THE CULPEPER
Non profit - Corporation
47 Beds
Independent
Data: November 2025
Trust Grade
73/100
#107 of 285 in VA
Photo by The Culpeper
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Last Inspection: October 2023
Over 2 years since last inspection. Current conditions may differ from available data.
Overview
The Culpeper nursing home has a Trust Grade of B, indicating it is a good choice for families, falling within the 70-79 range of the grading scale. In Virginia, it ranks #107 out of 285 facilities, placing it in the top half, and is the best option in Culpeper County among two facilities. However, the trend is worsening, with the number of issues increasing from 5 in 2022 to 10 in 2023. Staffing is a strong point, rated 5 out of 5 stars with a turnover rate of only 27%, significantly lower than the state average of 48%. On the downside, there were incidents where staff failed to provide adequate care for a resident's pressure injury, leading to its deterioration, and there were concerns about maintaining kitchen cleanliness and timely assessments for several residents. Despite these weaknesses, the facility has no fines on record and offers more RN coverage than 80% of Virginia facilities, which is a positive indication of care quality.
- Trust Score
- B
- In Virginia
- #107/285
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ✓ Good
- 27% annual turnover. Excellent stability, 21 points below Virginia's 48% average. Staff who stay learn residents' needs.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Virginia facilities.
- Skilled Nurses ✓ Good
- Each resident gets 67 minutes of Registered Nurse (RN) attention daily — more than 97% of Virginia nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 19 deficiencies on record. Higher than average. Multiple issues found across inspections.
73/100
Top 37%
Needs review
5 → 10 violations
★★★★☆
4.0
Overall Rating
★★★★★
5.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2022: 5 issues
2023: 10 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
Low Staff Turnover (27%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (27%)
21 points below Virginia average of 48%
Facility shows strength in staffing levels, staff retention, fire safety.
The Bad
No Significant Concerns Identified
This facility shows no red flags. Among Virginia's 100 nursing homes, only 1% achieve this.
The Ugly 19 deficiencies on record
1 actual harm
Oct 2023
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to implement the comprehensive care plan for three of 26 residents in the survey ...
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Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to implement the comprehensive care plan for three of 26 residents in the survey sample, Residents #34, #12, and #51.
The findings include:
1. For Resident #34 (R34), the facility staff failed to implement the care plan which instructed the staff to use a slow sip cup for fluid intake.
On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 6/19/23, R34 was coded as being as being severely cognitively impaired for making daily decisions. He was coded as coughing or choking during meals or when swallowing medications.
On 10/16/23 at 3:40 p.m., R34 was observed sitting up in bed. He was drinking a liquid from a regular cup with a standard plastic straw. A two-handled slow sip cup was observed on R34's overbed table adjacent to his bed. RN (registered nurse) #2 was observed walking out of the resident's room as he was finishing sipping the liquid through the straw.
A review of R34's clinical record revealed the following physician's order dated 7/6/23: Regular Diet, Mechanical Soft, Ground. Thin Liquids. Slow Sip Cup. The review also revealed the following physician's order dated 6/6/23: Pro-Stat .oral liquid .30 mls (milliliters) by mouth twice a day for skin health.
A review of R34's comprehensive care plan dated 9/14/23 revealed, in part: Provide slow sip cup for fluids.
On 10/17/23 at 3:35 p.m., LPN (licensed practical nurse) #2 was interviewed. She stated the purpose of the care plan is to tell the staff how best to meet a resident's needs. She stated the nurses and CNAs (certified nursing assistants) are responsible for implement the care plan.
On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1, the executive director, #2, the director of nursing, ASM #3, the assisted living administrator, and LPN #1, the quality improvement nurse, were informed of these concerns.
A review of the facility policy, Comprehensive Person-Centered Care Planning, revealed, in part: The resident will receive the services and/or items included in the plan of care.
No further information was provided prior to exit.
2. For Resident #12 (R12), the facility staff failed to implement the care plan to apply both right and left palm protectors to prevent pain.
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/13/23, R12 was coded as requiring the extensive assistance of two staff members for dressing and personal hygiene, and as having impairment in range of motion on both sides of her upper extremities.
On 10/16/23 at 11:22 a.m. and 3:36 p.m., R12 was observed in her wheelchair and did not have palm protectors on either hand. On 10/17/23 at 8:34 a.m., R12 was observed in her wheelchair and had a palm protector on her right hand, but not on her left.
A review of R12's clinical record revealed the following physician order dated 1/11/23: Bilateral palm protector splints. Apply in morning. Remove at bedtime. Resident to wear throughout the day as resident will allow .For pain r/t (related to) .contracture. The resident's progress notes for 10/16/23 and 10/17/23 contained no information related to the resident's palm protectors.
A review of R12's care plan dated 2/11/23 revealed, in part: [R12] wears .bilateral palm protectors during the day .Bilateral palm protectors - apply in the morning and remove at bedtime .for pain.
On 10/17/23 at 3:35 p.m., LPN (licensed practical nurse) #2 was interviewed. She stated she is familiar with caring for R12. She stated if there is an order for the palm protectors on both hands, the resident should have them on both hands. She stated the purpose of the care plan is to tell the staff how best to meet a resident's needs. She stated the nurses and CNAs (certified nursing assistants) are responsible for implementing the care plan.
On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1, the executive director, #2, the director of nursing, ASM #3, the assisted living administrator, and LPN #1, the quality improvement nurse, were informed of these concerns.
No further information was provided prior to exit.
3. For Resident #51 (R51), the facility staff failed to implement the resident's comprehensive care plan for bowel medication.
A review of R51's clinical record revealed a physician's order dated 4/4/23 for a bisacodyl suppository, ten milligrams- administer one suppository rectally one time a day as needed for no bowel movement in three days.
R51's comprehensive care plan dated 6/22/23 documented, Potential for Alteration in Bowel Elimination as related to: impaired mobility. Constipation .Administer medication as ordered by the physician .
A review of R51's bowel movement records revealed the resident did not have a bowel movement from 7/3/23 until 7/9/23. Further review of R51's clinical record and review of a 24-hour report sheet dated 7/7/23 revealed a suppository was not administered to R51 until 7/7/23 (five days after the resident had not had a bowel movement).
On 10/18/23 at 11:18 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated the purpose of the care plan is that it, Kind of describes what you are supposed to do to take care of them [the residents]. It's the plan of care. LPN #3 stated nurses can access residents' care plans in the computer system. LPN #3 reviewed R51's bisacodyl order and stated a suppository should have been given to the resident within three days of the resident not having a bowel movement.
On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to review and revise the comprehensive care plan for one of 26 residents in the su...
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Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to review and revise the comprehensive care plan for one of 26 residents in the survey sample, Resident #47.
The findings include:
For Resident #47 (R47), the facility staff failed to review and revise the resident's comprehensive care plan for the use of floor mats.
A review of R47's clinical record revealed a physician's order dated 3/16/22 for floor mats next to the bed while the resident is in the bed. R47's comprehensive care plan dated 2/3/22 failed to reveal documentation regarding floor mats.
On 10/16/23 at 11:34 a.m. and 10/17/23 at 8:54 a.m., R47 was observed lying in bed. A mat was observed on the right side of the bed, but a mat was not on the left side of the bed.
On 10/17/23 at 3:34 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated the purpose of the care plan is that It tells about how to meet their [residents'] needs the best. LPN #2 stated residents' care plans should be reviewed and revised to include the use of floor mats, so everyone knows to implement the mats.
On 10/17/23 at 4:38 p.m., ASM (administrative staff member) #1, the executive director and ASM #2, the director of nursing were made aware of the above concern.
The facility policy titled, Comprehensive Person-Centered Care Planning documented, The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans .
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
Based on staff interview, facility document review and clinical record review, the facility staff failed to provide care and services to promote a resident's highest level of well-being for one of 26 ...
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Based on staff interview, facility document review and clinical record review, the facility staff failed to provide care and services to promote a resident's highest level of well-being for one of 26 residents in the survey sample, Resident #51.
The findings include:
For Resident #51 (R51), the facility staff failed to administer a bisacodyl suppository per the physician's order.
A review of R51's clinical record revealed a physician's order dated 4/4/23 for a bisacodyl suppository, ten milligrams- administer one suppository rectally one time a day as needed for no bowel movement in three days.
A review of R51's bowel movement records revealed the resident did not have a bowel movement from 7/3/23 until 7/9/23. Further review of R51's clinical record and review of a 24-hour report sheet dated 7/7/23 revealed a suppository was not administered to R51 until 7/7/23 (five days after the resident had not had a bowel movement). R51 did not have a bowel movement until 7/9/23.
On 10/18/23 at 11:18 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated the computer generates a list of residents who have not had a bowel movement in two days. LPN #3 stated if a resident has not had a bowel movement in two days, then the nurses activate standing orders or reach out to the physician. LPN #3 reviewed R51's bisacodyl order and stated a suppository should have been given to the resident three days after not having a bowel movement.
On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern.
The facility policy titled, Constipation/Fecal Impaction documented, IV. Nurse in charge will be notified of signs and symptoms of constipation. Constipation will be treated with oral laxative, suppository or enema as ordered by the physician .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to implement a fall intervention for one of 26 residents in the survey sample, Res...
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Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to implement a fall intervention for one of 26 residents in the survey sample, Resident #47.
The findings include:
For Resident #47 (R47), the facility staff failed to implement physician ordered floor mats.
A review of R47's clinical record revealed a physician's order dated 3/16/22 for floor mats next to the bed while the resident is in the bed. Further review of R47's clinical record revealed the resident sustained a fall on 1/6/23, 3/4/23, 4/2/23, and 8/16/23.
On 10/16/23 at 11:34 a.m. and 10/17/23 at 8:54 a.m., R47 was observed lying in bed. A mat was observed on the right side of the bed, but a mat was not on the left side of the bed.
On 10/17/23 at 3:34 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated the nurses are aware of the need for floor mats via physician's orders and then the nurses tell the certified nursing assistants who needs floor mats. LPN #2 reviewed R47's physician's order for floor mats and stated that if plural floor mats are ordered then that would mean a floor mat should be placed on each side of the bed.
On 10/17/23 at 4:38 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern.
The facility policy titled, Fall Management Program documented, Other potential fall preventative interventions for residents at high risk: b) Floor mats .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to apply an adaptive device to prevent pain for one of 26 residents in the survey...
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Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to apply an adaptive device to prevent pain for one of 26 residents in the survey sample, Resident #12.
The findings include:
For Resident #12 (R12), the facility staff failed to apply both right and left palm protectors to prevent pain.
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/13/23, R12 was coded as requiring the extensive assistance of two staff members for dressing and personal hygiene, and as having impairment in range of motion on both sides of her upper extremities.
On 10/16/23 at 11:22 a.m. and 3:36 p.m., R12 was observed in her wheelchair, and did not have palm protectors on either hand. On 10/17/23 at 8:34 a.m., R12 was observed in her wheelchair, and had a palm protector on her right hand, but not on her left.
A review of R12's clinical record revealed the following physician order dated 1/11/23: Bilateral palm protector splints. Apply in morning. Remove at bedtime. Resident to wear throughout the day as resident will allow .For pain r/t (related to) .contracture. The resident's progress notes for 10/16/23 and 10/17/23 contained no information related to the resident's palm protectors.
A review of R12's care plan dated 2/11/23 revealed, in part: [R12] wears .bilateral palm protectors during the day .Bilateral palm protectors - apply in the morning and remove at bedtime .for pain.
On 10/17/23 at 3:35 p.m., LPN (licensed practical nurse) #2 was interviewed. She stated she is familiar with caring for R12. She stated if there is an order for the palm protectors on both hands, the resident should have them on both hands. If a resident refuses or will not tolerate them, the nurse should write a progress note indicating this. She stated R12 has contractures in both hands, and the palm protectors can aid in relieving the pain of the contractures.
On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1, the executive director, #2, the director of nursing, ASM #3, the assisted living administrator, and LPN #1, the quality improvement nurse, were informed of these concerns.
In response to a request for the facility policy regarding palm protectors, the facility staff provided the policy, Skin Integrity. A review of this policy revealed no information related to applying palm protectors as ordered by the physician.
No further information was provided prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0810
(Tag F0810)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to use an adaptive feeding device for one of 26 residents in the survey sample, R...
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Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to use an adaptive feeding device for one of 26 residents in the survey sample, Resident #34.
The findings include:
For Resident #34 (R34), the facility failed to utilize a slow sip cup for fluids on 10/16/23.
On the most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 6/19/23, R34 was coded as being as being severely cognitively impaired for making daily decisions. He was coded as coughing or choking during meals or when swallowing medications.
On 10/16/23 at 3:40 p.m., R34 was observed sitting up in bed, and was drinking a liquid from a regular cup with a standard plastic straw. A two-handled slow sip cup was observed on R34's overbed table adjacent to his bed. RN (registered nurse) #2 was observed walking out of the resident's room as he was finishing sipping the liquid through the straw.
A review of R34's clinical record revealed the following physician's order dated 7/6/23: Regular Diet, Mechanical Soft, Ground. Thin Liquids. Slow Sip Cup. The review also revealed the following physician's order dated 6/6/23: Pro-Stat .oral liquid .30 mls (milliliters) by mouth twice a day for skin health.
A review of R34's comprehensive care plan dated 9/14/23 revealed, in part: Provide slow sip cup for fluids.
On 10/16/23 at 3:50 p.m., RN #2 was interviewed. She stated she thought R34 was supposed to be using the slow sip cup for fluids since she saw it on the overbed table. She stated: I guess I just didn't realize what he needed at the time.
On 10/18/23 at 11:18 a.m., LPN (licensed practical nurse) was interviewed. She stated for R34, his dietary orders, including the slow sip cup, appear at the top of his information when anything about him is accessed on the electronic medical record. She stated his order for a slow sip cup appears as a warning at the top of the screen.
On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1, the executive director, #2, the director of nursing, ASM #3, the assisted living administrator, and LPN #1, the quality improvement nurse, were informed of these concerns.
A review of the policy, Adaptive Feeding Program, revealed in part: Nursing staff .will be responsible for observing individualized resident feeding needs and response to any modifications in resident's plan of care.
No further information was provided prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on staff interview, facility document review, and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for one of 26 residents in the survey samp...
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Based on staff interview, facility document review, and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for one of 26 residents in the survey sample, Resident #51.
The findings include:
For Resident #51, the facility staff failed to document the administration of a bisacodyl suppository on 7/7/23.
A review of R51's clinical record revealed a physician's order dated 4/4/23 for a bisacodyl suppository, ten milligrams- administer one suppository rectally one time a day as needed for no bowel movement in three days. R51's July 2023 MAR (medication administration record) documented the same order.
A review of a 24-hour report sheet dated 7/7/23 revealed documentation that R51 was administered a suppository on that date. Further review of R51's clinical record, including the July 2023 MAR and nurses' notes for 7/7/23, failed to reveal documentation that R51 was administered a suppository.
On 10/18/23 at 11:18 a.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that if a nurse administers a suppository, the nurse should write a note and sign the medication off on the MAR.
On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1 (the executive director) and ASM #2 (the director of nursing) were made aware of the above concern.
The facility policy titled, Medication Administration and Documentation documented, On administering a prn (as needed) med, the nurse charts the administration in e-MAR (electronic medication administration record) and effectiveness .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected multiple residents
Based on staff interview, facility document review, and clinical record review, the facility staff failed to complete quarterly MDS (minimum data set) assessments in a timely manner for four of 26 res...
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Based on staff interview, facility document review, and clinical record review, the facility staff failed to complete quarterly MDS (minimum data set) assessments in a timely manner for four of 26 residents in the survey sample, Residents #1, #48, #36 and #51.
The findings include:
1. For Resident #1 (R1), the facility staff failed to complete the resident's quarterly MDS with an ARD (assessment reference date) of 9/7/23 within 14 days.
A review of R1's clinical record revealed a quarterly MDS assessment with an ARD of 9/7/23. Further review of R1's clinical record revealed the MDS was not completed until 9/30/23 (23 days).
On 10/17/23 at 2:50 p.m., an interview was conducted with RN (registered nurse) #1 (the MDS coordinator). RN #1 stated MDS assessments should be completed within 14 days from the ARD. RN #1 stated she references the CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) manual when completing MDS assessments.
On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1,the executive director and ASM #2, the director of nursing were made aware of the above concern.
The CMS RAI manual documented, Completion Timing: - For all non-admission OBRA (Omnibus Budget Reconciliation Act) and PPS (Prospective Payment System) assessments, the MDS Completion Date (Z0500B) must be no later than 14 days after the Assessment Reference Date (ARD).
2. For Resident #48 (R48), the facility staff failed to complete the resident's quarterly MDS with an ARD of 8/17/23 within 14 days.
A review of R48's clinical record revealed a quarterly MDS assessment with an ARD of 8/17/23. Further review of R48's clinical record revealed the MDS was not completed until 9/15/23 (29 days).
On 10/17/23 at 2:50 p.m., an interview was conducted with RN (registered nurse) #1 (the MDS coordinator). RN #1 stated MDS assessments should be completed within 14 days from the ARD. RN #1 stated she references the CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) manual when completing MDS assessments.
On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1,the executive director and ASM #2, the director of nursing were made aware of the above concern.
3. For Resident #36 (R36), the facility staff failed to complete the resident's quarterly MDS with an ARD of 8/31/23 within 14 days.
A review of R36's clinical record revealed a quarterly MDS assessment with an ARD of 8/31/23. Further review of R36's clinical record revealed the MDS was not completed until 9/18/23 (18 days).
On 10/17/23 at 2:50 p.m., an interview was conducted with RN (registered nurse) #1 (the MDS coordinator). RN #1 stated MDS assessments should be completed within 14 days from the ARD. RN #1 stated she references the CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) manual when completing MDS assessments.
On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1,the executive director and ASM #2, the director of nursing were made aware of the above concern.
4. For Resident #51 (R51), the facility staff failed to complete the resident's quarterly MDS with an ARD of 8/24/23 within 14 days.
A review of R51's clinical record revealed a quarterly MDS assessment with an ARD of 8/24/23. Further review of R51's clinical record revealed the MDS was not completed until 9/18/23 (25 days).
On 10/17/23 at 2:50 p.m., an interview was conducted with RN (registered nurse) #1 (the MDS coordinator). RN #1 stated MDS assessments should be completed within 14 days from the ARD. RN #1 stated she references the CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) manual when completing MDS assessments.
On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1,the executive director and ASM #2, the director of nursing were made aware of the above concern.
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, staff interview, and facility documentation review, the facility failed to prepare and store food in a sanitary manner in one of two nourishment refrigerators, the rehab to home ...
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Based on observation, staff interview, and facility documentation review, the facility failed to prepare and store food in a sanitary manner in one of two nourishment refrigerators, the rehab to home unit refrigerator, and in one of two facility kitchens, the main kitchen.
The findings include:
The facility staff failed to maintain a clean main kitchen, and failed to store food safely in the main kitchen and in the rehab to home unit refrigerator.
On 10/16/23 at 10:15 a.m., observation was made of the main facility kitchen. The upper oven contained a large amount of baked-on grease and dark particles on the doors, sides, bottom and back. The areas around the burners on the stove contained cooked-on grease, and a large amount of crumbs and dark black debris. OSM (other staff member) #1, the director of dining services, stated: It all could use a good cleaning. She stated the oven and stove get a deep cleaning weekly, but should also be spot cleaned after each use. In the walk in freezer, a 10 by 10 plastic container of red frozen material rested on a shelf. There was no label on the container to indicate the use-by date or what the red material was. OSM #1 stated the material in the plastic container should have been labeled, and needed to be discarded. She stated all items in the walk-in freezer should be labeled.
On 10/17/23 at 3:22 p.m., observation was made of the nourishment refrigerator on the rehab to home unit. The refrigerator contained a small plastic container of potstickers and a small container of sauce. Neither container was labeled. The freezer contained a bag of chocolate covered coffee beans; the bag was not labeled.
On 10/18/23 at 9:37 a.m., OSM #1 stated the unit nourishment refrigerators were the responsibility of the dining services staff. She stated the dining services staff are supposed to check the unit refrigerators and freezers each time they deliver food to the units.
On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1, the executive director, #2, the director of nursing, ASM #3, the assisted living administrator, and LPN (licensed practical nurse) #1, the quality improvement nurse, were informed of these concerns.
A review of the facility policy, Cleaning and Sanitation of Dining and Food Service Areas, revealed, in part: The food and nutrition services staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule .Staff will be trained in the frequency of cleaning, as necessary .Staff will be held accountable for cleaning assignments.
A review of the facility policy, Food Storage, revealed, in part: Frozen Foods .All foods should be covered, labeled, and dated. All foods will be checked to assure foods will be consumed by their use by dates or discarded.
No further information was provided prior to exit.
MINOR
(B)
Minor Issue - procedural, no safety impact
MDS Data Transmission
(Tag F0640)
Minor procedural issue · This affected multiple residents
Based on staff interview, facility document review and clinical record review, the facility staff failed to transmit MDS (minimum data set) assessments in a timely manner for six of 26 residents in th...
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Based on staff interview, facility document review and clinical record review, the facility staff failed to transmit MDS (minimum data set) assessments in a timely manner for six of 26 residents in the survey sample, Residents #1, #48, #36, #51, #56 and #55.
The findings include:
1. For Resident #1 (R1), the facility staff failed to transmit a quarterly MDS with an ARD (assessment reference date) of 9/7/23 within 14 days of completion.
A review of R1's clinical record revealed the resident's quarterly MDS assessment with an ARD of 9/7/23 was completed on 9/30/23. Further review of R1's clinical record revealed the MDS was not transmitted until 10/17/23 (17 days).
On 10/17/23 at 2:50 p.m., an interview was conducted with RN (registered nurse) #1 (the MDS coordinator). RN #1 stated MDS assessments should be transmitted within 14 days from the completion date. RN #1 stated she references the CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) manual when transmitting MDS assessments.
On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1,the executive director and ASM #2, the director of nursing were made aware of the above concern.
The CMS RAI manual documented, Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date.
2. For Resident #48 (R48), the facility staff failed to transmit a quarterly MDS with an ARD of 8/17/23 within 14 days after the completion date.
A review of R48's clinical record revealed the resident's quarterly MDS assessment with an ARD of 8/17/23 was completed on 9/15/23. Further review of R48's clinical record revealed the MDS was not transmitted until 10/17/23 (32 days).
On 10/17/23 at 2:50 p.m., an interview was conducted with RN (registered nurse) #1 (the MDS coordinator). RN #1 stated MDS assessments should be transmitted within 14 days from the completion date. RN #1 stated she references the CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) manual when transmitting MDS assessments.
On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1,the executive director and ASM #2, the director of nursing were made aware of the above concern.
3. For Resident #36 (R36), the facility staff failed to transmit a quarterly MDS with an ARD of 8/31/23 within 14 days after the completion date.
A review of R36's clinical record revealed the resident's quarterly MDS with an ARD of 8/31/23 was completed on 9/18/23. Further review of R36's clinical record revealed the MDS was not transmitted until 10/17/23 (29 days).
On 10/17/23 at 2:50 p.m., an interview was conducted with RN (registered nurse) #1 (the MDS coordinator). RN #1 stated MDS assessments should be transmitted within 14 days from the completion date. RN #1 stated she references the CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) manual when transmitting MDS assessments.
On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1,the executive director and ASM #2, the director of nursing were made aware of the above concern.
4. For Resident #51 (R51), the facility staff failed to transmit a quarterly MDS with an ARD of 8/24/23 within 14 days after the completion date.
A review of R51's clinical record revealed the resident's quarterly MDS with an ARD of 8/24/23 was completed on 9/18/23. Further review of R51's clinical record revealed the MDS was not transmitted until 10/17/23 (29 days).
On 10/17/23 at 2:50 p.m., an interview was conducted with RN (registered nurse) #1 (the MDS coordinator). RN #1 stated MDS assessments should be transmitted within 14 days from the completion date. RN #1 stated she references the CMS (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) manual when transmitting MDS assessments.
On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1,the executive director and ASM #2, the director of nursing were made aware of the above concern.
5. For Resident #56 (R56), the facility staff failed to transmit a discharge MDS assessment when the resident discharged to an assisted living apartment on 6/22/23.
R56 discharged to an assisted living apartment on 6/22/23. A review of the resident's clinical record failed to reveal a discharge MDS assessment was transmitted.
On 10/18/23 at 11:10 a.m., an interview was conducted with RN (registered nurse) #1 (the MDS coordinator). RN #1 stated R56's discharge MDS should have been transmitted and was not.
On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1,the executive director and ASM #2, the director of nursing were made aware of the above concern.
6. For Resident #55 (R55), the facility staff failed to transmit a discharge MDS assessment when the resident discharged to an assisted living apartment on 9/20/23.
R55 discharged to an assisted living apartment on 9/20/23. A review of the resident's clinical record failed to reveal a discharge MDS assessment was transmitted.
On 10/18/23 at 11:10 a.m., an interview was conducted with RN (registered nurse) #1 (the MDS coordinator). RN #1 stated R55's discharge MDS should have been transmitted and was not.
On 10/18/23 at 12:27 p.m., ASM (administrative staff member) #1,the executive director and ASM #2, the director of nursing were made aware of the above concern.
Apr 2022
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to notify the ombudsman for a transfer to the emergency room for one of 21 re...
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Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to notify the ombudsman for a transfer to the emergency room for one of 21 residents in the survey sample, Resident #8 (R8).
The findings include:
On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 1/13/2022, the resident scored a four out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is severely cognitively impaired for making daily decisions.
The nurse's note dated, 3/27/2022 at 9:39 p.m. documented in part, @ (at) 2100 (9:00 p.m.) this writer heard yelling from resident's room. Upon entering, resident was observed laying on his right side on bathroom floor. Stated, 'he fell while transferring from toilet back to wheelchair.' Denies hitting his head but c/o (complained of) left leg pain. Resident remained on floor with pillows cushioning his head and right arm. Rescue Squad called for further assessment and resident was transferred to[name of hospital] ED (emergency department) for evaluation @ 2200 (10:00 p.m.) Care plan goals sent and written notice of transfer initiated.
A request was made on 4/6/2022 at 1:17 a.m. to ASM (administrative staff member) #1, the interim administrator, for the notification to the ombudsman of the transfer to the hospital for R8.
An email, documenting the residents that were transferred out of the facility for the month of March 2022, was presented. R8's name was not on the list.
An interview was conducted with OSM (other staff member) #2, the social worker, on 4/6/2022 at 3:39 p.m. When asked the process for notifying the ombudsman of transfers out of the facility, OSM #2 stated she completes a form monthly and sends it to the state ombudsman. When asked what type of transfers, OSM #2 stated residents that are transferred out fo the hospital and admitted , if the resident goes to the emergency room and comes back then she never does them.
The facility policy, Facility Initiated Transfer and Discharge documented in part, The facility will send a copy of the notice to a representative of the Office of the State Long-Term Ombudsman .Copies of notices for emergency transfers will be sent to the ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis.
ASM #1, ASM #2, the director of nursing, and ASM #3, the quality assurance/staff development/infection preventionist nurse were made aware of the above findings on 4/6/2022 at 5:19 p.m.
No further information was provided prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to cl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to clarify two physician orders for the treatment of pain for one of 21 residents in the survey smaple, Resident # 194 (R194).
The findings include:
On the Initial Nursing Assessment, dated, 3/30/2022, R194 was documented as being alert but not oriented.
The physician order dated 3/30/2022, documented, Acetaminophen (Tylenol - used to treat mild to moderate pain) (1) 500 mg (milligrams) tablet 1 tab (tablet) by mouth every 6 hours as needed for pain. A second order dated, 3/30/2022, documented, Celebrex (used to relieve pain, tenderness, swelling and stiffness caused by osteoarthritis, rheumatoid arthritis and to relieve other types of short-term pain including pain caused by injuries, surgery and other medical or dental procedures, or medical conditions that last for a limited time.) (2) 200 mg capsule - 200 mg by mouth twice a day as needed for pain.
The April 2022 MAR (medication administration record) documented the above orders. The Tylenol was administered once on 4/2/2022 at 7:25 p.m. and the Celebrex was administered on 4/3/2022 at 3:41 p.m.
The comprehensive care plan dated, 3/30/2022, documented in part, Problem: Alteration in comfort/pain related to compression deformities at T4 - T 6 (thoracic level 4 - 6), back pain, post fall and hx (history of) repeated falls. The Approach documented in part, Administer pain meds (medications) per MD (medical doctor) order. Evaluate effectiveness of pain management prn (as needed).
An interview was conducted with LPN (licensed practical nurse) #1 on 4/6/2022 at 4:53 p.m. The two medication orders were reviewed with LPN #1. When asked how she knows which one to give, LPN #1 stated she had only worked with R194 twice. LPN #1 stated there is no pain scale so I'm not sure which to give for what. When asked if those orders should be clarified, LPN #1 stated, yes.
A request for the facility policy on clarifying physician orders was requested on 4/7/2022 at approximately 10:00 a.m. At 10:50 a.m. ASM (administrative staff member) #2, the director of nursing, stated the facility does not have a policy on clarifying physician orders. When asked the standard of practice the facility follows, ASM #2 stated the facility follows their policies.
According to [NAME] and Perry's, Fundamentals of Nursing, 7th edition, page 268 documents the following statements: Clarifying an order is competent nursing practice, and it protects the client and members of the health care team. When you carry out an incorrect or inappropriate intervention, it is as much your error as the person who wrote or transcribed the original order.
ASM #1, ASM #2, the director of nursing, and ASM #3, the quality assurance/staff development/infection preventionist nurse were made aware of the above findings on 4/6/2022 at 5:19 p.m.
No further information was provided prior to exit.
(1). This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a681004.html.
(2) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a699022.html.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to store respiratory equipment in a sanitary...
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Based on observation, staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to store respiratory equipment in a sanitary manner for two of 21 residents in the survey sample, Residents # 193 (R193) and # 194 (R194).
The findings include:
1. For R193, the facility staff failed to store his CPAP (continuous positive airway pressure prevents episodes of airway collapse that block the breathing in people with obstructive sleep apnea and other breathing problems.) (1), in a sanitary manner.
On the most recent MDS (minimum data set) assessment, a Medicare assessment, with an ARD (assessment reference date) of 3/25/2022, the resident scored a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is not cognitively impaired for making daily decisions.
Observation was made of R193's room on 4/5/2022 at approximately 1:15 p.m. A CPAP machine was sitting on the night stand. The tubing for the CPAP machine was hanging over the machine with no covering over it. When asked if the staff had given him a bag or something to store the tubing for his CPAP machine when it wasn't in use, R193 stated the staff had not provided anything like that.
A second observation was made on 4/6/2022 at 8:15 a.m. and 8:50 a.m. the CPAP machine tubing was again noted hanging over the CPAP machine on the night stand.
The comprehensive care plan dated, 4/7/2022, failed to evidence the storage of the CPAP mask/tubing when not in use.
An interview was conducted on 4/6/2022 at 4:53 p.m. with LPN (licenses practical nurse) #1. When asked how a CPAP mask/tubing should be stored when it is not in use by the resident, LPN #1 stated it should be stored in a dated Ziploc bag. When asked the purpose of keeping the tubing in the plastic bag, LPN #1 stated it was to keep the germs off of it.
The physician order dated, 4/7/2022, documented, CPAP mask and tubing to be stored in dated Ziploc bag when not in use. 11-7 (11:00 p.m. to 7:00 a.m.) shift to initiate new Ziploc bag each week. Date when changed.
The facility policy, Use and Maintenance of BI-PAP/CPAP Machine failed to evidence documentation of how the tubing/mask is to be stored when not in use. The policy, documented in part, 1. 7-3 (7:00 a.m. to 3:00 p.m. shift) daily - wash BI-PAP/CPAP mask and humidifier chamber daily with soapy water, then rinse and let air dry.
ASM #1, ASM #2, the director of nursing, and ASM #3, the quality assurance/staff development/infection preventionist nurse were made aware of the above findings on 4/6/2022 at 5:19 p.m.
No further information was provided prior to exit.
(1) This information was obtained from the following website: https://medlineplus.gov/ency/article/001916.htm
2. For R194, the facility staff failed to store a CPAP mask/tubing in a sanitary manner.
On the Initial Nursing Assessment, dated, 3/30/2022, R194 was documented as being alert but not oriented.
Observation was made of R 194's room on 4/5/2022 at approximately 1:30 p.m. The CPAP machine was observed sitting on the night stand. The tubing/mask were hanging over the machine, not store in any manner.
A second observation was made on 4/6/2022 at 2:18 p.m. The resident was in their wheelchair watching TV. The CPAP tubing/mask were hanging over the headboard of the bed. Not in any type of covering.
The physician order dated, 4/1/2022, documented, BI-CPAP Use: 1. fill chamber to fill line with distilled water only. 2. To attach the water chamber to device, open top of machine, place chamber in device, chose top and secure. 3. Attach tubing to back of device and other end of the tube to the mask. Switch on device by pressing on/off button at bedtime.
The comprehensive care plan dated, 4/3/2022, failed to evidence documentation related to the storage of a CPAP machine.
An interview was conducted on 4/6/2022 at 4:53 p.m. with LPN (licenses practical nurse) #1. When asked how a CPAP mask/tubing should be stored when it is not in use by the resident, LPN #1 stated it should be stored in a dated Ziploc bag. When asked the purpose of keeping the tubing in the plastic bag, LPN #1 stated it was to keep the germs off of it.
ASM #1, ASM #2, the director of nursing, and ASM #3, the quality assurance/staff development/infection preventionist nurse were made aware of the above findings on 4/6/2022 at 5:19 p.m.
No further information was provided prior to exit.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected multiple residents
Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to have a complete pain management program for one of 21 residents in the su...
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Based on staff interview, facility document review, and clinical record review, it was determined the facility staff failed to have a complete pain management program for one of 21 residents in the survey sample, Resident # 24 (R24). The facility staff failed to clarify the physician orders, document the location of pain and document the level of pain for R24.
The findings include:
On the most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date (ARD) of 2/24/2022, the resident scored a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is not cognitively impaired for making daily decisions. In Section J - Health Conditions - R24 was coded as having frequent pain, the limited her day-to-day activities because of pain. The resident rated the pain as a 6 on a pain scale of 0 to 10, 10 being the worse pain ever felt and zero being no pain.
The physician orders dated, 3/11/2022, documented, Acetaminophen (Tylenol - used to treat mild to moderate pain) (1)325 mg (milligrams) tablet, 2 tabs (tablets) by mouth every 6 hours as needed for pain. The physician order dated, 3/11/2022, documented, Hydromorphone (Dilaudid) (used to relieve moderate to severe pain) (2) 2 mg tablet, 4 mg every 4 hours as needed for pain.
The March 2022 MAR (medication administration record) documented the above medication orders: The Tylenol was administered on the following dates: time and with a pain scale
3/19/2022 at 4:44 a.m. - pain scale of 3, no location documented
3/21/2022 at 7:29 p.m. - no pain scale documented, resident complained of body aches.
The March 2022 MAR documented the above medication orders. The Hydromorphone was administered on the following dates, time with a pain scale:
3/14/2022 at 5:00 p.m. -pain scale of 4 - no location documented.
3/19/2022 at 9:15 p.m. - pain level of 6 - no location documented.
3/20/2022 at 4:18 p.m. - pain level of 5 - no location documented.
3/21/2022 at 8:52 p.m. - pain level of 0 - location right hip and knee pain.
3/26/2022 at 3:06 p.m. - pain level of 0 - location right knee.
3/28/2022 at 3:08 p.m. - pain level of 5 - no location documented.
Review of the nurse's notes for March failed to document the location or pain scales above.
The April 2022 MAR documented the above medication orders. The Hydromorphone was administered on the following dates, time with a pain scale:
4/1/2022 at 2:03 p.m. - pain scale of 6, no location documented.
4/3/2022 at 4:28 p.m. - pain scale of 3, no location documented.
4/4/2022 at 7:45 p.m. - pain scale of 5, no location documented.
4/6/2022 at 7:47 a.m. - pain scale of 4, no location documented.
Review of the nurse's notes for April 2022 failed to evidence documentation of the location of the pain when the medication was administered.
The comprehensive care plan dated, 12/21/2021, documented in part, Problem: Alteration in comfort/pain related to .joint pain and right sided pain from falls PTS (prior to admission) that lead to R (right) hip fracture currently NWB (non - weight bearing) on RLE (right lower extremity). The Approaches documented in part, Complete pain assessment upon admission, quarterly and PRN (as needed) and when intensity/location of pain changes. Utilize pain scale to assess for intensity of pain.
An interview was conducted with LPN (licensed practical nurse) #1, on 4/6/2022 at 4:53 p.m. When asked the process for giving a pain medication, LPN #1 stated the nurse should assess the resident if in pain, try to do non-pharmacological interventions, offer repositioning, ice or heat packs. LPN #1 stated, skilled residents are alert and oriented and many times refuse non- pharmacological interventions. The above two medication orders were reviewed with LPN #1. LPN #1 stated she knew [R24] didn't have a scale, usually she's in moderate to severe pain, but sometimes [R24] requests the Dilaudid. When asked where the pain scale is documented, LPN #1 stated it should be on the MAR. When asked where the location is documented, LPN #1 stated, it's in a note on the MAR. When asked if a pain scale should be documented with the pain medications, LPN #1 stated those medications should have some kind of parameters to give like mild to moderate pain or moderate to severe pain or by the pain scale.
The facility policy, Resident Comfort/Pain Management documented in part, The physician and staff in collaboration with the resident/resident's representative will establish a treatment regiment based on considerations of the following: a. The resident's medical condition. b. Current medication regimen. c. Nature, severity and cause of the pain. d. Course of the illness and e. Treatment goals Pain management interventions shall reflect the sources, type and severity of pain . Pain Scale will be used each tine a prn (as needed) pain medication is administered. Pain Scale is posted in each MAR binder. Pain rating will be recorded along with the reason for the medication and with the results.
ASM (administrative staff member) #1, the interim administrator, ASM #2, the director of nursing, and ASM #3, the quality assurance/staff development/infection preventionist nurse were made aware of the above findings on 4/6/2022 at 5:19 p.m.
No further information was provided prior to exit.
(1). This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a681004.html.
(2) This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a682013.html.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, staff interview and facility document review, it was determined the facility staff failed to maintain clean kitchen equipment in one of two kitchens, the main kitchen.
The findi...
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Based on observation, staff interview and facility document review, it was determined the facility staff failed to maintain clean kitchen equipment in one of two kitchens, the main kitchen.
The findings include:
Observation was made of the main kitchen on 4/5/2022 at 11:28 a.m. The oven racks appeared to be covered in a brown substance. When asked what the cleaning schedule was, OSM (other staff member) #3, the executive chef, stated they should be cleaned on a weekly basis, but may have been missed last week. When asked if they could provide documentation when the ovens were cleaned last, OSM #1, the certified dietary manager, stated it was unlikely that they could provide that.
On 4/6/2022 at 10:41 a.m. OSM #1 was asked if they found the documentation of the oven having been cleaned, OSM #1 stated, she doubted [OSM #3] could find that documentation.
The facility policy, Cleaning and Sanitizing of Work Surfaces. documented in part, When cleaning fixed equipment, (mixers, slicers, and other equipment that cannot be readily immersed in water), the removable parts are washed and sanitized and non-removable parts are cleaned with detergent and hot water.
ASM #1, ASM #2, the director of nursing, and ASM #3, the quality assurance/staff development/infection preventionist nurse were made aware of the above findings on 4/6/2022 at 5:19 p.m.
No further information was provided prior to exit.
Feb 2021
4 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide the necessary care and services, consistent with professional standards of practice, to promote healing and prevent infection of a pressure injury for one of 20 residents in the survey sample, Resident #16. Resident #16 was readmitted to the facility on [DATE], with a stage two pressure injury on the sacrum/buttocks. The facility staff failed to complete ongoing thorough wound assessments including measurements and staging of the pressure injury from 10/30/20 thorough 11/19/20, and from 11/27/20 through 12/10/20, and failed to provide treatment to the pressure injury from 11/7/20 through 11/17/20, with the exception of 11/14/20. On 11/19/20 an assessment of the area, revealed the pressure injury had deteriorated from a stage two to an unstageable pressure injury, resulting in harm.
2. The facility staff failed to administer treatment per physician order for Resident #16's pressure injury on the buttocks on 11/25/20, 12/1/20 and 12/9/20.
3. The facility staff failed to conduct a complete thorough wound assessments including wound measurements of Resident #16's right heel pressure injury from 11/27/20 until 12/10/20, to determine if the wound had improved or declined.
The findings include:
1. Resident #16 was admitted to the facility on [DATE]. Resident #16's diagnoses included but were not limited to acute kidney failure, major depressive disorder and urinary tract infection. Resident #16's quarterly MDS (minimum data set) assessment with an ARD (assessment reference date) of 1/11/21, coded the resident as being cognitively intact. Section G coded the resident as requiring extensive assistance of two or more staff with bed mobility. Section M coded Resident #16 as having one stage three pressure injury (1) and one unstageable suspected DTI (deep tissue injury) (1).
Resident #16's comprehensive care plan dated 1/6/21 documented, Actual skin breakdown .Pressure ulcer Stage 3 (1) to coccyx/buttocks, R (right) heel DTI .(A) Nurse to measure and monitor wound status progression or deterioration q (every) week, notify MD (medical doctor) and family of changes. (A) Treatment as ordered .
Review of Resident #16's clinical record revealed the resident was readmitted from the hospital on [DATE] with a stage two pressure injury measuring 1 cm (centimeter) in length by 1 cm in width on the sacrum. Nutrashield (2) was applied per physician order on 10/26/20 and 10/27/20. On 10/28/20, the PA (physician assistant) evaluated the pressure injury and signed an order for greer's goo (3) to be applied to the pressure injury every shift for seven days then reassess. On 10/29/20, the physician evaluated the pressure injury and no new orders were written.
Further review of Resident #16's clinical record, including nurses' notes, PA notes, nurse practitioner notes and physician notes, failed to reveal any further complete and thorough assessments of the pressure injury, including measurements and staging until 11/19/20 when the pressure injury was documented as unstageable and measured 7.5 cm in length by 3 cm in width. In addition, review of nurses' notes and TARs (treatment administration records) for October 2020 and November 2020, failed to reveal any treatment was provided for the pressure injury from 11/7/20 until 11/13/20 and from 11/15/20 until 11/17/20.
Further review of the clinical record revealed a nurse's note dated 11/26/20, which documented in part, He continues to have dk (dark) red/purple area to the buttocks which measures approx (approximately) 6cm x 3cm with small wound which now measures approx 3.5cm x 3cm and wound bed is covered with slougjh (sic) (dead tissue), no odor noted from this area . Review of Resident #16's clinical record including nurses' notes, physician assistant notes, nurse practitioner notes and physician notes failed to reveal any further assessments of the pressure injury until 12/10/20, on this date the pressure injury was documented as unstageable and measured 3 cm in length by 1.6 cm in width.
On 2/17/21 at 2:32 p.m., an interview was conducted with RN (registered nurse) #1 (the assistant director of nursing) and LPN (licensed practical nurse) #2 (the quality assurance nurse). RN #1 stated the nurses are responsible for pressure injury assessments but she and LPN #2 conduct audits to ensure the nurses are completing the assessments. RN #1 stated a full skin assessment is conducted for each resident on admission and weekly. RN #1 stated if a pressure injury is observed, then the nurses should complete a full assessment of the wound, contact the physician and obtain a treatment order. RN #1 was asked to describe a full assessment of a pressure injury. RN #1 stated a full assessment consists of the measurement including the length, width and depth, drainage, appearance, tissue type, odor and stage. RN #1 stated a full assessment of a pressure injury should be conducted at least weekly. LPN #2 stated the facility policy documented these assessments should be done weekly unless there is a significant change.
On 2/18/21 at 11:15 a.m., a telephone interview was conducted with ASM (administrative staff member) #3, the PA who signed the 10/28/20 order for Greer's goo for seven days then reassess. ASM #3 was asked to describe her role in the assessment and treatment of pressure injuries. ASM #3 stated the initial provider who rounds at the facility evaluates the pressure injury and decides if the injury needs more specialized treatment. ASM #3 stated she provides guidance to the nurses regarding minor wounds but refers advanced wounds to a wound care physician. ASM #3 was asked what the facility nurses' responsibilities were regarding pressure injuries. ASM #3 stated the nurses have protocols for various stages of pressure injuries regarding treatments and dressing changes. ASM #3 was read Resident #16's physician's order for Greer's goo for seven days then reassess and was asked who was responsible for the reassessment. ASM #3 stated different providers round at the facility different days of the week. ASM #3 stated she only rounds on Wednesday mornings and the nurses tells her who needs to be seen. ASM #3 stated whoever rounded the day when Resident #16's pressure injury needed to be reassessed needed to reassess the injury but this would have needed to be initiated by the nursing staff.
On 2/18/21 at 11:27 a.m., a telephone interview was conducted with LPN #3. LPN #3 stated her role regarding the assessment and treatment of a pressure injury is to assess the wound, notify the doctor to see if he or she wants to evaluate the wound and develop a plan of action to treat the wound. LPN #3 stated the assessment of a pressure injury consists of measurements, odor and color. LPN #3 stated nurses evidence wound treatments by signing off the TAR in the computer, documenting a nurse's note and writing the date, time and initials on the wound dressing. LPN #3 was asked if one could say a treatment was done if there was no documentation. LPN #3 stated, No. LPN #3 was read Resident #16's physician's order for greer's goo and was asked who was responsible for reassessing the pressure injury seven days after the treatment was administered. LPN #3 stated she would assume the last person to sign the treatment for the wound would notify the assistant director of nursing, the director of nursing and then consult the physician for the next step.
On 2/18/21 at 11:53 a.m., a telephone interview was conducted with ASM #2 (the director of nursing), RN #1 and LPN #2. ASM #2, RN #1 and LPN #2 were made aware of the above concerns and asked to gather and provide any additional information.
On 2/18/21 at 1:34 p.m., another telephone interview was conducted with ASM #2, RN #1 and LPN #2. ASM #2 stated Resident #16 was extremely non-compliant with care. ASM #2 further stated that the physician is very involved with Resident #16's care and evaluates the resident every week. LPN #2 stated there were multiple nurses' notes that documented Resident #16's pressure injury was red, abraded, and had a foul odor. LPN #2 stated these notes were reflective of an assessment.
Review of Resident #16's clinical record revealed multiple nurses' notes, PA notes, NP (nurse practitioner) notes and physician notes that documented Resident #16 was non-compliant with turning and repositioning but failed to reveal the resident was non-compliant with pressure injury assessments and pressure injury treatments. The notes failed to reveal any further complete and thorough assessments of the pressure injury, including measurements and staging until 11/19/20 when the pressure injury was documented as having declined from a stage two, to an unstageable pressure injury that measured 7.5 cm in length by 3 cm in width.
Further review of Resident #16's clinical record revealed the NP, PA or physician evaluated the resident on 10/28/20, 10/29/20, 11/5/20, 11/16/20, 11/20/20, 11/23/20, 12/3/20 and 12/10/20. The notes dated 10/28/20, 10/29/20, 11/20/20 and 11/23/20, contained documentation regarding Resident #16's pressure injury but these notes were not written between 10/30/20 and 11/19/20 when there was no evidence of a thorough assessment and the pressure injury declined to unstageable. The notes dated 11/5/20, 11/16/20, 12/3/20 and 12/10/20 did not contain any documentation regarding the pressure injury.
The nurses' notes that LPN #2 stated were reflective of a pressure injury assessment were documented as followed:
-11/5/20 No new skin issues noted except abrased areas on his buttocks appear worse, skin is peeling in that area, on the scrotum and inner thigh area. He was cleaned and greers goo applied to the areas .
-11/9/20 Abraded area remains with redness to buttocks .
-11/14/20- Abraded area remains with redness to buttocks. Patch in place .
-11/15/20- His buttocks remain red and abrased .
-11/17/20- Abraded area remains to buttocks. Patch in place.
-11/18/20- Abraded area remains on buttocks, patch in place.
-11/22/20- Resident continues to have a Hydrocoloid (sic) Patch to his coccyx and buttocks for open pressure wounds which has a foul odor noted .
Review of the clinical record failed to reveal a documented physician order to apply a patch to Resident #16's pressure injury on the dates 11/9 through 11/18/20 noted above.
On 2/18/21 at 11:27 a.m., a telephone interview was conducted with LPN #3, the nurse who wrote the 11/5/20 note. When asked what was done other than greer's goo for the worsening area, or if the physician was made aware that the area was declining, LPN #3 stated that was so long ago and she could not remember.
On 2/18/21 at 2:39 p.m., a telephone interview was conducted with ASM #4 (Resident #16's physician), regarding the assessment and treatment of pressure injuries. ASM #4 stated he assesses pressure injuries, makes treatment recommendations and takes it from there. ASM #4 stated this is no different than any other health issues. When asked about the nurses' responsibilities for pressure injuries, ASM #4 stated the nurses should assess, document and notify him of any changes. ASM #4, was read Resident #16's 10/28/20, physician's order for greer's goo for seven days then reassess, and was asked who was responsible for the reassessment. ASM #4 stated the physician and the nurses were responsible. ASM #4 stated different providers round on different days of the week so he would expect the nurses to remind the providers. ASM #4 stated since approximately mid-December, he visits Resident #16 every week and there have been occasions that he has evaluated the resident's pressure injury.
On 2/19/21 at 2:59 p.m., a telephone interview was conducted with LPN #4, the nurse who documented the notes on 11/9/20, 11/14/20, 11/17/20 and 11/18/20. LPN #4 stated a pressure injury assessment consists of the size of the injury, color, slough (dead tissue), the way the area looks, a description of the tissue, any tunneling, measurements and if the treatment is working. LPN #4 stated she does not assess a pressure injury unless the weekly assessment is due or unless she is completing the treatment. LPN #4 was made aware of the notes she documented on 11/14/20, 11/17/20 and 11/18/20 that documented, patch in place. LPN #4 was asked if these notes meant that she completed dressing treatments on these dates or if she was purely documenting that a patch was in place. LPN #4 stated Resident #16's pressure injury treatments are completed on another shift and she does not complete them. LPN #4 stated she was probably just noting that a patch was in place to show treatment was continued from another shift. LPN #4 was made aware there was no documented physician order for a patch but she documented one was in place on these dates. LPN #4 stated she could not recall any specific details.
On 2/18/21 at 3:30 p.m., a telephone interview was conducted with LPN #6, the nurse who documented the 11/22/20 note. LPN #6 stated a pressure injury assessment consists of odor, drainage, if the wound is open, measurements, depth, undermining and tunneling. LPN #6 stated she documents this information when she completes a pressure injury assessment.
On 2/18/21 at 3:52 p.m., another telephone interview was conducted with ASM #4, (Resident #16's physician). ASM #4 stated any time he assesses a resident's pressure injuries, he documents this in his notes. ASM #4 stated if there is no documentation regarding Resident #16's pressure injuries in some of his notes then he did not assess the resident's pressure injuries on those dates.
On 2/19/21 at 4:41 p.m., ASM #1 (the administrator), ASM #2, RN #1 and LPN #2 were made aware of the above concerns and the concern for harm. ASM #2 stated she felt that she had showed enough evidence to demonstrate there was no harm and she thought this was a documentation issue. ASM #2 stated she had no additional information to provide.
The facility policy regarding pressure areas documented in part, POLICY: To provide optimum treatment to those residents who have developed pressure areas, promote healing and provide comfort .PROCEDURE .5. Clean wounds according to ordered procedure, use clean technique for treatment and dressings unless otherwise specified. 6. Place ordered medication on pressure ulcer. 7. Apply dressing as ordered by physician .10. Pressure Ulcer documentation will occur at least weekly and upon any significant change in pressure ulcer, documentation will include the following: A. Stages. B. Location. C. Size. D. Appearance. E. Drainage. F. Odor. G. Inflammation. H. Undermining .
The Pressure Ulcer Treatment Quick Reference Guide by NPUAP concerning pressure ulcer assessment states in part, Asses the pressure ulcer initially and re-assess it at least weekly, documenting findings .A 2-week period is recommended for evaluating progress toward healing. However, weekly assessments provide an opportunity for the health care professional to detect early complications and the need for changes in the treatment plan. With each dressing change, observe the pressure ulcer for developments that may indicate the need for a change in treatment (e.g., wound improvement, wound deterioration, more or less exudate, signs of infection, or other complications) . Assess and accurately document physical characteristics such as location, Category/Stage, size, tissue type (s), wound bed and periwound condition, wound edges, sinus tracts, undermining, tunneling, exudate, necrotic tissue, odor, presence/absence of granulation tissue, and epithelialization. Re-evaluate the pressure ulcer, the plan of care, and the individual if the pressure ulcer does not show progress toward healing within 2 weeks (or as expected given the individual's overall condition and ability to heal) .Signs of deterioration should be addressed immediately. This information was obtained from: National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Pressure Ulcer Prevention and Treatment: Clinical Practice Guideline. [NAME], DC: National Pressure Ulcer Advisory Panel, Second edition published 2014.
No further information was presented prior to exit.
2. The facility staff failed to administer treatment per physician order for Resident #16's pressure injury on the buttocks on 11/25/20, 12/1/20 and 12/9/20.
A skin evaluation form dated 11/19/20 documented Resident #16 as having an unstageable pressure injury (1) measuring 7.5 cm (centimeters) in length by 3 cm in width on the buttocks.
A note signed by the nurse practitioner on 11/23/20 documented, Sacral wound. Total redness approx (approximately) 8-1-cm. 3:00 position: area of stage 2. 12:00 position: area of purplish/blackish? necrotic vs [versus] deep tissue .
Review of Resident #16's clinical record revealed a physician's order dated 11/24/20 that documented, Santyl (4) 250 unit/gram topical ointment to coccyx wound to darked (sic) area and cover with hydrocolloid dressing-Topical. Apply Santyl to coccyx wound darked (sic) area q (every) day and cover with hydrocolloid dressing (5). Review of Resident #16's November 2020 and December 2020 TARs and nurses' notes failed to reveal evidence that the treatment was administered on 11/25/20, 12/1/20 and 12/9/20. On these dates, the treatment was not signed off on the TAR as being administered and there were no nurses' notes that documented the treatments were administered.
On 2/18/21 at 11:27 a.m., a telephone interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated her role regarding the assessment and treatment of a pressure injury is to assess the wound, notify the doctor to see if he or she wants to evaluate the wound and develop a plan of action to treat the wound. LPN #3 stated nurses evidence wound treatments by signing off the TAR in the computer, documenting a nurse's note and writing the date, time and initials on the wound dressing. When asked if one could say a treatment was done if there was no documentation on the TAR or in the clinical record, LPN #3 stated, No.
On 2/18/21 at 11:53 a.m., a telephone interview was conducted with ASM (administrative staff member) #2 (the director of nursing), RN (registered nurse) #1 and LPN #2. ASM #2, RN #1 and LPN #2 were made aware of the above concern and asked to gather and provide any additional information.
On 2/19/21 at 4:41 p.m., ASM #1 (the administrator), ASM #2, RN #1 and LPN #2 were made aware of the above concern.
No further information was presented prior to exit.
3. The facility staff failed to conduct a complete thorough wound assessments including wound measurements of Resident #16's right heel pressure injury from 11/27/20 until 12/10/20, to determine if the wound had improved or declined.
Review of a nurse's note and a skin evaluation dated 11/24/20 revealed Resident #16 acquired a DTI (deep tissue pressure injury) (1) measuring 4 cm in length by 4 cm (centimeters) in width on the right heel. Treatment was initiated per physician order. A nurse's note dated 11/26/20 documented the DTI on the right heel was a small purple blanchable area that measured 4 cm by 3 cm. Further review of Resident #16's clinical record, including nurses' notes, physician assistant notes, nurse practitioner notes and physician notes, failed to reveal any further assessments of the DTI until 12/10/20. A skin evaluation completed on that date documented the DTI was dark purple, non blachable and measured 3cm in length by 3cm in width.
On 2/17/21 at 2:32 p.m., an interview was conducted with RN (registered nurse) #1 (the assistant director of nursing) and LPN (licensed practical nurse) #2 (the quality assurance nurse). RN #1 stated the nurses are responsible for pressure injury assessments but she and LPN #2 conduct audits to ensure the nurses are completing the assessments. RN #1 stated a full skin assessment is conducted for each resident on admission and weekly. RN #1 stated if a pressure injury is observed, then the nurses should complete a full assessment of the wound, contact the physician and obtain a treatment order. RN #1 was asked to describe a full assessment of a pressure injury. RN #1 stated a full assessment consists of the measurement including the length, width and depth, drainage, appearance, tissue type, odor and stage. RN #1 stated a full assessment of a pressure injury should be conducted at least weekly. LPN #2 stated the facility policy documented these assessments should be done weekly unless there is a significant change.
On 2/18/21 at 11:27 a.m., a telephone interview was conducted with LPN #3. LPN #3 stated her role regarding the assessment and treatment of a pressure injury is to assess the wound, notify the doctor to see if he or she wants to evaluate the wound and develop a plan of action to treat the wound. LPN #3 stated the assessment of a pressure injury consists of measurements, odor and color.
On 2/18/21 at 11:53 a.m., a telephone interview was conducted with ASM #2 (the director of nursing), RN #1 and LPN #2. ASM #2, RN #1 and LPN #2 were made aware of the above concern and asked to gather and provide any additional information.
On 2/19/21 at 2:59 p.m., a telephone interview was conducted with LPN #4. LPN #4 stated a pressure injury assessment consists of the size of the injury, color, slough, the way the area looks, a description of the tissue, any tunneling, measurements and if the treatment is working. LPN #4 stated she does not assess a pressure injury unless the weekly assessment is due or unless she is completing the treatment. LPN #4 stated Resident #16's pressure injury treatments are completed on another shift and she does not complete them.
On 2/18/21 at 3:30 p.m., a telephone interview was conducted with LPN #6. LPN #6 stated a pressure injury assessment consists of odor, drainage, if the wound is open, measurements, depth, undermining and tunneling. LPN #6 stated she documents this information when she completes a pressure injury assessment.
On 2/19/21 at 4:41 p.m., ASM #1 (the administrator), ASM #2, RN #1 and LPN #2 were made aware of the above concern.
No further information was presented prior to exit.
References:
(1) A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue.
Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.
Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).
Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.
Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed.
Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss.
This information was obtained from the website: https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf
(2) Nutrashield is used to treat skin conditions. This information was obtained from the website: https://www.woundsource.com/product/remedy-olivamine-nutrashield
(3) Greer's goo is used to treat skin conditions. This information was obtained from the website: http://www.thoracentesis.science/2020/01/Greersgoo.html
(4) Santyl is an ointment used to treat wounds. This information was obtained from the website: https://santyl.com/hcp?gclid=EAIaIQobChMI3cnj6NH27gIVkIzICh07zQG3EAAYASAAEgJ52vD_BwE
(5) Hydrocolloid dressings are used to treat wounds. This information was obtained from the website: https://pubmed.ncbi.nlm.nih.gov/8509607/
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determine...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, facility document review and clinical record review, it was determined that facility staff failed to develop and implement the comprehensive care plan for two of 20 residents in the survey sample, Residents # 18 and # 12. The facility staff failed to develop a care plan to address the care required for Resident #18's bowel incontinence and failed to implement Resident # 12's comprehensive care plan for the administration of physician ordered oxygen.
The findings include:
1. Resident #18 was admitted to the facility on [DATE] with diagnoses including, but not limited to COPD (chronic obstructive pulmonary disease), heart failure, and arthritis (2). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/21/21, Resident #18 was coded as having no cognitive impairment for making daily decisions, having scored 15 out of 15 on the BIMS (brief interview for mental status). She was coded as totally dependent on two facility staff for transfers out of bed. Resident #18 was coded as always incontinent for bowel function.
On 2/16/21 at 10:41 a.m., Resident #18 was observed lying in her bed and agreed to be interviewed. When asked if she had any concerns about her care, she stated the staff took excellent care of her, but she wished she had more control of her bowels. Resident #18 stated she can never predict when she will have diarrhea, and it is very frustrating for her. When asked if the staff have offered to assist her to use a bedside commode or her bathroom, she stated, I don't like the bedpan. And I really don't like for them to move me out of bed.
A review of Resident #18's clinical record revealed CNA (certified nursing assistant) documentation that Resident #18 had bowel movements almost daily, and that she was incontinent of bowel.
Further review of Resident #18's clinical record revealed a bowel function assessment completed most recently on 1/22/21. The assessment documented Resident #18 was incontinent of bowel, and required a mechanical lift for transfers out of the bed.
A review of the attending physician's progress note dated 1/8/21 revealed, in part: Functional status: totally dependent .diarrhea: Will stop Omeprazole (3) as a potential cause of diarrhea.
A review of Resident #18's comprehensive care plan dated 6/17/20, and updated 7/24/20 failed to reveal any information or interventions related to Resident #18's bowel incontinence.
On 2/17/21 at 1:05 p.m., RN (registered nurse) #1, the assistant director of nursing, was interviewed. When asked who is responsible for developing the comprehensive care plan for a resident, RN #1 stated, The interdisciplinary team. She stated the MDS Coordinator is the point person for care plan development. When asked the purpose of a care plan, RN #1 stated it is a roadmap of care for all of the staff to use to best care for a resident. When asked if a resident's bowel incontinence should be included in the care plan, RN #1 stated, Yes. Absolutely.
The facility MDS Coordinator was not available for interview at the time of the survey.
On 2/17/21 at 1:11 p.m., LPN (licensed practical nurse) #1 was interviewed. She stated the resident's care plan should tell you how to take care of the resident so the resident can get where they need to be.
A review of the facility policy, Comprehensive Person-Centered Care Planning, revealed, in part: Person centered care is a focus on residents' emotional needs and care preferences, consistent with their lifestyle. The emphasis is on relationships in the care rather than task-centered approaches that focus on physical health of residents .The facility will develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs as identified throughout the comprehensive Resident Assessment Instrument (RAI) process .Each resident's comprehensive care plan will describe the following: .Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
On 2/17/21 at 3:10 p.m., ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing, were informed of these concerns.
No further information was provided prior to exit.
REFERENCES
(1) COPD is a general term for chronic, nonreversible lung disease that is usually a combination of emphysema and chronic bronchitis. Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124.
(2) 'Arthritis' literally means joint inflammation. Although joint inflammation is a symptom or sign rather than a specific diagnosis, the term arthritis is often used to refer to any disorder that affects the joints. Joints are places where two bones meet, such as your elbow or knee. This information is taken from the website https://www.niams.nih.gov/health-topics/arthritis#:~:text=Points%20To%20Remember%20About%20Arthritis,disorder%20that%20affects%20the%20joints.
(3) Prescription omeprazole is used alone or with other medications to treat the symptoms of gastroesophageal reflux disease (GERD), a condition in which backward flow of acid from the stomach causes heartburn and possible injury of the esophagus (the tube between the throat and stomach) in adults and children 1 year of age and older. This information is taken from the website https://medlineplus.gov/druginfo/meds/a693050.html.
2. The facility staff failed to implement Resident # 12's comprehensive care plan for the administration of physician ordered oxygen.
Resident # 12 was admitted to the facility with diagnoses that included but were not limited to heart failure, dyspnea [1] and pulmonary fibrosis [2].
Resident # 12's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 01/14/2021, coded Resident # 12 as scoring a six on the staff assessment for mental status (BIMS) of a score of 0 - 15, six- being severely impaired of cognition for making daily decisions. Section O Special Treatments, Procedures and Programs coded Resident # 12 for the use of oxygen.
On 02/16/21 at approximately 1:52 p.m., observation revealed Resident # 12 sitting in their wheelchair in their room receiving oxygen by a nasal cannula [3] that was connected to an oxygen concentrator. Observation of the oxygen concentrator [4] revealed an oxygen flow rate between two and two-and-a-half liters per minute.
On 02/16/21 at approximately 3:25 p.m., an observation conducted by another surveyor revealed the same circumstances as stated above.
On 02/17/21 at approximately 7:45 a.m., observation revealed Resident # 12 in bed, receiving oxygen by a nasal cannula connected an oxygen concentrator. The oxygen flow rate on the oxygen concentrator was observed to be between two and two-and-a-half liters per minute.
The POS [physician's order sheet] dated 02/2021 for Resident # 12 documented, Check O2 [oxygen] every shift and report abnormal findings; Oxygen @ [at]_2L [two liters]_mi [per minute]_via [by]_NC [nasal cannula] - Every Shift. Order Date 08/27/2020. Start Date 09/01/2020.
The comprehensive care plan for Resident # 12 dated of 04/24/2019 documented, (P) [Problem]: Needs O2 [oxygen] related to Related diagnosis/conditions Grade 3 [three] diastolic CHF [congestive heart failure], Severe pulmonary HTN [hypertension], Afib [atrial fibrillation], moderate persistent asthma, pulmonary fibrosis. Under (A) [Approaches] it documented in part, Administer O2 [oxygen] as ordered by MD [medical doctor]. Observe labs [laboratory tests], response to medication and treatments. Start Date 04/24/2019.
The facility's eTAR [electronic treatment administration record] dated 02/2021 for Resident # 12 documented, Check O2 every shift and report abnormal findings; Oxygen @_2L_mi_via_NC - Every Shift. Start Date 09/01/2020. Further review of the eTAR revealed documentation indicating that Resident # 12 received oxygen at two liters per minute on 02/16/2021 and 02/17/2021.
On 02/17/2021 at approximately 1:05 p.m., an interview was conducted with LPN [licensed practical nurse] # 1 regarding Resident # 12's comprehensive care plan. When asked to describe the purpose of a resident's care plan LPN # 1 stated, The care plan tells you how to take care of the resident. When asked if they were able to see and view a resident's comprehensive care plan LPN # 1 stated yes. After informing LPN # 1 of Resident # 12's care plan in regard to the oxygen flow and the observations described above, of Resident # 12's oxygen flow rate, LPN # 1 stated that the care plan was not implemented for Resident # 12's oxygen therapy.
The facility's policy Comprehensive Person-Centered Care Plan documented in part, Procedures: 2. The facility will develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs as identified throughout the comprehensive Resident Assessment Instrument (RAI) process. 9. The resident will receive the services and/or items included in the plan of care.
On 02/17/2021 at approximately 2:45 p.m. ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, RN [registered nurse] # 1, and LPN [licensed practical nurse] # quality improvement/staff development coordinator, were made aware of the above findings.
No further information was provided prior to exit.
References:
[1] When you're short of breath, it's hard or uncomfortable for you to take in the oxygen your body needs. You may feel as if you're not getting enough air. But shortness of breath can also be a sign of a serious disease. This information was obtained from the website: https://medlineplus.gov/breathingproblems.html.
[2] A condition in which the tissue deep in your lungs becomes scarred over time. This tissue gets thick and stiff. That makes it hard for you to catch your breath, and your blood may not get enough oxygen. This information was obtained from the website: https://medlineplus.gov/pulmonaryfibrosis.html
[3] Tubing used to deliver oxygen at levels from 1 to 6 L/min. The nasal prongs of the cannula extend approx. 1 cm into each naris and are connected to a common tube, which is then connected to the oxygen source. This information was obtained from the website: http://medical-dictionary.thefreedictionary.com/nasal+cannula.
[4] Is a medical device that concentrates oxygen from environmental air and delivers it to a patient in need of supplemental oxygen. This information was obtained from the website: https://www.oxygenconcentratorstore.com/help-center/what-is-the-medical-definition-of-an-oxygen-concentrator/
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to review and revise the comprehensive care plan for one of 20 residents in the survey sample, Resident #21. The facility staff failed to review and revise Resident #21's comprehensive care plan for oxygen therapy/respiratory care.
The findings include:
Resident #21 was admitted to the facility on [DATE] and readmitted from the hospital on 2/8/21. Resident #21's diagnoses included but were not limited to history of stroke, urinary retention and muscle weakness. Resident #21's significant change in status minimum data set assessment with an ARD (assessment reference date) of 1/28/21, coded the resident's cognition as severely impaired. Section O coded Resident #21 as having received oxygen therapy while not a resident.
Review of Resident #21's clinical record revealed a physician's order dated 2/8/21 for oxygen at the rate of two liters per minute. Resident #21's comprehensive care plan dated 2/8/21 failed to document information regarding oxygen therapy or respiratory care.
On 2/16/21 at 11:31 a.m. and 2:05 p.m., Resident #21 was observed lying in bed and receiving oxygen via a nasal cannula.
On 2/17/21 at 1:12 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated the care plan is a road map of care and tells you who, what, when and where, and goals. When asked if a resident's care plan should be reviewed and revised for the use of oxygen, RN #1 stated, Yes. Should at least have a respiratory portion to their care plan.
On 2/17/21 at 2:53 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.
The facility policy regarding comprehensive person-centered care planning documented in part, 15. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans .D. When the resident has been readmitted to the facility from a hospital stay .F. Updates are done with Medical Doctor Order changes .
No further information was presented prior to exit.
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, staff interview, facility document review and clinical record review, it was determined that the facility ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to provide respiratory care and services for two of 20 residents in the survey sample, Residents #21 and #12. The facility staff failed to administer oxygen to Residents #21 and #12 per the physician prescribed rate and failed to store Resident #12's nasal cannula in a sanitary manner when not in use. Resident #12's nasal cannula was observed uncovered and coiled over the rear handles on the wheelchair when not in use.
The findings include:
1. The facility staff failed to administer oxygen to Residents #21 per the physician prescribed rate of two liters.
Resident #21 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #21's diagnoses included but were not limited to history of stroke, urinary retention and muscle weakness. Resident #21's significant change in status minimum data set assessment with an ARD (assessment reference date) of 1/28/21, coded the resident's cognition as severely impaired. Section O coded Resident #21 as having received oxygen therapy.
Review of Resident #21's clinical record revealed a physician's order dated 2/8/21 for oxygen at the rate of two liters per minute. Resident #21's comprehensive care plan dated 2/8/21 failed to document information regarding oxygen.
On 2/16/21 at 11:31 a.m. and 2:05 p.m., Resident #21 was observed lying in bed and receiving oxygen via a nasal cannula connected to an oxygen concentrator. Observation revealed the oxygen concentrator was set at a rate of three and a half liters as evidenced by the center of the ball in the concentrator flow meter positioned on the three and a half liter line. On 2/17/21 at 7:48 a.m., Resident #21 was observed lying in bed and receiving oxygen via a nasal cannula. Observation revealed the oxygen concentrator was set at a rate of three liters as evidenced by the center of the ball in the concentrator flow meter positioned on the three liter line.
On 2/17/21 at 1:04 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 was asked to describe where the ball in an oxygen concentrator flow meter should be if a resident has a physician's order for two liters of oxygen. LPN #1 stated the two liter line should run through the middle of the ball in the flow meter.
On 2/17/21 at 2:53 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.
The oxygen concentrator manufacturer's manual documented in part, 5. Adjust the flow to the prescribed setting by turning the knob on the top of the flow meter until the ball is centered on the line marking the specific flow rate .
The facility policy regarding oxygen therapy documented in part, B. O2 (Oxygen) administration. 1. Verification of MD (medical doctor) order .6. Turn on O2 at prescribed rate .
No further information was presented prior to exit.
2. a. The facility staff failed to administer Resident # 12's oxygen according to the physician's orders.
Resident # 12 was admitted to the facility with diagnoses that included but were not limited to heart failure, dyspnea [1] and pulmonary fibrosis [2]. Resident # 12's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 01/14/2021, coded Resident # 12 as scoring a six on the staff assessment for mental status (BIMS) of a score of 0 - 15, six- being severely impaired of cognition for making daily decisions. Section O Special Treatments, Procedures and Programs coded Resident # 12 for the use of oxygen.
On 02/16/21 at approximately 1:52 p.m., an observation revealed of Resident # 12 sitting in their wheelchair in their room receiving oxygen by a nasal cannula [3] connected to an oxygen concentrator. Observation of the oxygen concentrator [4] revealed an oxygen flow rate between two and two-and-a-half liters per minute.
On 02/16/21 at approximately 3:25 p.m., an observation of Resident #12's oxygen conducted by another surveyor revealed the oxygen concentrator flow rate was set between two and two-and-a-half liters per minute.
On 02/17/21 at approximately 7:45 a.m., an observation revealed Resident # 12 in bed, receiving oxygen by a nasal cannula connected to an oxygen concentrator. The oxygen flow rate on the oxygen concentrator was observed set at between two and two-and-a-half liters per minute.
The POS [physician's order sheet] dated 02/2021 for Resident # 12 documented, Check O2 [oxygen] every shift and report abnormal findings; Oxygen @ [at]_2L [two liters]_mi [per minute]_via [by]_NC [nasal cannula] - Every Shift. Order Date 08/27/2020. Start Date 09/01/2020.
The comprehensive care plan for Resident # 12 dated of 04/24/2019 documented, (P) [Problem]: Needs O2 [oxygen] related to Related diagnosis/conditions Grade 3 [three] diastolic CHF [congestive heart failure], Severe pulmonary HTN [hypertension], Afib [atrial fibrillation], moderate persistent asthma, pulmonary fibrosis. Under (A) [Approaches] it documented in part, Administer O2 [oxygen] as ordered by MD [medical doctor]. Observe labs [laboratory tests], response to medication and treatments. Start Date 04/24/2019.
The facility's eTAR [electronic treatment administration record] dated 02/2021 for Resident # 12 documented, Check O2 every shift and report abnormal findings; Oxygen @_2L_mi_via_NC - Every Shift. Start Date 09/01/2020. Further review of the eTAR revealed documentation indicating that Resident # 12 received oxygen at two liters per minute on 02/16/2021 and 02/17/2021.
On 02/17/2021 at approximately 1:05 p.m., an interview was conducted with LPN [licensed practical nurse] # 1 regarding how to read the flow rate on a resident's oxygen concentrator. LPN # 1 stated that the liter line on the flow meter of the oxygen concentrator should pass through the middle of the float ball at the appropriate flow rate.
The [Name of Manufacturer] user manual for Resident # 12's oxygen concentrator documented in part, Adjust the flow to the prescribed setting by turning the knob on the top of the flow meter until the ball is centered on the line marking the specific flow rate.
The facility's policy Oxygen Therapy documented in part, B. O2 Administration. 10. Inspect equipment regularly for proper functioning.
On 02/17/2021 at approximately 2:45 p.m. ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, RN [registered nurse] # 1, and LPN [licensed practical nurse] # quality improvement/staff development coordinator, were made aware of the above findings.
No further information was provided prior to exit.
References:
[1] When you're short of breath, it's hard or uncomfortable for you to take in the oxygen your body needs. You may feel as if you're not getting enough air. But shortness of breath can also be a sign of a serious disease. This information was obtained from the website: https://medlineplus.gov/breathingproblems.html.
[2] A condition in which the tissue deep in your lungs becomes scarred over time. This tissue gets thick and stiff. That makes it hard for you to catch your breath, and your blood may not get enough oxygen. This information was obtained from the website: https://medlineplus.gov/pulmonaryfibrosis.html
[3] Tubing used to deliver oxygen at levels from 1 to 6 L/min. The nasal prongs of the cannula extend approx. 1 cm into each naris and are connected to a common tube, which is then connected to the oxygen source. This information was obtained from the website: http://medical-dictionary.thefreedictionary.com/nasal+cannula.
[4] Is a medical device that concentrates oxygen from environmental air and delivers it to a patient in need of supplemental oxygen. This information was obtained from the website: https://www.oxygenconcentratorstore.com/help-center/what-is-the-medical-definition-of-an-oxygen-concentrator/
2. b. The facility staff failed to store Resident #12's nasal cannula in a sanitary manner when not in use. Resident #12's nasal cannula was observed uncovered and coiled over the rear handles on the wheelchair when not in use.
On 02/16/21 at approximately 1:52 p.m., an observation revealed Resident #12 sitting in their wheelchair in their room receiving oxygen by a nasal cannula connected to an oxygen concentrator. Observation of Resident # 12's wheelchair revealed another nasal cannula and oxygen tubing connected to a portable oxygen cylinder on the back of the wheelchair. Further observation of the tubing and nasal cannula revealed it was uncovered and coiled over the rear handles on the wheelchair.
On 02/16/21 at approximately 3:25 p.m., an observation conducted by another surveyor revealed the same circumstances as stated above.
On 02/17/21 at approximately 7:45 a.m., an observation revealed Resident # 12 in bed and receiving oxygen by a nasal cannula that was connected to an oxygen concentrator. Observation of Resident # 12's wheelchair revealed another nasal cannula and oxygen tubing connected to a portable oxygen cylinder on the back of the wheelchair. Further observation of the tubing and nasal cannula revealed it was uncovered and coiled over the rear handles on the wheelchair.
The POS [physician's order sheet] dated 02/2021 for Resident # 12 documented in part, Oxygen tubing and mask or nasal cannula are to be stored in dated Ziploc bag when not in use. Order Date 08/27/2020. Start Date 09/01/2020.
On 02/17/2021 at approximately 1:05 p.m., an interview was conducted with LPN [licensed practical nurse] # 1 regarding the storage of a nasal cannula when it is not in use. LPN # 1 stated that the nasal cannula should be stored in a Ziploc bag when the resident is not using it. When asked why it was important to store the nasal cannula in a Ziploc bag LPN # 1 stated, For infection control purposes.
The facility's policy Oxygen Therapy documented in part, Procedure: C9. Oxygen tubing and mask or nasal cannula are to be stored in dated Ziploc bag when not in use.
On 02/17/2021 at approximately 2:45 p.m. ASM [administrative staff member] # 1, administrator, ASM # 2, director of nursing, RN [registered nurse] # 1, and LPN [licensed practical nurse] # quality improvement/staff development coordinator, were made aware of the above findings.
No further information was provided prior to exit.
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
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Virginia facilities.
- • 27% annual turnover. Excellent stability, 21 points below Virginia's 48% average. Staff who stay learn residents' needs.
Concerns
- • 19 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
Bottom line: Mixed indicators with Trust Score of 73/100. Visit in person and ask pointed questions.
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About This Facility
What is The Culpeper's CMS Rating?
CMS assigns THE CULPEPER an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Virginia, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is The Culpeper Staffed?
CMS rates THE CULPEPER's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 27%, compared to the Virginia average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at The Culpeper?
State health inspectors documented 19 deficiencies at THE CULPEPER during 2021 to 2023. These included: 1 that caused actual resident harm, 17 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates The Culpeper?
THE CULPEPER is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 47 certified beds and approximately 40 residents (about 85% occupancy), it is a smaller facility located in CULPEPER, Virginia.
How Does The Culpeper Compare to Other Virginia Nursing Homes?
Compared to the 100 nursing homes in Virginia, THE CULPEPER's overall rating (4 stars) is above the state average of 3.0, staff turnover (27%) is significantly lower than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting The Culpeper?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is The Culpeper Safe?
Based on CMS inspection data, THE CULPEPER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Virginia. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at The Culpeper Stick Around?
Staff at THE CULPEPER tend to stick around. With a turnover rate of 27%, the facility is 19 percentage points below the Virginia average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly. Registered Nurse turnover is also low at 21%, meaning experienced RNs are available to handle complex medical needs.
Was The Culpeper Ever Fined?
THE CULPEPER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is The Culpeper on Any Federal Watch List?
THE CULPEPER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.