESS, NAUSEA, AGGRESSIVE/IMPULSIVE BEHAVIOR. This was not documented on 7/3/21, 7/8/21, 7/10/21, 7/11/21, 8/9/21, 8/20/21, 8/22/21, 8/24/21, or 8/26/21.
b. Antianxiety target behavior #2: [STATEMENTS OF IMPENDING DOOM]. This was not documented on 7/3/21, 7/8/21, 7/10/21, 7/11/21, 8/9/21, 8/20/21, 8/22/21, 8/24/21, or 8/26/21.
c. Antianxiety target behavior: [REPETITIVE ANXIOUS QUESTIONS/CONCERNS]. This was not documented on 7/3/21, 7/8/21, 7/10/21, 7/11/21, 8/9/21, 8/20/21, 8/22/21, 8/24/21, or 8/26/21.
d. ANTIDEPRESSANT MEDICATION - MONITOR FOR INCREASED SEDATION/DROWSINESS, DRY MOUTH, BLURRED VISION, URINARY RETENTION, TACHYCARDIA, MUSCLE TREMOR, AGITATION, HEADACHE, SKIN RASH, PHOTOSENSITIVITY OF SKIN, EXCESS WEIGHT GAIN. This was not documented on 7/3/21, 7/8/21, 7/10/21, 7/11/21, 8/9/21, 8/20/21, 8/22/21, 8/24/21, or 8/26/21.
e. Antidepressant target behavior: Irritibility (sic). This was not documented on 7/3/21, 7/8/21, 7/10/21, 7/11/21, 8/9/21, 8/20/21, 8/22/21, 8/24/21, or 8/26/21.
f. ANTIPSYCHOTIC MEDICATION -MONITOR FOR DRY MOUTH, CONSTIPATION, BLURRED VISION, DISORIENTATION/CONFUSION, DIFFICULTY URINATING, HYPOTENSION, DARK URINE, YELLOW SKIN, N/V, LETHARGY, DROOLING, EPS SYMPTOMS (TREMORS, DISTURBED GAIT, INCREASED AGITATION, RESTLESSNESS, INVOLUNTARY MOVEMENT OF MOUTH OR TONGUE). This was not documented on 7/3/21, 7/8/21, 7/10/21, 7/11/21, 8/9/21, 8/20/21, 8/22/21, 8/24/21, or 8/26/21.
g. Antipsychotic target behavior #2: [PARANOIA-people out to get him]. This was not documented on 7/3/21, 7/8/21, 7/10/21, 7/11/21, 8/9/21, 8/20/21, 8/22/21, 8/24/21, or 8/26/21.
h. Antipsychotic target behavior: [DISTRESSING DELUSIONS]. This was not documented on 7/3/21, 7/8/21, 7/10/21, 7/11/21, 8/9/21, 8/20/21, 8/22/21, 8/24/21, or 8/26/21.
i. Monitor for serotonin syndrome: monitor for agitation or restlessness, confusion, rapid heart rate and high blood pressure, dilated pupils, loss of muscle coordination or twitching muscles, heavy sweating, diarrhea, headache, shivering or goose bumps. every day and night shift. This was not documented on 7/3/21, 7/8/21, 7/10/21, 7/11/21, 8/9/21, 8/20/21, 8/22/21, 8/24/21, or 8/26/21.
j. MOOD STABILIZER MEDICATION - MONITOR FOR DRY MOUTH, CONSTIPATION, BLURRED VISION, DISORIENTATION/CONFUSION, DIFFICULTY URINATING, HYPOTENSION, DARK URINE, YELLOW SKIN, N/V (nausea/vomiting), LETHARGY, DROOLING, EPS (extrapyramidal syndrome) SYMPTOMS (TREMORS, DISTURBED GAIT, INCREASED AGITATION, RESTLESSNESS, INVOLUNTARY MOVEMENT OF MOUTH OR TONGUE). This was not documented on 7/3/21, 7/8/21, 7/10/21, 7/11/21, 8/9/21, 8/20/21, 8/22/21, 8/24/21, or 8/26/21.
k. Mood Stabilizer target behavior: Mood swings. This was not documented on 7/3/21, 7/8/21, 7/10/21, 7/11/21, 8/9/21, 8/20/21, 8/22/21, 8/24/21, or 8/26/21.
l. Lorazepam 0.5 milligrams (mg) twice daily was not documented as being administered on 7/2/21, 7/9/21, 7/14/21, 7/16/21, 8/2/21, 8/6/21, 8/9/21, 8/13/21, 8/16/21, 8/23/21 or 8/27/21 in the morning. It was also not documented as being administered on 8/20/21 in the evening.
m. Oxycodone 5 mg twice daily was not documented as being administered on 7/2/21, 7/9/21, 7/14/21, 7/16/21, 8/2/21, 8/6/21, 8/9/21, 8/13/21, 8/16/21, 8/23/21 or 8/27/21 in the morning.
n. Cyclobenzaprine 10 mg three times daily was not documented as being administered on 8/20/21 in the evening.
4. Resident 4 was admitted to the facility on [DATE] with diagnoses which included but not limited to major depressive disorder, post-traumatic stress disorder, generalized anxiety, chronic migraine, conversion disorder with seizures or convulsions, personal history of traumatic brain injury, and bradycardia.
Resident 4's medical record was observed on 9/1/21.
A. An APPOINTMENT REFERRAL FORM for resident 4 was located within the paper medical record. Additional paper work belonging to a discharged resident and a Life Safety Code Documentation Checklist for Skilled Nursing Facilities was attached to resident 4's appointment referral form.
B. The August 2021 MAR was reviewed. The following medications were not documented as having been administered at bedtime on 8/4, 8/12, 8/15, 8/18, 8/24, and 8/30.
a. Abilify 5 mg daily (QD) related to (r/t) depressive disorder with psychotic symptoms.
b. Lamotrigine 150 mg QD r/t conversion disorder with seizures or convulsions.
c. Methocarbarnol 500 mg QD for muscle relaxant.
d. Topiramate 25 mg QD r/t conversion disorder with seizures or convulsions.
e. Trazodone 150 mg 2 tablets QD for insomnia r/t major depressive disorder with psychotic symptoms.
f. Clonazepam 1 mg two times a day (BID) r/t generalized anxiety disorder.
g. Keppra 500 mg BID r/t conversion disorder with seizures or convulsions.
h. Hydroxyzine 50 mg four times a day (QID) r/t generalized anxiety disorder.
In addition, Gabapentin 400 mg three times a day for neuropathic pain and Hydroxyzine 50 mg QID r/t generalized anxiety disorder were not documented in the PM on 8/4, 8/15, and 8/30.
5. Resident 7 was admitted to the facility on [DATE] with diagnoses which included but not limited to type 2 diabetes mellitus without complications, mood disorder, essential hypertension, atherosclerotic heart disease, and chronic kidney disease.
Resident 7's medical record was reviewed on 8/30/21.
The August 2021 MAR was reviewed. The following medications and treatments were not documented as having been administered at bedtime on 8/4, 8/12, 8/18, 8/24, 8/30, and 8/31.
a. Atorvastatin Calcium 40 mg QD for hyperlipidemia.
b. Senna 8.6 mg QD for constipation.
c. Blood pressure (BP) parameters. Hold BP medications and notify Medical Director if systolic is less than 110 or greater than 180.
d. Metformin 500 mg BID r/t type 2 diabetes mellitus without complications.
e. Metoprolol Tartrate 25 mg BID r/t essential hypertension.
f. Lantus Solution 100 Unit/milliliter 30 units QD r/t type 2 diabetes mellitus without complications. Additionally, the Lantus Solution was not documented on 8/15/21.
Furthermore, blood sugar checks before meals and at bedtime were not documented on 8/2 at 11:00 AM, 8/3 at 9:00 PM, 8/4 at 9:00 PM, 8/12 at 4:00 PM and 9:00 PM, 8/13 at 4:00 PM, 8/18 at 4:00 PM and 9:00 PM, 8/24 at 4:00 PM and 9:00 PM, 8/30 at 9:00 PM, and 8/31 at 4:00 PM and 9:00 PM.
6. Resident 98 was admitted to the facility on [DATE] with diagnoses that included sepsis, viral pneumonia, chronic obstructive pulmonary disease, acute respiratory failure, congestive heart failure, protein-calorie malnutrition, and dementia.
Resident 98's medical record was reviewed on 8/29/21 and again on 8/31/21.
Resident 98's physician orders were reviewed. Resident 98 had the following medications prescribed:
A. On 8/22/21, Lorazepam 2 milligrams per milliliter (mg/ml) 0.5 ml by mouth every 8 hours for anxiety and restlessness. [Note: Lorazepam is an anti-anxiety medication.]
Resident 98's August 2021 Medication Administration Record (MAR) was reviewed.
a. On 8/23/21, the resident was not administered Lorazepam at 12:00 AM or 8:00 AM. Review of the narcotic record revealed that the Lorazepam was administered at 12:00 AM and 8:00 AM.
b. On 8/25/21, the MAR indicated that the resident was not administered Lorazepam at 12:00 AM. However, the narcotic record revealed that a dose was given at 12:00 AM.
c. On 8/26/21, the MAR indicated that he resident was not administered Lorazepam at 12:00 AM. However, the narcotic record revealed that a dose was given at 12:00 AM.
d. On 8/28/21, the resident was not administered Lorazepam at 8:00 AM. However, review of the narcotic record revealed that the Lorazepam was administered at 8:00 AM.
e. On 8/29/21, the resident was administered Lorazepam at 8:00 AM. Review of the narcotic record revealed that the Lorazepam was not administered at 8:00 AM.
f. On 8/30/21, the resident was not administered Lorazepam at 12:00 AM. However, the narcotic record revealed that a dose was given at 12:00 AM.
B. On 8/22/21, Dilaudid 1 mg/ml 0.5 ml by mouth every 4 hours for pain of shortness of breath.
Resident 98's August 2021 MAR was reviewed.
a. On 8/23/21, the Dilaudid was not administered at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, or 8:00 PM. Review of the narcotic record revealed that the Dilaudid was not administered at noon, 4:00 PM, or 8:00 PM.
b. On 8/24/21, the Dilaudid was not administered at 12:00 AM or 4:00 AM. Review of the narcotic record revealed that the Dilaudid was not administered at 12:00 AM, 4:00 AM, 12:00 PM or 8:00 PM.
c. On 8/25/21, the Dilaudid was not administered at 12:00 AM or 4:00 AM. The narcotic sheets did not indicate that Dilaudid was administered on this date.
d. On 8/26/21, the Dilaudid was not administered at 12:00 AM or 4:00 AM. The narcotic sheets did not indicate that Dilaudid was administered on this date.
e. On 8/27/21, the Dilaudid was not administered at 12:00 AM, 4:00 AM or 12:00 PM. The narcotic sheets did not indicate that Dilaudid was administered on this date.
f. On 8/28/21, the Dilaudid was not administered at 12:00 AM, 4:00 AM, or 8:00 AM. The narcotic sheets did not indicate that Dilaudid was administered on this date.
g. On 8/29/21, the Dilaudid was not administered at 12:00 AM, 4:00 AM, or 8:00 AM. The narcotic sheets did not indicate that Dilaudid was administered on this date.
h. On 8/30/21, the Dilaudid was not administered at 12:00 AM or 4:00 AM. The narcotic sheets did not indicate that Dilaudid was administered on this date.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility did not ensure that the Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of correction to correct identif...
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Based on interview and record review, the facility did not ensure that the Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of correction to correct identified quality deficiencies. Specifically, the facility was found to be in non-compliance at a harm level with F688 and F692, as well as at substandard quality of care in F679. In addition, several deficiencies were cited during the 2019 recertification survey, and again during the 2021 survey. Resident identifiers: 5, 13, 15, 17, 22, 24, 25, 27, 28, 32, 35, 36, 42, and 43
Findings include:
1. Based on interview, observation and record review, the facility did not provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 14 of 30 sample residents. Resident identifiers: 5, 13, 15, 17, 22, 24, 25, 27, 28, 32, 35, 36, 42, and 43.
[Cross refer to F679]
2. Based on interview and record review, the facility did not ensure that 1 of 30 sample residents maintained acceptable parameters of nutritional status. Specifically, a resident who was exclusively tube fed lost weight without timely interventions to prevent further weight loss. The findings were cited at a harm level. Resident identifier: 24.
[Cross refer to F692]
3. Based on observations, interviews and record review it was determined the facility did not ensure a resident with limited range of motion received appropriate treatment and services to increase their range of motion and to prevent further decrease in range of motion. Specifically, a resident with documentation of a contracture to the right and left hand was not provided with treatment and services to increase their range of motion or to prevent further decrease in range of motion. This finding resulted in a harm deficiency. Resident identifier: 28.
4. During the an abbreviated complaint survey completed on 6/9/21, the facility was cited for non-compliance with regulations F550, F679, and F880. These were cited again during the current recertification survey.
5. During a recertification survey with an end date of 6/24/19, the facility was cited for non-compliance with regulations F578, F584, F609, F656, F684, F687, F689, F760, F756, F761, F842, F867, and F880. These same tags were cited on the survey completed on 9/1/21. This demonstrated the inability to maintain compliance.
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** 3. Resident 28 was originally admitted to the facility on [DATE] with medical diagnoses that included but not limited to, Alzhei...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 28 was originally admitted to the facility on [DATE] with medical diagnoses that included but not limited to, Alzheimer's disease with dementia, restlessness and agitation, dizziness and giddiness, repeated falls, diarrhea, polyneuropathy, hyperlipidemia, hypothyroidism, chronic leukemia, history of urinary tract infection, pleural effusion, depressive episodes, and chronic respiratory failure with hypoxia.
A physician's order dated 5/1/19, documented PRN (as needed) O2 (oxygen) to keep saturation >90% two times a day.
On 8/29/21 at 10:57 AM, resident 28 was observed in bed with the oxygen concentrator running and the nasal canula (nc) was on the ground near the foot of the bed.
On 9/1/21 at 8:02 AM, resident 28's nasal canula was observed on the floor near the foot of the bed.
4. Resident 44 was originally admitted to the facility on [DATE] with medical diagnoses that included but not limited to, paranoid schizophrenia, major depressive disorder, hypertension, heart failure, chronic obstructive pulmonary disease, gastro-esophageal reflux disease, diverticulosis, hypoxemia, urinary incontinence, morbid obesity, type 2 diabetes mellitus, pulmonary edema, asthma, adenoviral pneumonia, acute and chronic respiratory failure, obstructive sleep apnea, chronic kidney disease, anemia in chronic kidney disease, history of urinary tract infection, osteoarthritis, chronic pain, and history of COVID-19.
A physician's order dated 9/11/17, documented 02 @ 2-5L (liters) via nc every day and night shift for COPD (chronic obstructive pulmonary disease).
On 8/29/21 at 10:35 AM, resident 44's nasal canula was observed to be laying on the floor near dust piles and crumbs from a sandwich which was observed on resident 44's bedside table.
On 8/30/21 at 11:43 AM, resident 44 was observed in the dining room for lunch and within resident 44's room the nasal canula was observed to be on the floor near dust piles.
On 8/30/21 at 12:58 PM, CNA 2 brought resident 44 to her room for a nap. CNA 2 was observed to offer resident 44 her nasal canula from the floor.
On 8/31/21 at 10:10 AM, CNA 6 was observed to help resident 44 with walking from her room. Resident 44's nasal canula was observed on the floor near her bed as resident 44 and CNA 6 left the room. CNA 6 stated it can be hard to keep track of the nasal canulas and keep them off the floor on the 100 hall.
Based on observation and interview it was determined the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, staff were observed without eye protection when the county positivity rate was greater than 5%. A nurse was observed to recap and place a used insulin syringe in her scrub top pocket, oxygen nasal canulas were observed on the floor, and staff used their bare hands to handle resident food. Resident identifiers: 28, 33 and 44.
Findings include:
1. On 8/29/21 at 8:00 AM, the survey team entered the facility. A housekeeping staff member was observed without eye protection. Registered Nurse (RN) 3 assisted the survey team with Coronavirus Disease 2019 (Covid19) screening and RN 3 was observed without eye protection.
On 8/4/21 to 8/17/21, the county positivity rate was documented at 12.4%.
On 8/11/21 to 8/24/21, the county positivity rate was documented at 13.5%.
On 8/18/21 to 8/31/21, the county positivity rate was documented at 12.9%.
On 8/29/21 at approximately 8:14 AM, a tour of the facility was conducted. The Kitchen Cook, Dietary Manager, Certified Nursing Assistant (CNA) 5, and CNA 7 were observed without eye protection and in resident areas of the facility. CNA 5 was observed assembling face shields at the nurses station.
On 8/29/21 at 8:25 AM, a CNA entered the main dining room, and a resident stated, What's with the shield?!
On 8/29/21 at approximately 9:00 AM, the Business Office Manager (BOM) was observed without eye protection and in resident areas of the facility. The BOM had her eyeglasses on, which are not approved by the Centers for Disease Control (CDC) as appropriate eye protection. https://www.cdc.gov/niosh/topics/eye/eye-infectious.html
On 8/30/21 at 2:15 PM, an interview was conducted with the Director of Nursing (DON). The DON stated staff were required to wear a surgical mask and depending on the county positivity rate the staff were required to wear an N95 mask. The DON stated eye protection was dependent on the county positivity rate also. The DON stated staff were required to wear eye protection approximately 2 or 3 weeks ago and should be wearing eye protection currently. The DON stated the Charge Nurse should monitor staff Personal protective equipment (PPE) when she was not in the facility. The DON stated RN 3 was the Charge Nurse on 8/29/21. The DON stated she was not surprised that no one was wearing eye protection when the survey team entered the facility. The DON stated every week she would go over the PPE required to wear and had numerous staff in-services. The DON stated when she was at the facility things went well.
On 8/30/21 at 1:18 PM, 2:05 PM, and again at 3:06 PM, the DON was observed without eye protection and in resident areas of the facility.
On 8/30/21 at 3:10 PM, the DON an observation was made of resident 33's left foot with the DON. The DON entered the room, and observed the wound on the resident's foot without wearing eye protection.
On 8/31/21 at 8:07 AM, an interview was conducted with RN 3. RN 3 stated eye protection was considered universal PPE and should wrap around to cover the eyes. RN 3 stated she was the Charge Nurse on 8/29/21, when the survey team entered the facility. RN 3 stated the staff were not wearing eye protection on 8/29/21. RN 3 stated it was early in the morning and the staff were trying to get their eye protection on.
2. On 8/31/21 at 7:23 AM, RN 3 was observed to prepare and administer Lantus Solution 45 units subcutaneously to resident 33. RN 3 was observed to recap the used insulin syringe and place the used insulin syringe in the pocket of her scrub top.
On 8/31/21 at 7:56 AM, RN 3 was observed to remove the used insulin syringe from the pocket of her scrub top and dispose of the used insulin syringe in the sharps container on the medication cart.
On 8/31/21 at 11:14 AM, an interview was conducted with RN 3. RN 3 stated she would place a used syringe in the sharps container located on the side of the medication cart. RN 3 stated she usually did not put a used syringe in her scrub pocket.
On 9/1/21 at 9:29 AM, an interview was conducted with the DON. The DON stated nursing staff should follow the cap and uncap policy for syringes and use the sharps container immediately after the use of a syringe. The DON stated there was no reason that a nurse should ever recap a used syringe and put the used syringe in their pocket.
5. On 8/29/21 the lunch meal was observed in the main dining room. A staff member was observed be assisting a resident with dining. The staff member placed a resident's dinner roll directly on the table. The staff member then picked up the roll with her bare hands, and placed the roll directly on a different area of the table.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 11. Resident 17 was admitted to the facility on [DATE] with medical diagnoses that included Alzheimer's disease with dementia, h...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 11. Resident 17 was admitted to the facility on [DATE] with medical diagnoses that included Alzheimer's disease with dementia, hyperlipidemia, hypertension, major depressive disorder and history of Coronavirus disease 2019 (COVID-19).
On 8/29/21 at 1:45 PM, resident 17 was observed wandering within the memory care unit hallway. Resident 17 was observed to enter another residents' room, and was then observed to attempt opening the exit door located at the front end of the memory care unit hallway.
On 8/29/21 at 9:57 AM, resident 17 was observed to be at the exit door located at the far end of the memory care unit hallway. After attempting to open the door, resident 17 began to wander toward the other end of the memory care unit hallway.
On 8/30/21 at 1:23 PM, resident 17 was observed to enter another residents' room. Resident 17 walked into the room, stood in the center of the room for several seconds and then exited the other residents' room.
On 8/30/21 at 1:33 PM, resident 17 was observed to enter a different residents' room. Resident 17 stood near a resident's wardrobe closet and then turned and left the resident's room several seconds later.
On 9/1/21 a review of resident 17's medical record was completed.
A care plan with a focus that stated, Resident is at potential risk for changes to mood, behavior, and psychosocial well being related to recent COVID-19 restrictions as dictated by the CDC (Centers for Disease Control and Prevention). These restrictions make changes to visitation from resident's friends and family, and an intervention was noted as, Offer supportive and in room activities that are of interest to resident.
A care plan entitled, Socially Inappropriate Behavioral Care Plan was reviewed. The care plan problem stated, Potential impaired social interaction manifested by verbally abusive, physically abusive, making disruptive sounds, inappropriate sexual behavior, wandering, taking others possesions (sic). An intervention noted was, Encourage increased socialization and participation in activities as a therapeutic use of distraction.
A care plan entitled, Altered Thought Process; Recreational Therapy was reviewed. The care plan problem/need was written as, I have STM [short term memory] and LTM[ long term memory] loss, I have difficulties with recall skills and orientation. I am easily distracted and have a short attention span. I wander. An intervention was listed as, Involve me in activities of appropriate cognitive level that might hold my attention such as: Music, manicure, special events, current events, exercise, cookouts, socials, outings, active games, crafts, reminisce, trivia, flower arranging.
12. Resident 25 was admitted to the facility on [DATE] with medical diagnoses that included Alzheimer's disease, major depressive disorder, hyperlipidemia, history of urinary tract infection, and history of COVID-19.
On 08/29/21 at 9:32 AM, resident 25 was observed seated at a sofa in the communal dining room, with no other residents and with no activity or engagement item near her. Resident sat at the sofa until 10:11 AM, without engagement, and resident spent this time itching her red, inflamed eye. At 10:17 AM, resident 25 then attempted to walk unassisted to her wheelchair located behind the sofa.
On 08/29/21 at 1:17 PM, resident 25 was observed to be falling asleep while seated in front the the television in the communal dining area.
A review of resident 25's medical record was completed on 09/01/21.
A care plan with a focus that stated, Resident is at potential risk for changes to mood, behavior, and psychosocial well being related to recent COVID-19 restrictions as dictated by the CDC. These restrictions make changes to visitation from resident's friends and family. An intervention was noted as, Offer supportive and in room activities that are of interest to resident.
A care plan entitled, Altered Thought Process: Recreation Therapy and the problem/Need was listed as, Alteration in thought Process (sic). I have a severe thought process impairment. I have difficulties with recall skills and orientation. I am easily distracted and have a short attention span. An intervention listed was, Invite me to activities of appropriate cognitive level such as: Music activities, crafts, active games, current events, outings, exercise, movies, reminisce, special events, trivia, socials, reading, cooking.
An assessment entitled, Therapeutic Recreation Assessment 2. The assessment stated, Leisure: [Resident 25] likes to attend special events, current events, pet visits, socials, crafts, music, reminiscing, active games, tv and movies. She says having reading material, pet visits and keeping up on the news are somewhat important to her. Listening to music, group activities, getting fresh air on a good day and doing her favorite activities are very important to her. Within the Analysis of Needs and Interests it was listed, Activity Pursuit Areas Impressions: [Resident 25] identified activities of interest. She likes group activities.
On 8/30/21 at 2:53 PM, an observation was made of a Weekend Activity Book in the kitchen area of the SNU. Inside the book were instructions for activities that could be held. The top of the first page was titled March Saturday Activities. Activities that were listed included an ice cream activity with instructions for staff to take the resident to the ice cream room to eat ice cream. A daily chronicle and word packet were included with instructions to pass it out to residents. Other activities that were listed were give out a deck of cards or a board game. A list of residents was included in the book with instructions to mark the residents that participated in the activities. There were no markings by any of the resident's names in the book.
On 8/31/21 at 3:19 PM, Certified Nursing Assistant (CNA) 3 was interviewed. CNA 3 stated the facility had not had an activities director for about 2 months. CNA 3 stated bingo was offered in the main part of the facility if residents wanted to go. CNA 3 stated a staff member took the residents from the SNU if they wanted to go. CNA 3 stated only 2 residents wanted to participate in bingo. CNA 3 stated bingo was held on Tuesday afternoons. CNA 3 stated some days the residents colored and it helps them relax. CNA 3 stated when the virus hit activities were stopped completely. CNA 3 stated the facility resident advocate (RA) was in the facility 2-3 times per week and would visit with residents on a 1:1 basis.
On 8/30/21 at 1:25 PM, CNA 2 was interviewed. CNA 2 stated the facility was not doing any in-room activities at this time. CNA 2 stated activities that were held included bingo, which was held on Wednesdays. CNA 2 stated Since COVID started [the facility] hasn't been doing anything. CNA 2 also reported the residents do not appear to have enough activities in the memory care unit, and the residents, seem to get bored.
On 8/30/21 at 2:09 PM, a resident within the memory care unit was observed at their bedroom doorway. When the resident was asked, How are you? their response was, I am bored.
On 9/1/21 at 11:07 AM, CNA 4 was interviewed. CNA 4 stated residents on the memory care unit wandered a lot, and the CNA's tried to keep residents busy, but that was tough because the memory care unit did not have a lot of planned activities.
On 9/1/21 at 9:15 AM, Licensed Practical Nurse (LPN) 1 was interviewed. LPN 1 stated There are not a lot of activities in the memory care unit. LPN 1 stated the memory care unit did keep a movie playing at most times, and in the past, the unit did provide female residents with a nail painting activity. LPN 1 stated, It has been a while since we have done that.
On 8/31/21, the BOM provided the consultant notes from the facility Certified Therapeutic Recreation Specialist (CTRS) for the previous 10 months. The consultant notes indicated that the CTRS had not provided oversight from 11/30/20 until 5/25/21. The notes further revealed that the CTRS did not provide oversight in June 2021.
On 9/1/21 at 3:38 PM, the Therapeutic Recreation Therapist (TRT) was interviewed. The TRT stated that she came to the building twice a month for a couple of hours each time, and she was last in the building on 7/29/21. The TRT stated that she has been trying to keep up with the activity logs, but had not been able to. The TRT stated that she did not document what activities were happening, and which residents were attending. The TRT stated she attempted as many one on one visits as she could when she came in every other week, but she also had to complete paperwork for the residents such as assessments and care plans during that time. The TRT stated it had been approximately 2 years since she had worked at the facility full time.
On 9/1/21 at 3:48 PM, the Resident Advocate (RA) was interviewed. The RA stated that he would visit the facility twice a week, for a total of about 15 hours. The RA stated that he played bingo with the residents every Friday, and assisted residents with ordering things online. The RA stated that he would attempt to meet with everyone one on one, but its hard to do it weekly. The RA stated the facility had been attempting to hire a new TRT because the residents need and want more activities than I can offer them on my own. The RA stated that every time he conducted an activity, he would mark the names of the participants on a census sheet, and those sheets were kept in a filing cabinet, not as an individual log in each resident's medical record.
On 8/31/21 at 3:30 PM, the ADM was interviewed. The ADM stated that the facility was having one type of religious meetings twice a month and they plan to start having family home meetings once a week. The ADM stated individual visits for residents who were part of the another religion were being provided once a month, and once a month a minister met with residents in the facility's sunroom. The Administrator reported the facility was trying to hold regular concerts and there have been 2 held within the last month. When the ADM was asked what regular activities were held to engage the residents in the memory care unit, the ADM stated that staff were encouraged to do activities as they could. The Administrator also stated the facility was not following the posted activity schedule because they did not have staff to run the activities. The ADM confirmed that the CTRS did not provide oversight from 11/30/20 to 5/25/21.
9. Resident 27 was admitted to the facility on [DATE] with diagnoses which included dementia, type 2 diabetes, chronic viral hepatitis C, hypertension, major depressive disorder, and osteoarthritis.
On 8/30/21 at 9:01 AM, an interview was conducted with resident 27. Resident 27 stated there are no activities when asked if he participated in facility activities. An observation was made of resident 27's room. Resident 27 did not have any activity supplies in his room and he was observed to be laying on his bed.
On 8/31/21 resident 27's medical record was reviewed.
On 3/21/19 an activities assessment was completed for resident 27. Resident 27's activity assessment revealed that resident 27 was interested in music, watching TV, watching movies, social gatherings, and cookouts. Resident 27's activity preferences revealed resident 27 preferred activities in small groups, independently and 1:1. Resident 27's leisure interests were documented as reading newspapers, doing things with groups of people, and getting fresh air. The activities assessment was updated on 7/1/19, 12/20/19, and 5/19/2020.
An annual MDS dated [DATE] revealed that resident 27 felt that keeping up with the news, doing things with groups of people, doing favorite activities, and going outside when the weather was good were very important.
Resident 27's care plan revealed Offer supportive and in room activities that are of interest to resident dated 2/5/21, and Provide activities in the SNU (Special Needs Unit) or supervised while outside of the SNU was dated 8/3/2021.
10. Resident 36 was admitted to the facility on [DATE] with diagnoses that included, but not limited to, schizoaffective disorder, dementia, anxiety disorder, type 2 diabetes, and chronic obstructive pulmonary disease.
On 8/29/21 at 2:15 PM, resident 36 stated what activities when asked if he participates in facility activities. During the survey observations was made of resident 36 in his room. Resident 36 was watching television and did not have any activity materials in his room.
On 8/31/21 resident 36's medical record was reviewed.
An MDS admission assessment dated [DATE] revealed that resident 36 felt that having books, newspapers, and magazines were very important. Other activities documented as very important were listening to music he liked, doing things with groups of people, doing favorite activities, going outside to get fresh air when the weather was good, and participating in religious services or practices.
On 5/21/21 an activities assessment was completed for resident 36. Resident 36's activity assessment revealed that leisure interests included having reading materials, books and newspapers, listening to music, doing things with groups of people, doing favorite activities, getting fresh air on a good day, playing bingo, special events, sporting events and participating in religious activities were very important. Activity preferences were documented as being one on one, independent and in small groups.
Based on interview, observation and record review, the facility did not provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 14 of 30 sample residents. Resident identifiers: 5, 13, 15, 17, 22, 24, 25, 27, 28, 32, 35, 36, 42, and 43.
Findings include:
1. On 8/29/21 at 8:15 AM, an observation was made of the activities calendar posted at the facility. The calendar listed the following activities:
a. On 8/29/21 - Daily Chronicle, TV time, Bible quote of the week
b. On 8/30/21 - Doorway exercise, Daily Chronicle, Overhead positivity, One on one visits, and Banking
c. On 8/31/21 - Doorway exercise, Doorway Bingo, Travel Bug, Leisure Cart, Sensory one on ones.
During the duration of the survey from 8/29/21 through 9/1/21, no activities were observed to be occurring at the facility.
2. On 8/31/21 at 10:00 AM, an interview was conducted with six residents from the resident council. The resident council members all stated that the facility did not have an Activities Director.
Multiple residents stated that they had not had resident council meetings regularly for several months, and that they missed having the council meetings.
Resident 13 stated that there was nothing to do at the facility, including participate in resident council meetings, so she read, watched television and slept .
Resident 42 stated that the only activity at the facility was bingo once a week, so he just entertained himself by watching television.
Resident 15 stated there were no activities so I just read.
When asked about the activity calendar posted in the hallway, all of the residents stated that the activities listed on the calendar were not being done.
Resident 28 stated that the lack of activities at the facility had been brought up by residents multiple times in resident council, but that there were still no activities occurring. Resident 28 further stated that the facility had been trying to use the resident advocate to also lead the activities but that the resident advocate was too busy to do activities.
The resident council notes from the previous several months were reviewed and revealed the following: [Note: Resident council was conducted on 11/5/20, 4/22/21, 5/27/21, 6/25/21, and 7/23/21. An interview with the Administrator (ADM) on 8/31/21 at 1:12 PM, confirmed that no resident council meetings occurred between November 2020 and April 2021.]
a. On 4/22/21, the notes indicated that the activities occurring in the facility were church services every other week.
b. On 5/27/21, the notes indicated that residents were requesting the facility hire a recreational therapist. The residents requested bingo, van rides, outdoor cookouts, movie nights, balloon game in the hall, and yahtzee.
c. On 6/25/21, the notes indicated that the residents wanted to sing, play dominoes, and socialize more. The notes also indicated that church services were happening every other week.
d. On 7/23/21, the notes indicated that the residents were again requesting van rides, outside walks, and a book club. The notes also indicated that there was a music group coming on 8/10/21.
3. On 8/29/21 at 1:30 PM, an interview was conducted with residents 43 and 35, who resided in the same room. Resident 35 stated that there used to be more activities. Resident 35 stated that the facility used to employ an activities person but they don't anymore. Resident 35 stated that he would like it if there were more activities. Resident 43 stated that the only activity currently happening at the facility was bingo.
4. Resident 24 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included COVID-19, schizophrenia, anxiety disorder, conversion disorder, chronic kidney disease, and cognitive communication deficit.
Resident 24 was observed multiple times throughout the survey from 8/29/21 through 9/1/21. At no time was resident 24 observed to be out of his bed in his room.
Resident 24's medical record was reviewed on 8/29/21.
On 12/31/20, the facility completed an annual Minimum Data Set (MDS) for resident 24. The MDS indicated that a care plan for activities should have been developed.
Review of resident 24's medical record indicated that neither an assessment of resident 24's activity needs, nor an activities care plan had been developed.
Review of resident 24's physician orders revealed that the resident was receiving a tube feeding that was running at 85 ml an hour for 24 hours a day. The physician orders also revealed that the resident had been on a 24 hour continuous tube feeding since his readmission to the facility on [DATE].
On 9/1/21 at 8:42 AM, an interview was conducted with the facility Registered Dietitian (RD). The RD was asked if she had considered changing the resident's tube feeding, so that it was not running 24 hours a day, allowing the resident to leave his room and potentially attend activities. The RD stated that she had not considered that option, and that some residents preferred to stay in their room.
On 9/1/21 at 9:30 AM, an interview was conducted with the facility Director of Nursing (DON). The DON confirmed that resident 24 was confined to his room, and stated that she wanted to get resident 24 more socialized and out of bed and less isolated. The DON stated that she had been in communication with the Speech Therapist, in an attempt to have a percutaneous endoscopic gastrostomy (PEG) tube placed. The DON stated that the PEG tube placement would allow resident 24 to potentially leave his room and attend activities. The DON stated that she had spoken with the Business Office Manager (BOM) and Administrator (ADM) about the PEG tube placement to see if it could be completed, because they were in charge of making resident appointments, but had not heard back
5. Resident 5 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus, coronary artery disease, hyperlipidemia, hemiplegia, transient ischemic attack, and arthritis.
On 8/29/21 at 12:30 PM, an interview was conducted with resident 5. Resident 5 stated, there's no activities here. I spend 90 percent of my time in bed. There is only bingo.
Resident 5's medical record was reviewed on 8/29/21.
Resident 5's MDS admission assessment dated [DATE], revealed that resident 5 should have an activities care plan developed.
Review of resident 5's medical record revealed that no activities care plan had been developed for resident 5.
6. On 8/30/21 at 8:53 AM an interview was conducted with resident 22. When asked about the activities program at the facility, resident 22 stated, if you don't play bingo, its pretty damn boring. Resident 22 stated that he mostly smoked cigarettes to keep himself entertained. Resident 22 also stated that there was not an activities director at the facility.
7. On 8/29/21 at 11:49 AM, an interview was conducted with resident 32. Resident 32 stated that there were no activities being held at the facility except bingo. Resident 32 stated, I just sleep and smoke. There's nothing else to do.
8. On 8/29/21 at 11:00 AM, an interview was conducted with resident 42. Resident 42 stated that there was not an activities director at the facility. Resident 42 stated that there used to be one, but ever since she left, its just boring . It would be nice to do other things.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected most or all residents
Based on interview it was determined that the facility did not ensure that the designated Infection Preventionist (IP) who was responsible for the facility's infection prevention and control program h...
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Based on interview it was determined that the facility did not ensure that the designated Infection Preventionist (IP) who was responsible for the facility's infection prevention and control program had completed specialized training in infection prevention and control. Specifically, the Director of Nursing (DON) who was the designated IP had not completed the specialized training in infection prevention and control.
Findings include:
On 8/30/21 at approximately 2:15 PM, an interview was conducted with the DON. The DON stated she was the designated IP and had completed specialized training.
On 9/1/21 at 2:00 PM, the DON provided the IP specialized training she had completed to the survey team. The training consisted of an inservice titled Addendum to Antibiotic Stewardship Program policy and procedures update, the Antibiotic Stewardship Policy, a flyer titled Viruses or Bacteria What's got you sick?, and a flyer titled Be Antibiotics Aware flyer. The DON stated that she was trained to be an IP by the facility Administrator on 8/6/19, and was provided the flyer described above. The DON stated that she had not completed any specialized training, such as the Centers for Disease Control (CDC) training.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 6 life-threatening violation(s), Special Focus Facility, 16 harm violation(s), $100,991 in fines. Review inspection reports carefully.
- • 120 deficiencies on record, including 6 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $100,991 in fines. Extremely high, among the most fined facilities in Utah. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility is on CMS's Special Focus list for poor performance. Consider alternatives strongly.
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About This Facility
What is Mountain View Health Services's CMS Rating?
CMS assigns Mountain View Health Services an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Utah, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Mountain View Health Services Staffed?
CMS rates Mountain View Health Services's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 60%, which is 14 percentage points above the Utah average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 57%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Mountain View Health Services?
State health inspectors documented 120 deficiencies at Mountain View Health Services during 2021 to 2024. These included: 6 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 16 that caused actual resident harm, and 98 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 Mountain View Health Services?
Mountain View Health Services is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 155 certified beds and approximately 43 residents (about 28% occupancy), it is a mid-sized facility located in Ogden, Utah.
How Does Mountain View Health Services Compare to Other Utah Nursing Homes?
Compared to the 100 nursing homes in Utah, Mountain View Health Services's overall rating (2 stars) is below the state average of 3.3, staff turnover (60%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Mountain View Health Services?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the facility's high staff turnover rate, and the below-average staffing rating.
Is Mountain View Health Services Safe?
Based on CMS inspection data, Mountain View Health Services has documented safety concerns. Inspectors have issued 6 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Utah. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Mountain View Health Services Stick Around?
Staff turnover at Mountain View Health Services is high. At 60%, the facility is 14 percentage points above the Utah average of 46%. Registered Nurse turnover is particularly concerning at 57%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Mountain View Health Services Ever Fined?
Mountain View Health Services has been fined $100,991 across 1 penalty action. This is 3.0x the Utah average of $34,089. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Mountain View Health Services on Any Federal Watch List?
Mountain View Health Services is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.