HENRICO HEALTH & REHABILITATION CENTER
Non profit - Corporation
120 Beds
LIFEWORKS REHAB
Data: November 2025
5 Immediate Jeopardy citations
Trust Grade
0/100
Last Inspection: October 2023
Over 2 years since last inspection. Current conditions may differ from available data.
Overview
Henrico Health & Rehabilitation Center has received a Trust Grade of F, indicating significant concerns about the quality of care provided. The facility does not rank among the healthcare options in Virginia or Henrico County, which suggests a lack of competitive standing. The situation is worsening, with the number of reported issues increasing from 7 in 2024 to 11 in 2025. Staffing is a concern, as they have a high turnover rate of 54%, slightly above the Virginia average, and the RN coverage is less than that of 87% of state facilities. Additionally, the facility has incurred $334,071 in fines, which is higher than 99% of Virginia facilities, pointing to serious compliance problems. Specific incidents highlight serious care deficiencies, such as failures to implement necessary COVID-19 precautions, which increased the risk of virus transmission among residents, and violations of their abuse policy that resulted in harm to a resident due to inadequate staff background checks. While it's clear there are significant weaknesses in this facility, families should be cautious and thoroughly consider these issues before making a decision.
- Trust Score
- F
- In Virginia
- #112/223
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 54% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $334,071 in fines. Lower than most Virginia facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 21 minutes of Registered Nurse (RN) attention daily — below average for Virginia. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 94 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Top 50%
Review needed
7 → 11 violations
☆☆☆☆☆
0.0
Overall Rating
☆☆☆☆☆
0.0
Staff Levels
☆☆☆☆☆
0.0
Care Quality
☆☆☆☆☆
0.0
Inspection Score
↔
Stable
2024: 7 issues
2025: 11 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
Staff Turnover: 54%
Near Virginia avg (46%)
Higher turnover may affect care consistency
Federal Fines: $334,071
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: LIFEWORKS REHAB
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 94 deficiencies on record
5 life-threatening 7 actual harm
Jul 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and facility documentation, the facility staff failed to report allegations of abuse...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and facility documentation, the facility staff failed to report allegations of abuse or neglect for 1 Resident (#114) in a survey sample of 55 Residents.The findings included: For Resident #114, the facility staff failed to report the resident eloping from the facility on several occasions. Resident #114 was admitted to the facility on [DATE] with diagnoses that included but were not limited to pancreatic cancer, bile duct obstruction, palliative care, chronic bronchitis, muscle weakness, depression, general anxiety disorder, insomnia due to medical condition, psychotic disorder with hallucinations due to a known physiological condition (paranoid schizophrenia), and psychotic disorder with delusions due to a known physiological condition (paranoid schizophrenia).Resident #114's most recent BIMS (Brief Interview of Mental Status) scored the Resident at 15/15 indicating no cognitive impairment. Resident #114's clinical record included a document entitled Provider Attestation for Schizophrenia/Schizoaffective/Schizophreniform Diagnosis that listed the medications for this diagnosis as Seroquel ER 150 mg per day, Depakote 500 mg 2 times daily and Haldol 10 mg 2 times daily. All meds read for diagnosis of Psychotic disorder with hallucinations due to a known physiological illness.On 7/16/25 the Administrator was asked for all reportable incidents involving Resident #114 during the time of his stay at the facility. The Administrator supplied 2 documents entitled Facility Reported Incident one was dated 8/10/24 and the other was dated 8/11/24. The Administrator was asked if this was all of them and she stated it was.A review of the clinical record revealed the following excerpts: 6/13/24 7:25 p.m. Resident was involved in a verbal/physical altercation with another resident in which Mr. V. [NAME] pushed [Resident name redacted] on her right shoulder, grabbed her right leg, stomped her glasses and kicked her phone in the grass. Writer questioned Resident about the incident, and he stated that she triggered him by saying what she said to him. 6-26-24 6:12 am. - On this date 06/12/2024 during my shift, resident was seen going out of the facility 0540, when asked where he was going, resident says what kind of question are you asking me, I want to get a cigarette lighter at nearby store. All effort to redirect him back to the facility was prove abortive until a staff followed him and drove him back to the facility. 6/29/24 5:16 - Resident was noted to be seen by staff at 0130. Staff went to resident room to check on him and he was nowhere to be found. Resident apparently had left the building unbeknownst to staff. Staff immediately did a sweep of the interior and exterior of the facility unable to locate Mr. [NAME]. Police were called and given a picture and description of the clothing the resident was wearing when last seen. Staff notified DON, RP and provider. Officers spoke with other officers in a different jurisdiction which stated they had him at [Convenience store name redacted] Staff was told by officers they would have to transport [Resident 114 name redacted] back to facility 6/29/24 5:58 a.m. - This writer saw resident at 0130 entered the dining room and later went to resident room to check on him and he was nowhere to be found. Resident had walk [sic] away from the building unknown to staff. Sweeping of the interior and exterior of the facility was done still unable to find [Resident #114 name redacted] Police were called and given a picture and description of the clothing the resident was wearing when last seen. DON was notified, RP and provider. Officers spoke with other officers in a different jurisdiction which stated they found him at [convenience store name redacted]. Staff was [sic] told by officers they would have to transport [Resident#114 name redacted] back to facility. Staff drove to the location where he was found (approximately 7.1 miles away from the facility) and bring [sic] him back to the facility. Head to toe Skin assessment was done and intact. Resident was later sent out to hospital for psych consult EMS notified and resident was transported to the hospital by 2 EMS at 0535. 7/2/24 9:30 a.m.- I was able to find legal Guardian's phone number. I called her to speak about resident's wander guard. She said that resident has a history of wandering, and she would really appreciate him having a wander guard. She asked if it had a tracking device, and I explained that it only alerted us when he went out the building. She said that it was fine and appreciated the call.On 7/16/25 at approximately 11:45 a.m. an interview was conducted with the Administrator; she was asked why the first 3 incidents of elopement were not reported to the OLC and other entities as required by regulations. The Administrator stated that Resident #114 had a High BIMS score and therefore he could leave the facility if he signed himself out. She stated that he did not sign himself out of the facility. The Administrator was asked if Resident #114 had Any conditions that would affect his decision-making ability, she stated that he had a diagnosis of Schizophrenia. On 7/17/25 an interview was conducted with Employee L who was asked if a Resident with a BIMS of 15 can leave the facility unescorted, Employee L stated that it would depend on the physical and mental state of the Resident. When asked if BIMS alone could determine the ability of a Resident to leave the facility unescorted and she stated the BIMS was only one piece of the equation. Employee L stated that the Resident must be safe to ambulate independently and able to make safe decisions and notify the facility when he or she is leaving the facility. She stated that the RP must also be aware of the residents leaving the facility. Employee L also stated that the LOA (Leave of Absence) form must be signed prior to leaving the facility.On 7/18/25 the Administrator was made aware of the concerns, and no further information was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review and facility documentation, the facility staff failed to ensure resident...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review and facility documentation, the facility staff failed to ensure residents were free from accidents and hazards for 3 Residents (#'s 114, 59, and 65) in a survey sample of 55 residents. The Findings included:1. For Resident #114 the facility staff failed to provide adequate supervision to prevent the residents from eloping from the facility.Resident #114 was admitted to the facility on [DATE] with diagnoses that included but were not limited to pancreatic cancer, bile duct obstruction, palliative care, chronic bronchitis, muscle weakness, depression, general anxiety disorder, insomnia due to medical condition, psychotic disorder with hallucinations due to a known physiological condition (paranoid schizophrenia), and psychotic disorder with delusions due to a known physiological condition (paranoid schizophrenia).Resident #114's most recent BIMS (Brief Interview of Mental Status) scored the Resident at 15/15 indicating no cognitive impairment. Resident #114's clinical record included a document entitled Provider Attestation for Schizophrenia/Schizoaffective/Schizophreniform Diagnosis that listed the medications for this diagnosis as Seroquel ER 150 mg per day, Depakote 500 mg 2 times daily and Haldol 10 mg 2 times daily. All meds read for diagnosis of Psychotic disorder with hallucinations due to a known physiological illness.On 7/14/25 at approximately 1:30 p.m. Residents were observed sitting in front of the building without supervision from staff. On 7/15/25- 7/17/25 at various times throughout the day residents were observed without supervision, outdoors in front of the building in wheelchairs or independently ambulating. Supervision was provided to Residents in the gazebo smoking, and fluids were provided to the residents at the exit door on south hall that leads to the gazebo. No supervision or fluids were being offered at the front main entrance. A review of the clinical record revealed the following excerpts: 6/13/24 7:25 p.m. Resident was involved in a verbal/physical altercation with another resident in which Mr. V. [NAME] pushed [Resident name redacted] on her right shoulder, grabbed her right leg, stomped her glasses and kicked her phone in the grass. Writer questioned Resident about the incident, and he stated that she triggered him by saying what she said to him. 6/26/24 6:12 am. - On this date 06/12/2024 during my shift, resident was seen going out of the facility 0540, when asked where he was going, resident says what kind of question are you asking me, I want to get a cigarette lighter at nearby store. All effort to redirect him back to the facility was prove abortive until a staff followed him and drove him back to the facility. 6/29/24 5:16 - Resident was noted to be seen by staff at 0130. Staff went to resident room to check on him and he was nowhere to be found. Resident apparently had left the building unbeknownst to staff. Staff immediately did a sweep of the interior and exterior of the facility unable to locate Mr. [NAME]. Police were called and given a picture and description of the clothing the resident was wearing when last seen. Staff notified DON, RP and provider. Officers spoke with other officers in a different jurisdiction which stated they had him at [Convenience store name redacted] Staff was [sic] told by officers they would have to transport [Resident 114 name redacted] back to facility 6/29/24 5:58 a.m. - This writer saw resident at 0130 entered the dining room and later went to resident room to check on him and he was nowhere to be found. Resident had walk [sic] away from the building unknown to staff. Sweeping of the interior and exterior of the facility was done still unable to find [Resident #114 name redacted] Police were called and given a picture and description of the clothing the resident was wearing when last seen. DON was notified, RP and provider. Officers spoke with other officers in a different jurisdiction which stated they found him at [convenience store name redacted]. Staff was [sic] told by officers they would have to transport [Resident#114 name redacted] back to facility. Staff drove to the location where he was found (approximately 7.1 miles away from the facility) and bring [sic] him back to the facility. Head to toe Skin assessment was done and intact. Resident was later sent out to hospital for psych consult EMS notified and resident was transported to the hospital by 2 EMS at 535. 7/2/24 9:30 a.m.- I was able to find legal Guardian's phone number. I called her to speak about resident's wander guard. She said that resident has a history of wandering, and she would really appreciate him having a wander guard. She asked if it had a tracking device, and I explained that it only alerted us when he went out the building. She said that it was fine and appreciated the call.On 7/16/24 at approximately 11:45 a.m. an interview was conducted with the Administrator; she was asked why the first incidents of elopement were not reported to the OLC and other entities as required by CMS Guidelines. The Administrator stated that Resident #114 had a High BIMS score and therefore he could leave the facility if he signed himself out. She stated that he had scored high on his BIMS and then eloped. She stated that he did not sign himself out of the facility. The Administrator was asked if Resident #114 had Any conditions that would affect his decision-making ability, she stated that he had a diagnosis of Schizophrenia.On the afternoon of 7/17/25 an interview was conducted with Employee L who was asked if a Resident with a BIMS of 15 can leave the facility unescorted, Employee L stated that it would depend on the physical and mental state of the Resident. When asked if BIMS alone could determine the ability of a Resident to leave the facility unescorted and she stated the BIMS was only one piece of the equation. Employee L stated that the Resident must be safe to ambulate independently and able to make safe decisions and notify the facility when he or she is leaving the facility. She stated that the RP must also be aware of the residents leaving the facility. Employee L also stated that the LOA (Leave of Absence) form must be signed prior to leaving the facility.A review of the policy entitled Leave of Absence Policy revealed the following: When a patient leaves the center for reasons other than a medical transfer initiated by the center, the patient and or responsible party will provide signature, accept complete responsibility of the patient and absolving the management, personnel and the attending physician of responsibility for any deterioration in condition or accident that may happen while the patient is away.1. Before a patient leaves the premises for any reason, other than medical transfer initiat3ed by the center, the patient and or responsible party must notify a licensed nurse on the unit.2. A licensed nurse ensures that medical approval of the leave has been provided by the patient's provider.3. The Release of Responsibility for Leave of Absence (LOA) form is filled out prior to leaving the center, the date and time and signature of the person accepting responsibility is filled in 4. The estimated time of return is provided to a licensed nurse. A review of the clinical record revealed that the Resident was not his own RP, and his Guardian did not wish him to leave the facility unescorted, and she had not filled out a Release of Responsibility form.On 7/18/25 the Administrator was made aware of the concerns, and no further information was provided.2. For Resident #59, the facility staff failed to provide adequate supervision to prevent Resident #59 from falling while in the parking lot.Resident #59 was admitted to the facility on [DATE] with diagnoses that included but were not limited to injury of bladder, type 2 diabetes, difficulty walking, cerebral ischemia, fractured pelvis, chronic viral hepatitis, muscle weakness, subdural hemorrhage, sepsis, anemia, major depressive disorder, insomnia, retinal artery occlusion to right eye (causing blindness) and bilateral cataracts. Resident #59's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 6-20-25 coded the resident as having a BIMS (Brief Interview of Mental Status) score of 14/15 indicating no cognitive impairment. Section G (Functional Status) coded the resident as requiring (3) Extensive Mobility with (2) One-person physical assistance for bed mobility, (4) Total assistance with (2) one-person physical assistance for bed mobility and (4) Total assistance with (2) one-person physical assistance for toileting.On 7/15/25 at approximately 12:55 p.m. an interview was conducted with Resident #59 who stated that she had a fall in the parking lot on 7/11/25. She stated that the CNA brought her out so that she could get some fresh air and that she was left unattended outside. She stated that she wanted to go see the gazebo, so she attempted to wheel herself down the sidewalk to the gazebo. However, she stated that she lost control of her wheelchair and went over the curb and fell and the wheelchair fell on top of her. She stated that she did not get injured and the staff responded, pretty quickly. When asked if she continues to go outside since the fall, she stated that she does. She stated that she does not venture away from the front doors anymore without assistance. When asked how she would get assistance if she needed help, she stated that she would have to go inside and ask for help or wait for staff to come outside.OT Consult dated 6/16/25 read: Pt presents with max A [assistance] x2 for bed mobility, max A x2 for lateral scooting along EOB [edge of bed] and transfers. Total A for lower body ADL's and set up to supervision for support3ed sitting upper body ADLs, Mod A at trunk for dynamic activity. Patient primarily limited by sitting Balance deficits, BLE (Bilateral Lower Extremity) weakness, impairing functional mobility, fine motor coordination deficits, global deconditioning, impaired activity tolerance, increased fall risk, need for increased time to complete tasks, preexisting injuries /ROM limitations which are severely impacting their ability to independently complete ADL's. 7/11/25 3:27 p.m. - Description of the fall/V/S/injuries if any: Phone call made to unit to notify staff that resident was on the ground outside. Nursing staff ran to front entrance and outside, observed resident wheelchair in between 2 cars at the front of the building. Resident noted laying on right with wheelchair on top of her. Resident assessed and placed back into chair by staff. Resident states she was trying to wheel herself to the gazebo. Resident states she was wheeling herself and lost control, and went over the curb. V/S 90/58-73-73-18-97.8-97% What Interventions were in place at the time of the fall? Resident in wheelchair wheels locked. What are the risk factors that could have contributed to the fall? Resident propelling self without assistance What new Interventions were implemented in response to the fall? Educate resident to ask for assistance when propelling wheelchair on uneven surfaces. Was the Provider/resident and RP notified at the time of the fall? yes, NP and daughter notified.‘7/12/25 7:28 a.m. - LATE ENTRY Situation : Date and time the fall occurred: 07/11/2025 12:00 PM Background : Circumstances of the fall: resident was propelling outside in wheelchair unassisted Assessment (RN)/Appearance (LPN) : Current status of the resident's injuries or reports of pain from the fall: no injuries or pain reported Recommendation : Interventions currently in place to prevent additional falls: resident to ask for assistance when propelling on uneven surfaces. 7/15/25 1:00 p.m. - Patient was seen for follow- up psychotherapy session for monitoring and treatment of mental health symptoms. Patient was located outside and agreed to engage in session. Client details of fall she had outside of the facility, stating she was embarrassed, so happy she did not hurt herself.On 7/20/25 at approximately 2:00 p.m. an interview was conducted with the DON who was asked if fall assessments are a part of the admission process and she stated that they were. When asked how often they are done she stated that they are done on admission, quarterly and after any falls A review of the clinical record revealed there was no fall assessment completed until 7/11/25 after the resident had the fall on 7/11/25. The fall assessment coded Resident #59 as being a moderate fall risk.On 7/20/25 during the end-of-day meeting the Administrator was made aware of the concerns and no further information was provided.2. For Resident #65, the facility failed to provide appropriate and sufficient supervision to prevent the risk of potential accident hazards as evidenced by observing 2 pills on the floor near other residents exhibiting wandering behaviors. Resident #65 was admitted to the facility 7/30/2024 with diagnoses including but not limited to: lumbar spinal bifida with hydrocephalus, paraplegia, immunodeficiency, neurogenic bowel, neuromuscular dysfunction, constipation and mood disorder due to known physiological condition with major depression-like episode.On the most recent MDS (Minimum Data Set) an annual assessment with ARD (assessment reference date) of 5/28/2025, Section C: Cognitive Patterns was coded as 15 out of a possible score of 15 indicating no cognitive impairment.On 07/16/2025 at 10:00 am during interview with Resident #65, 2 tablets were observed on the floor under the bedside table: one (1) round orange and one (1) round white tablet with scuff marks. The Resident stated she didn't know how long they had been there. On 7/16/2025 at 10:15am LPN-B was notified of the tablets on the floor. An inspection of the medication cart and review of Resident #65's Physician's orders and Medication Administration Record (MAR) was completed to identify the 2 tablets.The Medication Administration Record (MAR) revealed an order for Senokot 8.6 mg. 3 tablets every 24 hours (round orange) and was documented as being given July 2 - July 15.On July 1 the MAR revealed the resident refused Senokot and an order for Acetaminophen ES PRN (white round) with no documentation on the MAR for [DATE] as being administered. On 7/16/2025 at approximately 10:30am Employee C was interviewed, and she stated she had entered the room after Resident #65 and surveyor had exited to clean the room, she stated the room always smells so bad that she cleans as quick as she can. Further interview with Employee C what she would do if she saw pills on the floor she replied, I would sweep them up and throw them in the trash can.On 7/16/25 at 10:44 am the Director of Nursing was interviewed on what her expectations for the nurse in administering medications to residents would be and she replied, to ensure they swallow their medications.On 7/17/2025, a list of residents who self-administer medications was requested by the Administrator. The list did not contain Resident #65's name as self-administering her medications.On 7/21/ 2025 at 11:43 am LPN-B was interviewed regarding whether she had any residents on her unit with wandering behavior and she said Oh, maybe [Resident #70 name redacted] might wander up and down hallOn 7/21/2025 at 11:47 am C.N.A-B was interviewed on whether she was aware of any residents on her unit exhibiting wandering behaviors and she said [Resident #70 name redacted] sometimes wanders up and down halls he goes to the end of hall because he wants to go out outside but he doesn't go in other residents rooms just goes to the end of the hall where the door is.On 7/20/2025 at 12:02 pm an interview was conducted with C.N.A-C on whether she had any residents on her unit who exhibited wandering behaviors, and she stated, I don't know of anyone that wanders.Resident #70 was admitted to the facility on [DATE] with diagnoses including but not limited to traumatic subdural hemorrhage without loss of consciousness and unspecified dementia. MDS ARD State Optional 7/15/25 Section C: Cognitive Patterns coded as 3 out of a possible score of 15 indicating severe cognitive impairment. Record review for Resident #70's progress notes dated 7/17/25 at 16:46 by the Nurse Practitioner; [Resident #70 name redacted] is being seen and followed up today for increased confusion in the setting of advanced dementia. The residence remains confused at baseline. He is normally easily redirected. The nursing staff reports that he has been more and has been wandering more through the facility. He needs more frequent redirection. The nursing staff has a wander guard in place to prevent elopement from the facility.Resident #70 resided in a room near the room where the tablets were observed on the floor.Review of facility document Policy #8.2 General Guidelines for Medication Administration 17. The resident is always observed after administration to ensure that the dose was completely ingested.No further information and/or documentation was presented prior to the exit conference on 07/22/2025. 3. For Resident #65, the facility failed to provide appropriate and sufficient supervision to prevent the risk of potential accident hazards as evidenced by observing 2 pills on the floor near other residents exhibiting wandering behaviors.Resident #65 was admitted to the facility 7/30/2024 with diagnoses including but not limited to: lumbar spinal bifida with hydrocephalus, paraplegia, immunodeficiency, neurogenic bowel, neuromuscular dysfunction, constipation and mood disorder due to known physiological condition with major depression-like episode.On the most recent MDS (Minimum Data Set) an annual assessment with ARD (assessment reference date) of 5/28/2025, Section C: Cognitive Patterns was coded as 15 out of a possible score of 15 indicating no cognitive impairment.On 07/16/2025 at 10:00 am during interview with Resident #65, 2 tablets were observed on the floor under the bedside table: one (1) round orange and one (1) round white tablet with scuff marks. The Resident stated she didn't know how long they had been there. On 7/16/2025 at 10:15am LPN-B was notified of the tablets on the floor. An inspection of the medication cart and review of Resident #65's Physician's orders and Medication Administration Record (MAR) was completed to identify the 2 tablets.The Medication Administration Record (MAR) revealed an order for Senokot 8.6 mg. 3 tablets every 24 hours (round orange) and was documented as being given July 2 - July 15.On July 1 the MAR revealed the resident refused Senokot and an order for Acetaminophen ES PRN (white round) with no documentation on the MAR for [DATE] as being administered. On 7/16/2025 at approximately 10:30am Employee C was interviewed, and she stated she had entered the room after Resident #65 and surveyor had exited to clean the room, she stated the room always smells so bad that she cleans as quick as she can. Further interview with Employee C what she would do if she saw pills on the floor she replied, I would sweep them up and throw them in the trash can.On 7/16/25 at 10:44 am the Director of Nursing was interviewed on what her expectations for the nurse in administering medications to residents would be and she replied, to ensure they swallow their medications.On 7/17/2025, a list of residents who self-administer medications was requested by the Administrator. The list did not contain Resident #65's name as self-administering her medications.On 7/21/ 2025 at 11:43 am LPN-B was interviewed regarding whether she had any residents on her unit with wandering behavior and she said Oh, maybe [Resident #70 name redacted] might wander up and down hallOn 7/21/2025 at 11:47 am C.N.A-B was interviewed on whether she was aware of any residents on her unit exhibiting wandering behaviors and she said [Resident #70 name redacted] sometimes wanders up and down halls he goes to the end of hall because he wants to go out outside but he doesn't go in other residents rooms just goes to the end of the hall where the door is.On 7/20/2025 at 12:02 pm an interview was conducted with C.N.A-C on whether she had any residents on her unit who exhibited wandering behaviors, and she stated, I don't know of anyone that wanders.Resident #70 was admitted to the facility on [DATE] with diagnoses including but not limited to traumatic subdural hemorrhage without loss of consciousness and unspecified dementia. MDS ARD State Optional 7/15/25 Section C: Cognitive Patterns coded as 3 out of a possible score of 15 indicating severe cognitive impairment. Record review for Resident #70's progress notes dated 7/17/25 at 16:46 by the Nurse Practitioner; [Resident #70 name redacted] is being seen and followed up today for increased confusion in the setting of advanced dementia. The residence remains confused at baseline. He is normally easily redirected. The nursing staff reports that he has been more and has been wandering more through the facility. He needs more frequent redirection. The nursing staff has a wander guard in place to prevent elopement from the facility.Resident #70 resided in a room near the room where the tablets were observed on the floor.Review of facility document Policy #8.2 General Guidelines for Medication Administration 17. The resident is always observed after administration to ensure that the dose was completely ingested.No further information and/or documentation was presented prior to the exit conference on 07/22/2025.
May 2025
4 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews, staff interviews, and review of facility documents, the facility staff failed to protect a residen...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews, staff interviews, and review of facility documents, the facility staff failed to protect a resident's right to be free of sexual abuse for 2 of 5 residents (Resident #1 and Resident #3) in the survey sample, which constituted harm.
The findings included:
Resident #1 was initially admitted to the facility on [DATE]. The current diagnoses included other mechanical complications of the internal right hip prosthesis, muscle weakness, chronic kidney disease, other sickle-cell disorders without crisis, anxiety disorder, and major depressive disorder.
The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 2/15/25, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated that Resident #1's cognitive abilities for daily decision-making were intact.
Resident #3 was no longer a resident of the facility; therefore, a closed record review was conducted. Resident #3 was admitted to the facility on [DATE], was discharged home on 4/25/25. The resident's diagnoses included metabolic encephalopathy, unspecified cirrhosis of the liver, muscle wasting and atrophy, and end-stage renal disease.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/28/25 coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated that Resident #3's cognitive abilities for daily decision-making were intact.
An interview was conducted on 5/6/25 at 4:55 PM with Resident #1. Resident #1 stated that in February 2025 (not sure of the exact date), the Receptionist said to him, You are too stressed out. You need your dick sucked. Resident #1 also stated that a few days later, the same Receptionist displayed a picture on his phone to Resident #1 of him giving oral sex to another male. Resident #1 further stated that he informed the Activities Assistant regarding these two occurrences.
During the interview, Resident #1 stated that at the end of March 2025 (not sure of the exact date), the Receptionist puckered his lips up, blew a kiss, and made smacking sounds directed towards him. Resident #1 also stated, I felt humiliated and got angry. Resident #1 further stated that immediately after this incident occurred, he saw the Assistant Director of Nursing (ADON) in the hallway laughing and felt as if she was laughing at him. Resident #1 stated that he asked the ADON why she was laughing and said to her, Everyone knows what that faggot did to me.
On 5/6/25 at 5:55 PM, during the interview, Resident #1 became very emotional and began crying. Resident #1 stated, I have not had the best life. I've seen a lot of things. It's been hard for me to get this out of my mind. Why did he target me? I'm someone that has health issues. He was trying to take advantage of me. I feel like people are laughing at me. Am I a video game? I'm not gay. It's about my dignity. It's embarrassing and humiliating, and I'm angry.
An interview was conducted on 5/7/25 at 3:15 PM with Certified Nursing Assistant (CNA) #2. CNA #2 stated that on 3/29/25, a Transportation Driver approached him and stated that the receptionist was very inappropriate in a sexual manner with him. CNA #2 also stated that on this same day, the receptionist got very close to him as well and started making funny noises in his ear. CNA #2 further stated that he perceived the actions that the receptionist did were sexual and told the receptionist, I don't go that way. Don't even try it. CNA #2 lastly stated that he did not tell the management team about these occurrences until the following week on 4/2/25 when he was asked questions by the Director of Nursing (DON) regarding the receptionist.
A review of a written statement dated 4/2/25 by the Transportation Driver read: On Saturday, March 29, 2025, I came to pick up a resident for dialysis. As I was walking to push the resident's wheelchair, the weekend ambassador stood in front of me and tried to grab my private area. I pushed his hand away. He tried to touch my private area again, so I left to get a witness. I grabbed a CNA, and he stopped trying to touch me. After that, I had no more incidents with him.
An interview was conducted on 5/7/25 at 5:35 PM with the Administrator. The Administrator stated that a Facility Reported Incident was initiated and investigated regarding the incidents that occurred over the weekend of 3/29/25-3/30/25. The Administrator also stated that the police were contacted on 4/3/25 to inform them of the sexual allegations, and a police report was filed. The Administrator further stated that the Receptionist was terminated and is not registered with any licensing board. The Administrator lastly stated that sexual abuse was confirmed for four individuals (Resident #1, Resident #3, CNA #2, and the Transportation Driver), and the allegations of sexual abuse are substantiated.
An interview was conducted on 5/8/25 at 12:20 PM with the former ADON. The former ADON stated that on 3/31/25, Resident #1 told her that the receptionist puckered his lips up, blew him a kiss, and made a smacking sound. The former ADON also stated, Resident #1 was very agitated, upset, and visibly irritated.
An interview was conducted on 5/8/25 at 12:38 PM with the Discharge Planning Assistant. The Discharge Planning Assistant stated that she interviewed Resident #3 on 4/2/25 regarding interaction with the weekend receptionist. The Discharge Planning Assistant also stated that Resident #3 informed her that on one occasion the Receptionist came to his room to inform him that his ride was on the way and said to him, I want to suck that dick. The Discharge Planning Assistant further stated that Resident #3 said he was unsure if he heard him correctly. However, the Receptionist repeated it again as they got closer to the double doors. The Discharge Planning Assistant lastly stated that Resident #3 said when he came back to the facility from his dialysis appointment, the receptionist was standing in the business office with the lights off and was beckoning him to come in, however he ignored him.
An interview was conducted on 5/8/25 at 2:10 PM with the Activities Assistant. The Activities Assistant stated that Resident #1 told her that the male receptionist said to him, have you ever had your dick sucked? The Activities Assistant also stated that Resident #1 said that the receptionist has videos of it on his phone. The Activities Assistant further stated, I'm a mandated reporter, so I told the Social Worker Assistant and the Social Worker about this, and then the Administrator wanted to speak with me.
The Facility's Abuse/Neglect/Misappropriation/Crime policy with an effective date of 10/17/23 read: Patients of the Center have the legal right to be free from verbal, sexual, mental, and physical abuse, corporal punishment, involuntary seclusion including abuse facilitated or enabled through the use of technology, and free from chemical and physical restraints except in an emergency and/or as authorized in writing by a physician.
On 5/8/25 at approximately 5:00 PM, a final interview was conducted with the Administrator, Director of Nursing, and Regional Director of Clinical Services. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on staff interviews and review of facility documents, the facility staff failed to ensure a violation involving abuse was reported to the administrator of the facility and to other officials (in...
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Based on staff interviews and review of facility documents, the facility staff failed to ensure a violation involving abuse was reported to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services), within two hours of the violation occurring.
The findings included:
An interview was conducted on 5/7/25 at 2:50 PM with the Director of Nursing (DON). The DON stated that CNA #2 disclosed information on 4/2/25 during an interview regarding sexual allegations that occurred on 3/29/25. The DON stated that CNA #2 should have reported this to the Administrator, the Director of Nursing, or his immediate supervisor no later than two hours after the incidents occurred.
An interview was conducted on 5/7/25 at 3:15 PM with Certified Nursing Assistant (CNA) #2. CNA #2 stated that on 3/29/25 a transporting driver approached him and stated that the receptionist was very inappropriate in a sexual manner with him. CNA #2 also stated that on this same day the receptionist got very close to him as well and started making funny noises in his ear. CNA #2 further stated that he perceived the actions that the receptionist did was in a sexual manner and told the receptionist, I don't go that way. Don't even try it. CNA #2 lastly stated that he did not tell the management team about these occurrences until the following week on 4/2/25 when he was asked questions by the Director of Nursing (DON) regarding the receptionist.
A review of a written statement dated 4/2/25 by the Transportation Driver read: On Saturday March 29, 2025, I came to pick up a resident for dialysis. As I was walking to push the resident's wheelchair, the weekend ambassador stood in front of me and tried to grab my private area. I pushed his hand away. He tried to touch my private area again, so I left to get a witness. I grabbed a CNA, and he stopped trying to touch me. After that, I had no more incidents with him.
An interview was conducted on 5/7/25 at 5:35 PM with Administrator. The Administrator stated that a Facility Reported Incident was initiated and investigated regarding the incidents that took place on the weekend of 3/29/25-3/30/25. The Administrator also stated that sexual abuse was confirmed for four individuals. The Administrator further stated that the allegation of sexual abuse is substantiated.
Review of a reportable incident filed by the facility, documented the report was faxed to the Office of Licensure and Certification on 3/31/25 at 4:33 PM.
The Facility's Abuse/Neglect/Misappropriation/Crime policy with an effective date of 10/17/23 read: All employees are responsible for immediately (no later than two hours after the allegation is made if the incident involves abuse or bodily injury, no later than 24 hours if the incident does not involve abuse or bodily injury) reporting to the Administrator, or in their absence, the Director of Nursing, or their immediate supervisor any and all suspected or witnessed incidents of patient abuse, neglect, theft, exploitation and/or mistreatment of a patient as well as any reasonable suspicion of a crime against a patient.
On 5/8/25 at approximately 5:00 PM, a final interview was conducted with the Administrator, Director of Nursing, and Regional Director of Clinical Services. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on resident interview, staff interviews, clinical record review, and review of facility documents, the facility staff failed to follow the professional standards of quality regarding two trained...
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Based on resident interview, staff interviews, clinical record review, and review of facility documents, the facility staff failed to follow the professional standards of quality regarding two trained staff members assisting with mechanical lifts and transfers for 1 of 5 residents (Resident # 5 ), in survey sample.
The findings included:
Resident #5 was originally admitted to the facility 11/22/22. The current diagnoses included chronic kidney disease, type 2 diabetes mellitus with other diabetic kidney complication, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and muscle weakness.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/5/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 09 out of a possible 15. This indicated Resident #5's cognitive abilities for daily decision making were moderately impaired.
An interview was conducted on 5/12/25 at 3:30 PM with Resident #5. Resident #5 stated that she was hit in the head by the Hoyer lift bar when a Certified Nursing Assistant (CNA) was providing care for her. Resident #5 also stated that she told the CNA that she was hit in the head by the bar. Resident #5 further stated that there was only one CNA in the room when this incident occurred.
An interview was conducted on 5/12/25 at 5:13 PM with the Director of Nursing (DON). The DON stated that it was an accident when the Hoyer sling bar hit Resident #5 in the head. The DON also stated that due to this occurring, Resident #5 received a small hematoma on the head. The DON further stated that two trained staff members must assist with mechanical lifts and transfers.
An interview was conducted on 5/13/25 at 10:45 AM with CNA #3. CNA #3 stated that she began giving Resident #5 care, and called for help, but no one came. CNA #3 also stated that she was transferring Resident #5 with the Hoyer lift and the leg of the Hoyer lift got caught on the roommates bed and the Hoyer lift began to tip. CNA #3 further stated that she maneuvered Resident #5 in the sling, called for help, and when help arrived, they unhooked Resident #5. CNA #3 lastly stated that she never saw the Hoyer lift sling bar hit Resident #5 in the head. When asked if it is standard protocol for one (1) person to operate a mechanical lift alone? CNA #3 stated, No it is not. It's standard to have two (2) individuals assisting with Hoyer lift transfers.
The facility's Mechanical Lift policy with an effective date of 1/29/24 read: Two trained staff must assist with mechanical lift and transfer.
According to the Office of People with Developmental Disabilities (State of New York): The number of staff required to perform a transfer is at the discretion of the practitioner who prescribed or recommended use of a mechanical lift device. However, it is always best practice to use mechanical lift equipment with a minimum of two staff. One staff member's primary role is the operation and movement of the lift equipment. The second staff is primarily responsible for the safe positioning of the individual in the sling or harness system during the transfer. Both staff should continually observe and communicate with each other and the individual throughout the transfer.
chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://opwdd.ny.gov/system/files/documents/2021/09/2021-use-of-mechanical-lifts.pdf
On 5/13/25 at approximately 4:40 PM, a final interview was conducted with the Administrator, Director of Nursing, Regional Director of Clinical Services, Regional Director of Operations, and Corporate Compliance Specialist. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on resident interview, staff interviews, clinical record review, and review of facility documents, the facility staff failed to provide two-person assistance while transferring Resident #5, whic...
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Based on resident interview, staff interviews, clinical record review, and review of facility documents, the facility staff failed to provide two-person assistance while transferring Resident #5, which resulted in the resident being struck in the head by the Hoyer lift sling bar for 1 of 5 residents in the survey sample.
The findings included:
Resident #5 was originally admitted to the facility 11/22/22. The current diagnoses included chronic kidney disease, type 2 diabetes mellitus with other diabetic kidney complication, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and muscle weakness.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/5/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 09 out of a possible 15. This indicated Resident #5's cognitive abilities for daily decision making were moderately impaired.
An interview was conducted on 5/12/25 at 3:30 PM with Resident #5. Resident #5 stated that she was hit in the head by the Hoyer lift bar when a Certified Nursing Assistant (CNA) was providing care for her. Resident #5 also stated that she told the CNA that she was hit in the head by the bar. Resident #5 further stated that there was only one CNA in the room when this incident occurred.
An interview was conducted on 5/12/25 at 5:13 PM with the Director of Nursing (DON). The DON stated that it was an accident when the Hoyer sling bar hit Resident #5 in the head. The DON also stated that due to this occurring, Resident #5 received a small hematoma on the head. The DON further stated that two trained staff members must assist with mechanical lifts and transfers.
An interview was conducted on 5/13/25 at 10:45 AM with CNA #3. CNA #3 stated that she began giving Resident #5 care, and called for help, but no one came. CNA #3 also stated that she was transferring Resident #5 with the Hoyer lift and the leg of the Hoyer lift got caught on the roommates bed and the Hoyer lift began to tip. CNA #3 further stated that she maneuvered Resident #5 in the sling, called for help, and when help arrived, they unhooked Resident #5. CNA #3 lastly stated that she never saw the Hoyer lift sling bar hit Resident #5 in the head. When asked if it is standard protocol for one (1) person to operate a mechanical lift alone? CNA #3 stated, No it is not. It's standard to have two (2) individuals assisting with Hoyer lift transfers.
An interview was conducted on 5/13/25 at 12:10 PM with Licensed Practical Nurse (LPN) #2. LPN #2 stated she heard CNA #3 yelling for help and upon entering Resident #5's room, she saw Resident #5 in the chair, the Hoyer lift was tilted, and the CNA was holding the Hoyer. LPN #2 also stated that she assisted the CNA with unhooking the sling off the Hoyer Bar. LPN further stated that about 15 minutes later she was called to dining room and informed by Resident #5's son that the resident had a bruise on top of her head.
An interview was conducted on 5/13/25 at 1:24 PM with LPN #3. LPN #3 stated an assessment was completed immediately upon being notified of the Hoyer lift bar possibly hitting Resident #5 in the head. LPN #3 also stated that a raised area on top of Resident #5's head was observed. LPN #3 further stated that the CNA providing care for Resident #5 should not have been operating the Hoyer lift alone.
A review of the eInteract Change in Condition Evaluation form dated 5/8/25 at 12:19 PM read: Writer notes nurse reports that while resident was being transferred by hoyer lift, resident reported that the lift bar hit the resident in the top of her head. Skin Status Evaluation: Raised area on top of head.
A review of the Nursing Progress Note dated 5/8/25 at 1:58 PM read: Nursing observations, evaluation, and recommendations are: Writer notes nurse reports that while resident was being transferred by hoyer lift, resident reported that the lift bar hit the resident in the top of her head.
A review of the MEDICAL (MD,NP,PA) Progress Note dated 5/9/25 at 1:48 PM read: Head trauma from hoyer lift. Appears accidental injury, but APS filed by family for further investigation, Patient currently denied any pain at the site of injury, had ED visit 5/8/2025 where she had thorough trauma evaluation and no acute injuries noted. Small hematoma on crown region reported by nursing staff yesterday has now resolved Continue pain control with acetaminophen, may use lidocaine patch if convenient.
A review of the Emergency Department After Visit Summary dated 5/8/25 read: You were seen in the ER after hitting your head. Our trauma team evaluated you and found no significant injuries or reasons to be admitted to the hospital. You are cleared to go back to your facility.
The facility's Mechanical Lift policy with an effective date of 1/29/24 read: Two trained staff must assist with mechanical lift and transfer.
On 5/13/25 at approximately 4:40 PM, a final interview was conducted with the Administrator, Director of Nursing, Regional Director of Clinical Services, Regional Director of Operations, and Corporate Compliance Specialist. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information.
Feb 2025
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility document review, the facility failed to ensure that one Resident ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility document review, the facility failed to ensure that one Resident (Resident #7), in a survey sample of 12 residents was informed, in advance, of the care to be provided and their rights upon admission.
The findings include:
For Resident #7, the facility staff failed to ensure that resident was informed, in advance, of the care to be provided and their rights upon admission and provide admission contract and rights on admission.
Resident #7 was admitted to the facility on [DATE], and discharged on 10/14/2024, with diagnoses of, but not limited, Type 2 diabetes, kidney transplant status, end stage renal disease, pulmonary hypertension, nutritional anemia, and multiple fractures of ribs.
The most recent MDS (minimum data set) was an admission assessment with an (ARD) assessment reference date of 09/03/2024 was reviewed and revealed Resident #7's (BIMS) Brief Interview for Mental Status was coded a score of 15 out a possible 15 indicating no cognitive impairment.
A review of Resident #7 admission packet and contracts was reviewed and revealed that Resident#7 was admitted on [DATE], but that admission process was not explained for forms signed and provided to the resident until 09/05/2024
On 02/18/2025 at 1:30 p.m., an interview was conducted with the Director of Nursing (DON) who was asked what and when admissions documents, contract and rights forms are provided to the residents and or the resident representative. The DON stated that the admission packet is discussed, and forms signed on admission, and if the admission is afterhours with 24 hours. medications are expected to be administered by licensed staff as ordered by the physician the ordered dose and time.
A review of the document entitled admission Policy was reviewed and revealed that The admission Director will ensure all proper documents are completed copied and filed appropriately whenever a patient applies for admission or er- admission.
On 02/24/2025 during the end of day meeting, the Administrator and Director of Nursing was made aware of the concerns. No further information was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interviews the facility staff failed to provide a comfortable, and homelike ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interviews the facility staff failed to provide a comfortable, and homelike environment for 1 of 12 residents (Resident #5), in the survey sample.
The findings included:
Resident #5 was originally admitted to the facility 2/11/2025. The current diagnoses included wedge compression fracture of third lumbar vertebra, type 2 diabetes mellitus without complications, major depressive disorder, and muscle weakness.
The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/17/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #5's cognitive abilities for daily decision making were moderately impaired.
On 2/18/25 during an observation tour for room [ROOM NUMBER], it was observed that the cove base was missing around the entire perimeter of the room as well as the perimeter of the bathroom. It was also observed that cold air was coming out of the open areas and the cold air was flowing out into room [ROOM NUMBER].
On 2/18/25 at 3:30 PM an interview was conducted with Resident #5. Resident #5 stated, I'm [AGE] years old and I don't understand why they would put me in a room like this. Resident #5 also stated, they did not finish the construction of this room, and I can feel the cold air coming in from the open areas.
On 2/18/25 at 4:40 PM an interview was conducted with the Maintenance Director. The Maintenance Director stated that room [ROOM NUMBER] was being renovated and the work has not been completed. The Maintenance Director also stated that room [ROOM NUMBER] has been in its current state for about a month. The Maintenance Director further stated that the room is not appropriate for a resident to be in due to its present condition.
On 2/18/25 at 4:50 PM an interview was conducted with the Regional Maintenance Director. The Regional Maintenance Director stated that the Corporate Maintenance Team has been working on the rooms and the reason that room [ROOM NUMBER] is not completed is due to the cove base being sent to another facility instead of this facility.
On 2/18/25 at 5:25 PM an interview was conducted with the Administrator. When asked about room [ROOM NUMBER] looking the way it does, the Administrator stated, it's a Corporate Maintenance Team issue, I have nothing else to say about that.
On 2/19/25 at 9:50 AM an interview was conducted with the Administrator. The Administrator stated that when Resident #5 was admitted into room [ROOM NUMBER], this room was the only room to put the resident in. The Administrator also stated that the Admissions Department put the resident in this room due to not having anywhere else to put the resident. When asked if room [ROOM NUMBER] was appropriate for Resident #5 to be in due to its condition, the Administrator further stated, I'm not going to answer that question.
On 2/24/25 at approximately 4:37 p.m., a final interview was conducted with the Administrator, Director of Nursing, Assistant Administrator, Regional [NAME] President of Operations, and Regional Director of Clinical Services. An opportunity was offered to the facility's staff to present additional information. The Administrator stated, these issues were fixed, and I do not agree with this. The Regional [NAME] President of Operations stated, the issues were fixed the same day.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0624
(Tag F0624)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, family interview and clinical record review, the facility's staff failed to remove/discontinue a Midl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, family interview and clinical record review, the facility's staff failed to remove/discontinue a Midline Intravenous Catheter before discharging a resident home therefore increasing the chance of complications, including infections, bleeding, and or dislodgement for 1 of 12 residents in the survey sample, Resident #12, a closed record sample.
The findings included:
Resident #12 was originally admitted to the facility 11/08/24 and discharged on 12/05/24 after an acute care hospital stay. The current diagnoses included: OTHER BACTERIAL INFECTIONS OF UNSPECIFIED SITE, FRACTURE OF UNSPECIFIED PART OF NECK OF RIGHT FEMUR, SUBSEQUENT ENCOUNTER FORCLOSED FRACTURE WITH ROUTINE HEALING.
The admission, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/14/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 3 out of a possible 15. This indicated Resident #12 cognitive abilities for daily decision making were severely impaired.
In sectionGG(Functional Abilities Goals) the resident was coded as requiring
Partial/Moderate assistance with eating, requiring Substantial/maximal assistance with oral hygiene, toileting hygiene, shower/bath self, upper and lower body dressing, personal hygiene, roll left and right, walking 150 feet and dependent with putting on taking off footwear.
The Care Plan dated 11/08/24 indicated that Resident #12 is at risk for pressure ulcers. The Goals: The resident will not have a skin impairment thru the review period. The interventions are to assess resident for risk of skin breakdown, Keep skin clean and dry as possible.
The Medication Administration Record (MAR) read: Dextrose-NaCl Solution 5-0.45 % (Dextrose-Sodium Chloride) Use 80 ml/hr intravenously every shift for Hydration for 2 Days until finished 2 L is infused 11/22/24.
A review of the November 2024 MAR show that Day, Evening and Night Shift IV fluids were administered.
Dextrose-Sodium Chloride Intravenous Solution 5-0.45 % (Dextrose w/ Sodium Chloride) Use 2 liter intravenously every 24 hours for Hypernatremia Infuse 2 liters at 80cc/hour. Dated 11/20/2024.
A review of the November 2024 MAR show that IV fluids were administered on 11/21/24, 11/22/24 and 11/23/24 per doctor's order. Place midline for hydration therapy one time only for Hydration.
A health status note dated 11/20/24 at 9:46 PM., read: IV started in the R forearm/wrist area 22 gauge on first attempt.pt tolerated with minimal discomfort. IV fluids started D51/2NS at 80 cc's per hour. Per orders.
A review of a Health Status note dated 11/22/2024 at 2:09 PM., read: Patient alert and responsive. Patient has double lumen midline in right upper extremity. Patient has D5 1/2 NS running through midline,80cc/hr until 2 L infused. Patient received 240cc during this shift,tolerated well. Responsible Party (RP) contacted and notified of new orders and verbalized understanding.
A review of the skilled daily documentation note dated 11/30/2024 at 3:48 PM., read that Resident #12 had a Midline Intravenous (IV) access for hydration.
A review of the skilled daily documentation dated 12/03/24 read: That the resident does not have IV access.
IV Timeline:
11/20/24 8:20 AM., IV access present. Clysis started for hydration.
11/22/2024 10:25 AM., Place midline for hydration therapy one time only for Hydration.
11/20/24 9:46 PM., Health Status note. IV fluids started.
11/22/2024 9:53 PM., midline providing extra hydration from d50.45 saline at 80 ml/hr x 2 bags. no pain or distress noted this shift.
11/23/24 9:16 PM., Clysis discontinued. IV fluids started. Midline Access present.
11/23/24 at 10:41 PM., No midline. D50.45 iv had concluded in the previous shift.
11/23/24 1:45 AM., Midline access present. Health status note read: double lumen midline in rightupper extremity with no sign/symptomsof infection. On D5 1/2 N patent andinfusing through midline, 80cc/hr until 2 AM., Patient alert and responsive.No labored breathing nor distress noted.Patient on continuous oxygen 2 L viaNC. Noted double lumen midline in rightupper extremity with no sign/symptomsof infection. On D5 1/2 N patent andinfusing through midline, 80cc/hr until 2.
11/24/24 12:15 PM., Dextrose-NaCl Solution 5-0.45 %. Use 80 ml/hr intravenously every shift for Hydration for 2 Days until finished 2 L is infused 2L has been infused, order complete.
11/24/2024 11:16 PM., No Midline access present.
11/25/2024 11:55 PM.,No Midline access present.
11/27/2024 11:20 PM., No Midline access present.
11/26/2024 8:44 PM., No Midline acces present.
11/28/2024 1:39 PM., Midline IV access present.
11/29/2024 2:08 PM., Midline IV access present.
11/29/2024 10:59 PM No IV access present.
11/30/2024 3:48 PM., Midline IV access present.
12/1/2024 4:22 PM., No IV access present.
12/02/24 1:52 PM., Midline IV access present.
12/03/24 12/03/24 read: Does the resident have any Intravenous access=No
12/04/24 11:15 PM., Skilled Note- IV Therapy, IV access present: No
According to the timeline listed above the resident would have occassional IV access due to hydration concerns.
According to the review there was no indication that during discharge that an IV Midline catheter was ever discontinued from Resident #12.
A review of the Discharge summary dated [DATE] at 9:00 AM., Read: Resident discharging home with son. Resident was ordered a hospital bed, wheelchair, and oxygen. Resident was sent home with medications. Son will provide transportation. Resident will have home health (OT, PT, skilled nursing)through Center Well home health.
A review of the medical records and discharge summary did not reveal that a Midline IV was discontinued by staff before resident was discharged home.
On 2/21/25 at approximately 1:05 PM., an interview was conducted with Certified Nursing Assistant (CNA) #1. CNA #1 said an IV would be seen hooked up on her side of the bed, but on her day of discharge, she dressed but didn't notice an IV.
On 2/21/25 at approximately 2:10 PM., an interview was conducted with Licensed Practical Nurse (LPN) #1. LPN #1 said that Resident #12 did have a Midline IV in her arm but she wasn't there when the resident was discharged from the facility.
On 2/21/25 at approximately 4:45 PM., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON said that the resident's daughter in law called saying we had left the IV in the resident's arm. The ADON said that they would initially use a contracted outside service to put the Midline IV's in and that a Registered Nurse has to discontinue the Midline IV's in the facility. The ADON also said that transportation was initially called to pick up the resident but her son called and said he would pick her up instead which caused an abrupt discharge.
On 2/21/25 at approximately 5:25 PM., an interview was conducted with LPN #2. LPN #2 said that she didn't know that the resident had a midline IV in because she wasn't my patient. I was helping another LPN with the discharge process. LPN #2 said that the LPN took care of Resident #12 but was no longer working at the facility. LPN #2 also mentioned that the ADON, Director of Nursing (DON) and a Registered Nurse (RN) were present in the facility, could have pulled it (IV), because LPNs are not allowed pull Midline IV's.
On 2/24/25 at approximately 2:30 PM., an interview was conducted with the Director of Nursing (DON). The DON said that the ADON reported to her that a family member called the facility saying that Resident #12 had been discharged with her IV still intact. She stated that they discussed the incident in clinical rounds the next day but didn't document anything because once a chart closes you shouldn't go back in. The DON also mentioned that complications such as infection and bleeding could happen from having a midline IV in.
On 2/24/25 at approximately 2:35 PM., an interview was conducted with the ADON concerning Resident #12. The ADON said that an RN should have discontinued the IV before discharge.
On 2/24/25 at approximately 4:35 PM., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no additional information was provided.
Midline catheters should be selected based on the intended purpose and duration of use, known complications, and experience of individual catheter inserters. Midline catheters are a type of peripheral catheter, longer than short PIVs, and indicated for patients requiring therapy for more than five days but less than a few weeks ([NAME] et al., 2021; [NAME] et al., 2015). Generally, 8-25cm long, Midline catheters are inserted with ultrasound guidance into the larger diameter veins of the upper arm and tend to last longer than a PIV. The CDC states to use a Midline catheter or PICC instead of a short peripheral catheter if the duration of IV therapy will likely exceed six days (O'Grady et al., 2011). Midline catheters typically do not last without complications for more than a few weeks but can provide patients with a longer, more reliable access alternative to the short PIV (https://www.accessvascularinc.com/take-action/when-to-choose-piccs-vs-midlines-[NAME]-[NAME]).
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, Resident interview, staff interview, facility documentation review, and clinical record review, the facili...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, Resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to maintain the industry standards of diabetic management for one Resident (Resident #3) in a survey sample of 12 Residents.
The findings included:
For Resident #3, the facility staff failed to Assess and monitor the Resident, and update the plan of care for a morbidly obese immobile Diabetic Resident including removal of Diabetic medication management, removal of a therapeutic diet to decrease blood sugars, and removal of blood sugar checks, and resident weights. There was no assessment nor monitoring for a significant weight gain, while in the presence of worsening Respiratory illness, with continuous oxygen use, pneumonia, sleep apnea, and after hospitalization with an acute bout of congestive heart failure.
Resident #3, was initially admitted to the facility on [DATE]. Diagnoses included; diabetes mellitus, acute congestive heart failure, morbid obesity due to excess calories, sleep apnea with CPAP/BIPAP use, essential hypertension, and anxiety. The Resident was clinically complicated.
Resident #3's most recent MDS (minimum data set) with an ARD (assessment reference date) of 12-17-24 was coded as an annual assessment. Resident #3 was coded as a Brief interview for Mental Status score of 15 indicating no cognitive impairment, no short and long term memory deficits and required no assistance with making daily life decisions. The Resident was also coded as requiring extensive to total assistance of one to two staff members to perform most activities of daily living, due to immobility related to severe obesity from excess caloric intake. The Resident was coded as did not refuse treatment or care.
Resident #3 was observed and interviewed on 2-19-25, and 2-24-25 during the lunch meal in his room. The Resident stated during those interviews Look at this mess, (the lunch meal) they are trying to kill me., and I have to eat what they bring me, or I won't eat, and it's never what I ask for or what's on the ticket. The Resident also stated They say you can get a salad, but every time I asked they say they are out of them., and Everything on that alternate list except salads is carbs, just go look at it. during the lunch meal both days. The Resident was asked if we could weigh him today, and his response was Sure. The meal trays consisted of the following;
On 2-19-25 - Large Portion Regular Diet - 2 dinner rolls, 4 large double battered and fried chicken chunks approximately 1 ounce each, 2 scoops (like and ice cream scoop) of mashed potatoes, 1 cup of green beans buttered, 1 bowl (1 cup) apple crisp desert, and 8 ounces of sweet tea to drink. The only items which were not sugary carbohydrates were the small chicken pieces inside the thick fried batter and the green beans, however, they were buttered.
The tray ticket on this day was not observed to be followed, and specified a different meal than the Resident received, which was: - Large Portion 2 grilled cheese sandwiches on white bread, buttered green beans, buttered egg noodles, 1 peanut butter and jelly sandwich, apple crisp, and tea (all carbohydrate with the exception of the green beans).
On 2-24-25 - Large Portion Regular Diet - 2 Philly cheese steak sandwiches on submarine 6 inch sandwich rolls, sauteed peppers & onions, potato salad, 1 peanut butter and jelly sandwich, tea 8 ounces. The only items which were not sugary carbohydrates were the small pieces of beef and vegetables inside the 2 large 6 inch rolls.
The tray ticket on this day was observed to be followed, with only 2 changes. The 1 peanut butter and jelly sandwich was not on the tray, and a chocolate brownie was added to the tray as desert.
Immediately following the lunch meal the Dining Services Director was interviewed with the Corporate food services Director present. Both stated that Large portion meant anything on the plate was doubled, and Double portion would constitute everything on the entire tray would be doubled. They were asked for the menu and alternate menu, and it was supplied. The alternate menu consisted of carbohydrate dense foods, except for the 2 salad options listed.
They were asked if this (tray ticket) looked like a meal a morbidly obese Diabetic Resident should receive, they both stated No.
Physician orders were reviewed and revealed 3 diabetic medication orders for the Resident. Those follow below;
1. Farxiga 10 mg (milligrams) daily from 12-14-23 to 12-27-23 then discontinued.
* No order existed for Diabetic medication management in the clinical record from 12-27-23 to 3-9-24.
2. Jardiance 25 mg once daily from 3-09-24 to current.
3. Glimipiride 2 mg twice daily from 3-24-24 to current.
Further review of Resident #3's clinical record revealed the following;
Only 2 weights were documented in the clinical record. On admission on [DATE] Resident #3's weight was measured as 479.5 pounds. On 10-2-24 it was documented as 498 pounds (a 19 pound weight gain). The Resident had a history of a recent hospitalization with acute/resolved congestive heart failure, however, was not prescribed a diuretic.
Upon admission on [DATE] through 12-19-23 the Resident was prescribed a Heart healthy diet. This was discontinued on 12-19-23, and no other diet was specified in the physician orders until 1-8-24.
1-8-24 Regular diet. Discontinued on 3-12-24.
From admission to 3-12-24, Resident #3's blood sugars were measured daily to be consistently above 200 and at times above 300 up to 337.
On 3-7-24 the Resident received a diabetes laboratory blood test for hemaglobin A1C with a result of 10.0. The normal range is 4.0 to 6.0, and the Resident was very high revealing uncontrolled high blood sugar over time.
On 3-12-24 a physician's order for Diabetic diet was issued and continued through 9-24-24. No weight was assessed nor documented as being taken.
From 3-13-24 to 9-26-24 the Residents blood sugars began to normalize and by 4-13-24 it was consistently under 200 and between 84, and 185. By October of 2024, they were consistently within normal range with the following being documented; 10-9-24 - (104), 10-15-24 (87), 10-20-24 - (105).
On 6-27-24 the Resident received a diabetes laboratory blood test for hemaglobin A1C with a result of 6.8. The result had improved at the halfway point after the diet change.
On 7-17-24 the Resident was diagnosed with pneumonia, and given antibiotics, however, the Resident's blood sugar continued to improve.
On 9-26-24 A new physician's order was received for Regular diet to be begun again with no assessment nor justification.
On 11-1-24 (one month and 4 days later) the Resident's blood sugars were back up to 232 mg/dl.
On 11-29-24 a physician's order was given to discontinue blood sugar checks (finger stick blood sugar) FSBS. Which had been originally ordered and started on 2-13-24.
Registered Dietician (RD) notes were reviewed and follow below;
Nutrition Assessments were conducted 4 times for the Resident in 14 months after the initial assessment completed on 12-19-24. The initial assessment stated Resident history, and discontinue the Heart Healthy diet for a Regular diet, add a multivitamin with minerals ordered 12-20-23, monitor weights and meal intake and follow up.
On 1-8-24, The Resident's diet was not changed and the interventions on admission were Continued.
On 6-17-24 the Resident was changed to a Diabetic diet in the note and lists the admission weight of 479.5 on admission, as no other weights were obtained until 10-2-24, and to Continue the admission interventions.
9-16-24 a quarterly MDS assessment was completed, everything was continued and the note still stated as did the MDS the admission weight as no other weights were obtained.
On 9-26-24 the diet was changed back to regular, a month later the Resident's blood sugar was back up, and on 11-29-24 blood sugars were discontinued without any monitoring, assessed reason, nor care plan changes.
Finally on 12-17-24 the Resident's diet lists Regular again in the last RD note in the clinical record as of the time of survey and no reason is given, with no other changes.
On 2-24-25 an interview was conducted with the Registered Dietician (RD). She stated that A liberalized diet is used if blood sugars are not high. She was asked if Resident #3 who had high blood sugars should be on a large portion regular diet. She stated she was unsure why he was placed on the diet , and why the diabetic diet was removed, however, progress notes should reveal assessments and team meetings or care planning. No updates from admission were found. She stated that large portion was less defined and more of a guess when preparing a Resident tray, whereas double was self explanatory. She was informed that no assessments for diabetic management was found in the clinical record while reviewing the chronological history of this Resident's diabetic management care. She stated that decisions should always be based on data and outcomes.
Review of the care plan revealed that on 12-19-23 the initial admission base line care plan listed the 2 following focuses with the interventions related to dietary management and diabetic management;
1. Focus - Resident at risk of weight fluctuations, loss or malnutrition related to respiratory failure, CHF (congestive heart failure), severe morbid obesity due to excess calories, high BMI (body mass index) which measures the body fat based on height and weight (BMI equal to or greater than 30 = obesity) (The Resident's BMI was 61).
Interventions - RD consult as needed, record meal intake percentage, weights as ordered.
2. Focus - Diabetes Mellitus - Resident is at risk for complications and blood glucose fluctuations related to diagnosis.
Interventions - Administer medications as ordered, observe for signs and symptoms of hyper/hypoglycemia and notify MD as indicated, RD consult as needed.
The only changes made to this initial care plan during the Resident's 14 month stay were the following 2 items;
1. Therapeutic diet as ordered (created 6-20-24) (resolved 1-22-25)
2. Resident consistently refusing to be weighed, added by the RD on 1-24-25. Offer the Resident to choose the day, time, frequency of weights in order to increase compliance and support desired autonomy.
The MDS assessment stated that the Resident did not refuse care nor assessments, weights were not completed as ordered and not by facility policy. Medications were omitted for a period of 2.5 months while the Resident experienced dangerously high blood sugar readings, and there is no indication that the physician was ever made aware or intervened in any way. The therapeutic Diabetic diet was ordered on 3-12-24 and discontinued 9-24-24. The care plan was not updated to reflect the new therapeutic diet for 3 months, and not updated to indicate it had been discontinued until 4 months later. The purpose of a nursing care plan is to inform staff and drive patient care.
Review of Physician progress notes also do not indicate a reason for the diet change, nor do they illustrate monitoring of the history of the increasing blood sugars or resultant lower blood sugars when the diet was changed to a therapeutic Diabetic Diet. Weights were not monitored, and Diabetic medication management was lacking from 12-27-24 to 3-9-24 (2.5 months) while receiving a Regular Large Portion Diet.
Clinical records do not indicate any ongoing assessments for; Weight gain, discontinuance of diabetic medication management for 2.5 months, discontinuance of a successful therapeutic diet, and discontinuance of blood sugar monitoring. The data clearly showed successful interventions which were then discontinued. The diet was returned to a Regular large portion diet, and blood sugars began to rise again, which continued without any further assessment for 2 further months up until the time of survey.
LPN's (Licensed Practical Nurses) on both nursing units were interviewed by surveyors during the course of the survey, and asked if a Resident with Diabetes and high blood sugar checks should be consuming a large portion high carbohydrate diet, they unanimously stated no. When asked why, each stated a different side effect; Their blood sugars will go through the roof, Their sugar will be high and could send them into ketoacidosis, it could cause kidney failure and dialysis. All of their responses were correct, and could be a reasonable outcome.
Review of the facility's policy entitled Weight Monitoring and Tracking included:
Procedure #2. Patients will be weighed on admission/readmission and weekly time 4 weeks thereafter, or until the interdisciplinary team determines the weight is stable, then monthly thereafter.
The Resident was not weighed monthly, and no progress notes indicate a reason until the RD placed in the care plan refusals by the Resident on 1-24-25. As the Resident was morbidly obese and weights would require large scales and multiple staff to complete, it appears weights were omitted for staff convenience.
One star out of 5 stars was applied to the facility for staffing levels for the preceding year, by CMS (Centers for Medicare/Medicaid Services) in their payroll based journal staffing reports, CMS Compare. This indicated sub par staffing in the facility, and excessively low weekend staffing in the third and fourth quarters of 2024.
On 2-24-25 at the end of day debrief the Administrator and corporate representatives were made aware of findings. No further information was provided.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
Based on Observations, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to schedule sufficient nursing staff to maintain the highest...
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Based on Observations, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to schedule sufficient nursing staff to maintain the highest practicable well being of each resident.
The findings included;
During the course of the survey from 2-19-25 through 2-24-25 a complaint was investigated by the state agency. No date, nor date range was included for an allegation of insufficient nursing staff. The receipt of the complaint in the state agency occurred initially on 2-8-24.
Residents placed in the survey sample were interviewed as well as nursing staff. They stated that staffing had been an issue at times over the past year, however, staffing had become more normalized within the last few months.
Residents were observed to be dressed in clean clothing, no pervasive odors existed in the facility, and the general population of Residents were seen to be engaged in activities, therapies, and independent leisure activity outside on the front porch area, and in their own rooms.
Residents clinical records were reviewed for Activities of daily living care (ADL's), medication administration, therapies, and dining activities. The care was ongoing and appeared at the time of survey to be sufficient currently.
As worked staffing schedules and time clock punches were also reviewed and found to be sufficient currently.
Since no exact dates can be ascertained, the previous year of CMS (Centers for Medicare/Medicaid Services) payroll base journal submissions, and CMS Compare reports were reviewed. This included Fiscal year 2024 quarter one through quarter 4. In those reports, one star out of 5 available stars was applied to the facility for staffing levels for the preceding year, by CMS in their payroll based journal staffing reports, and CMS Compare. This indicated sub par staffing in the facility for that time period, and excessively low weekend staffing in the third and fourth quarters of 2024.
On 2-24-25 at the end of day debrief the Administrator and corporate representatives were made aware of findings. No further information was provided.
Sept 2024
4 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, clinical record review, and facility documentation, the facility staff failed to ensure the Residents were ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, clinical record review, and facility documentation, the facility staff failed to ensure the Residents were free of accident hazards and provided adequate supervision for two (2) Residents (#3 and #4) in a survey sample of nine (9) Residents. This resulted in immediate jeopardy for Resident #3 and potential for harm for Resident #4.
The findings included:
1. For Resident # 3, the facility staff failed to provide supervision while smoking outside of the building, allowing Resident #3 to leave the facility grounds unsupervised.
Resident #3 was admitted to the facility on [DATE] with diagnoses that included but were not limited to generalized anxiety disorder, depression, unspecified intellectual disability, alcohol dependence with withdrawal, alcohol-induced persistent dementia, other symptoms and signs involving cognitive awareness, and respiratory conditions due to smoke inhalation.
Resident #3's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/5/24, assessed by the facility Social Worker, scored Resident as a 5/15, indicating severe impairment in cognitive skills.
On 9/4/24, a review of the smoking policy revealed the following information:
Patients smoking in the designated smoking grounds area are to be supervised as deemed appropriate through their individual Safe Smoking Assessment.
The Safe Smoking Assessment screening was reviewed on 5/27/24 and 8/27/24. Resident #3 received scores of 2 and 0. According to the key, a score of 0-4 is considered safe to smoke unsupervised. [Please note that the smoking assessment screens explicitly for the ability to light and handle smoking materials physically.]
A review of the elopement assessments revealed that on 2/14/24, Resident #3 scored a 10; on 5/14/24, again, a 10; and on 8/14/24, 11 was scored, all three indicating a high risk of elopement.
On 9/4/24 at approximately 1:00 p.m., Resident #3 was noted to be outside the building smoking with other residents, and she returned to the building after she finished smoking.
On 9/4/24, at approximately 2:00 p.m., Resident #3 was interviewed. She said she never left the building unsupervised or went to the store. She stated that the staff always opened the door for her to smoke outside. She denied ever wandering off or going to buy beer at a store. At this point, Resident #3 ended the interview by walking away.
On 9/4/24, at approximately 11:00 a.m., the receptionist was observed bypassing the wander guard alarm for another resident to go outside to smoke. When asked what the sound was, she stated it was the wander guard alarm. When asked if she bypassed it by putting in the code, she said she did. When asked why, she stated that the Resident was a smoker and allowed to go and smoke.
A review of the clinical record on 9/4/24 revealed that Resident #3 had eloped from the facility grounds on several occasions since May 23, 2024.
The following excerpts are from the clinical record regarding Resident #3's elopement:
5/23/24 1:39 p.m. -Writer contacted by nurse that resident was seen near road at entrance of facility when nurse tried to redirect resident walked back towards back of facility. Writer traveled to back of building where resident was located. Resident stated that she was just walking around. Writer explained to resident that it is not safe to walk around outside the facility without a staff escort. Resident stated she was trying to exercise. RP was made aware.
6/12/24 2:03 p.m. - Code orange called at 1250 pm as patient was seen walking off the premises. Patient was able to be redirected inside the building when asked why she left patient stated she no longer wanted to live here, she is bored and has nothing to do.
6/14/24 6:09 p.m. - She eventually put out the cigarette but continuously kept trying to walk off the facility premises. Twice she was redirected back while she agitated and using profane words at staff. She refused all her medications. RP notified.
7/18/24 10:18 a.m. - Left facility unsupervised to go to the store. Resident found at the store purchasing Alcohol.
7/28/24 8:39 p.m. - [Resident name redacted] was seen by staff at approximately 6:00 pm. A fellow resident who had walked to the store stated she was at the store with him but when he turned around, she was gone. The supervisor called a code orange, notified the police, called the RP, notified the DON and the administrator. Within 10 minutes she was located by her RP. Police were notified that she was found safe and was with a relative. The administrator and DON were also notified. The RP stated she would keep her for an hour or so to calm her down and then return her to the facility. Upon her return resident was still noted to be agitated and still continued to leave the premises. She attempted to hit staff and was physically aggressive with her aunt. Resident will be seen by psych services this week. MD notified. Skin assessment completed no injuries.
8/1/24 3:51 p.m. - Spoke with [Responsible party name redacted] to make her aware that [Resident #3 name redacted] left the property and was at the [NAME] store and the cashier explained to staff that [Resident name redacted] is banned from their property.
8/2/24 7:30 p.m. - Resident has been leaving facility property since 2130 [sic]. Care staff was able to redirect resident back into facility. Resident then later insisted on going to the nearby store for something she wanted, and she wasn't coming back into the facility until she was ready. Resident was assisted back to facility by another staff member where she remains in her room on the phone at the time of this writing.
8/2/24 8:36 p.m. - Type of Behavior: Elopement
Non-pharmacological Intervention: Talked and walked around the parking lot w/ her for a few minutes until she was ready to go back inside.
8/2/24 9:11 p.m. - Writer noticed resident walking by with alcohol in a bag going to her room. Writer attempted to ask resident to see what she had but she refused.
8/2/24 9:35 p.m. - Resident has left facility grounds unattended.
8/2/24 9:52 p.m. - Resident returned back to facility at 7:45 pm accompanied by writer
8/4/24 5:27 p.m. - Resident was reported to have left the facility unattended. Writer went outside in search of resident and CNA followed in her car. Resident was found at the [name of store redacted] store and she stated she was getting a drink but had no money. When advised to get in the car so she could return to the facility, she refused, crossed the street and kept walking towards the direction of the highway. Another nurse [nurse's name redacted] was informed at the facility to contact resident's RP while writer kept following Resident down the street, advising her to return. Resident eventually turned around, and her RP picked her up mid-way back to the facility.
8/23/24 6:56 p.m. - Resident was noticed to have left the facility around 1730 [5:30 p.m.]. A code orange was called but resident could not be found in or around the building. She could not be found at the [NAME] gas station. RP and DON were notified. Resident was found coming back from the direction leading to the 7-11. She was encouraged by writer and RP who had driven to the facility to assist in finding resident to return back to the facility. Resident walked back to building with writer.
Immediate Jeopardy (IJ) was identified and verified after consultation with the state Licensure and Certification supervisory Staff on 9/5/24 at 12:47 p.m.
The facility Administrator and Director of Nursing (DON) were made aware of IJ on 9/5/24 at 12:50 p.m.
On 9/6/24 at 2 p.m., the facility submitted approved IJ Removal Plan:
a) Immediate Supervision:
As of 9/5/24 at 1:35 p.m., resident #3 is now under 1:1 supervision 24/7 to prevent elopement.
As of 9/5/24, a dedicated staff member has been assigned to always monitor during smoke breaks.
b) Wander Guard System:
On 9/5/2024 at 1:35 p.m., the Resident #3 wander guard bracelet was assessed and functioning well.
On 9/5/2024, the maintenance team re-evaluated and recalibrated the facility's wander guard system to ensure it functions correctly. All in-place wander guards have been checked and are working successfully.
As of 9/5/2024, the facility has initiated training for all its staff on the importance of not passing the wander guard system and the potential consequences of doing so.
c) Environmental Modifications:
The front door will remain locked, and staff will continue to monitor exit doors, especially during high-risk periods when Resident #3 is likely to attempt to leave (e.g., smoking times).
d) Smoking:
As of 9/5/2024, Resident #3 will continue not to be allowed to smoke unsupervised.
A designated smoking area has been established within a secure part of the facility, and staff will escort Resident #3 to and from this area.
e) Staff Education and Training:
On 9/5/2024, all staff will undergo immediate re-education on elopement risks, supervision requirements, and the specific needs of residents with cognitive impairments.
Training sessions have been initiated to reinforce the importance of adhering to safety protocols and using the wander guard system. The plan is for all staff to report for oncoming shifts; they will not work until all re-education is complete.
f) Resident Care Plan Review:
On 9/5/2024 at 1:35 p.m., Resident #3's care plan was reviewed and updated to include specific interventions to prevent elopement. The care plan now includes detailed instructions for staff on supervising Resident#3 during all activities, including smoke breaks.
The facility alleges compliance as of 9/6/24 at 1:00 p.m.
Long Term Actions:
i.) Ongoing Monitoring
Regular audits will ensure compliance with the updated supervision protocols.
While the patient remains in the facility, Resident #3's care plan will be reviewed monthly to assess the effectiveness of the interventions and make necessary adjustments.
ii.) Family and Resident Involvement:
As of 9/5/2024 at 1:50 p.m., Resident #3 and her family have been informed of the situation and steps to ensure her safety.
Regular meetings will be held with the family to discuss concerns and provide updates on Resident #3's status.
iii.) Policy Review and update:
As of 9/5/2024, the facility's elopement policy has been reviewed and updated to reflect the new measures.
All staff have received a copy of the updated policy and must acknowledge their understanding and commitment to following it.
iv.) Quality Assurance
As of 9/5/2024, a QA committee has been established to oversee the implementation of the abatement plan and ensure ongoing compliance. The QA committee will meet bi-weekly to review incident reports, monitor the effectiveness of interventions, and recommend further improvements as needed.
The Survey Team verified that the following components of the Removal plan had been fully implemented on 9/6/24:
The survey team reviewed the education provided and interviewed the staff on duty to ensure they had been trained and understood the content. The staff were questioned about Resident #3's supervision during smoke breaks and when she was out of the facility. The survey team reviewed the policy to ensure the updates included supervision while smoking in the designated smoke area.
A review of the clinical record revealed that the facility staff updated the care plan to include, due to the resident's cognitive status, the need for supervision at all times while smoking. The facility staff documented contacting the Resident's Responsible Party and working together to find a facility with a more appropriate setting to provide enhanced security for the Resident.
On 9/5/24, at approximately 2:00 p.m. (after the facility was informed of the immediate jeopardy), staff members were observed walking in the hallway with Resident #3. On 9/6/24, at approximately 9:00 a.m., Resident #3 was observed to have one-to-one (1:1) supervision outside in a sanctioned area during a smoke break. On 9/6/24 at 10:30 AM, the resident was also observed during a structured activity with 1:1 supervision.
On 9/6/24 at 3:00 p.m., the survey team informed the Administrator that the IJ was removed based on validation of their removal plan and the scope and severity of the deficiency was lowered to a level 2, isolated.
2. For Resident #4, the facility staff failed to ensure the maintenance person had removed all tools from the roof after repairs, causing a hammer to fall on Resident #4's head, resulting in an evaluation in the emergency room.
Resident #4 was admitted to the facility on [DATE]. Diagnoses for Resident #4 included but were not limited to pulmonary embolism, type 2 diabetes, acute kidney failure, seizure, substance abuse, hypertension, pancreatic cancer, and emphysema.
Resident #4's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 7/16/24 coded Resident #4 with a BIMS (Brief Interview of Mental Status) score of 13/15 indicating no cognitive impairment. Minimum Data Set Coded Resident #4 as #1- supervision from staff for Activities of Daily Living care.
On 9/5/24, a review of the clinical record revealed the following notes:
8/24/24 3:08 p.m.- On the day of Aug. 24, 2024, resident was involved in incident where nursing staff felt an assessment from E.R. should be required. [Resident #4 name redacted] at one point began to refuse to go to ER to be evaluated because he was afraid of losing room placement. We assured him that admission would follow up with him and he would be notified before any changes would occur. Resident later after strong encouragement from staff decided to go to E.R. to be evaluated.
8/25/24 1:30 p.m. -LATE ENTRY
-Situation: Date and time the fall occurred: 08/24/2024 1:21 PM
Background: Circumstances of the fall: Resident's cane was placed on roof of building, resident attempted to retrieve his cane from roof, and was hit in the head by object off roof.
Assessment (RN)/Appearance (LPN): Current status of the resident's injuries or reports of pain from the fall: Resident has area to top of scalp, dry and intact Resident c/o pain 5/10
Recommendation: Interventions currently in place to prevent additional falls: Resident educated to ask for assistance resident's response to new interventions: Resident compliant.
On 9/5/24, a clinical record review revealed that Resident #4 went to the ER on [DATE] and was evaluated and released. There were no new orders; CT imaging of the head and neck was done to confirm no acute fractures or serious injury from the incident.
The following excerpt was from the physician's notes.
9/2/24 1:00 p.m. -Patient discussed that he has been recovering and attempting to feel better physically. He reports a hammer fell off the roof the building when he attempted to retrieve his cane from the roof. Patient said it was hanging off the side of the building and a hammer fell and hit him on the head. Patient then reports he did not recall a lot of things. Patient said he was medically cleared at a hospital and has been following doctor's order.
9/5/24 at approximately 12:00 p.m. an interview was conducted with Resident #4 who stated he is feeling much better and still did not know how his cane came to be hanging off the side of the roof. He stated that he reached for it and then it must have knocked the hammer off when it came down on his head. He stated that he went to the emergency room, and they did some tests and x-rays and sent him back to the facility. When asked if he felt fearful or unsafe at the facility, he stated that he did not. He stated it was a 'Crazy accident.'
On 9/5/24 at approximately 3:00 p.m. an interview was conducted with the Administrator who stated that the incident did happen an investigation was done, and the maintenance person was educated on ensuring tools were not left where they could injure residents.
On 9/5/24 during the end of day meeting the Administrator was made aware of the concerns and no further information as provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on interview, clinical record review and facility documentation the facility staff failed to review and revise care plan for 1 Resident in survey sample of 9 Residents.
The findings included:
Fo...
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Based on interview, clinical record review and facility documentation the facility staff failed to review and revise care plan for 1 Resident in survey sample of 9 Residents.
The findings included:
For Resident #3 the facility staff failed to review and revise care plan after 9 incidents of elopement or attempted elopement between 5/23/24 and 8/23/24.
A review of the clinical record revealed the following excerpts from the care plan:
FOCUS: The resident is at risk for elopement related to exit seeking.
GOAL: Resident will be monitored for exit attempts, constant staff observations for attempts Date Initiated: 02/01/2024
Revision on: 05/08/2024
The resident will not elope thru review period Date Initiated: 11/14/2023 Revision on: 05/14/2024
INTERVENTION: check function weekly Date Initiated: 11/14/2023, check placement every shift Date Initiated: 11/14/2023 Code orange when occur Date Initiated: 04/29/2024, elopement risk assessment as needed Date Initiated: 05/14/2024, Redirect from exit
Date Initiated: 11/14/2023.
On 9/5/24 at approximately 3 p.m. an interview was conducted with LPN B who stated that care plans should be updated when there are any new changes in Resident care or condition. When asked if this included if a Resident elopes or wanders away from the building, and she stated that it should be included in the care plan and the care plan should be updated to add any new interventions to prevent it from happening again.
On 9/5/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of the facility, they failed to provide a sanitary environment for residents, staff and the public.
The fi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of the facility, they failed to provide a sanitary environment for residents, staff and the public.
The findings included:
The facility staff failed to provide a sanitary environment for residents, staff and the public.
During the initial tour of the facility on 9/3/2024 at 8:30 p.m., three grills were observed outside the door of the wing (unit) facing the left side of the parking lot. At 9:15 p.m., two surveyors looked near the area around the grills. Several large cockroaches were observed scurrying on the sidewalk and in the bushes near the door. The cockroaches were approximately 3 inches in length. When the lids to each grill were lifted, there were soiled aluminum foil sheets observed on each of the grill grates with noted food debris. The grills remained in the same location until 9/5/2024 around 4:00 p.m. in the afternoon, after the administrator was informed about the findings.
On 09/04/2024, at approximately 10:00 AM, during a morning meeting, the surveyors were approached by a resident's family member. She stated she was concerned with the facility and rodents. Stated that her mom was admitted to room [ROOM NUMBER] on 09/03/ 24 in the afternoon. She went on to say that after getting her mom (Resident #6) settled in her room for the night, she left the facility at approximately 7:00 p.m. The family member states that her mom, (Resident #6), called her at 11:00 p.m. and informed that she had mice in her room. Resident # 6 went on the say that there were mice running from the bathroom to the hole seen under the sink in her room. Also stating that she saw 4 mice at one time. The family member provided pictures the mice.
On 09/04/2024, at approximately 12:45 p.m., during an afternoon tour room [ROOM NUMBER] on the South Unit was observed to have a small hole under the sink and a medium size hole in the bathroom. There was 1 bated paper trap, and 2 Sticky traps, which captures everything crawling across it, and the insect or rodent would be trapped in the glue covered top.
On 09/05/2024, an interview was conducted with Resident #6. The Resident stated that she was just laying in bed and noticed out the corner of her eye a mouse run across the floor. She states that she saw four at one point and what appeared to be a potato chip bag. Resident #6 also provided pictures that she captured from her bed of mice and what appeared to be a large water bug.
On 09/05/2024 an interview was conducted with the Maintenance Manager who states they have had issues with mice and some insects. He went on to say they have a Pest Control Contract, and that the Contractor comes once a week, on Thursdays, and treats all common areas and areas of sightings.
A review of the pest control log revealed the Control Company provided service weekly to common areas, and most recently spot and room treatments to room [ROOM NUMBER], 33, 39, 34, 43, 59, 57, and 47 on 08/26/24 with Glue Boards.
On 9-04-24 the Administrator and the Director of Nursing were made aware of the findings.
No further information was provided.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility documentation, the facility staff failed to maintain an effective pest control pro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility documentation, the facility staff failed to maintain an effective pest control program.
The findings included:
The facility staff failed to maintain an effective pest control program so that the facility is free of pests, to include mice, involving 2 of 2 units in the facility.
During the initial tour of the facility on 9/3/2024 at 8:30 p.m., three grills were observed outside the door of the wing (unit) facing the left side of the parking lot. At 9:15 p.m., two surveyors looked near the area around the grills. Several large cockroaches were observed scurrying on the sidewalk and in the bushes near the door. The cockroaches were approximately 3 inches in length. When the lids to each grill were lifted, there were soiled aluminum foil sheets observed on each of the grill grates with noted food debris. The grills remained in the same location until 9/5/2024 around 4:00 p.m. in the afternoon, after the administrator was informed about the findings.
On 09/04/2024, at approximately 10:00 AM, during a morning meeting, the surveyors were approached by a resident's family member. She stated she was concerned with the facility and rodents. Stated that her mom was admitted to room [ROOM NUMBER] on 09/03/ 24 in the afternoon. She went on to say that after getting her mom (Resident #6) settled in her room for the night, she left the facility at approximately 7:00 p.m. The family member states that her mom, (Resident #6), called her at 11:00 p.m. and informed that she had mice in her room. Resident # 6 went on the say that there were mice running from the bathroom to the hole seen under the sink in her room. Also stating that she saw 4 mice at one time. The family member provided pictures the mice.
On 09/04/2024, at approximately 12:45 p.m., during an afternoon tour room [ROOM NUMBER] on the South Unit was observed to have a small hole under the sink and a medium size hole in the bathroom. There was 1 bated paper trap, and 2 Sticky traps, which captures everything crawling across it, and the insect or rodent would be trapped in the glue covered top.
On 09/05/2024 an interview was conducted with Resident #6. The Resident stated that she was just laying in bed and noticed out the corner of her eye a mouse run across the floor. She states that she saw four at one point and what appeared to be a potato chip bag. Resident #6 also provided pictures that she captured from her bed of mice and what appeared to be a large water bug.
On 09/05/2024 an interview was conducted with the Maintenance Manager who states they have had issues with mice and some insects. He went on to say they have a Pest Control Contract, and that the Contractor comes once a week, on Thursdays, and treats all common areas and areas of sightings.
A review of the pest control log revealed the Control Company provided service weekly to common areas, and most recently spot and room treatments to room [ROOM NUMBER], 33, 39, 34, 43, 59, 57, and 47 on 08/26/24 with Glue Boards.
On 9-04-24 the Administrator and the Director of Nursing were made aware of the findings.
No further information was provided.
May 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on staff interview, facility document review, and clinical record review, the facility staff failed to review and revise the comprehensive care plan for one of 13 residents in the survey sample,...
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Based on staff interview, facility document review, and clinical record review, the facility staff failed to review and revise the comprehensive care plan for one of 13 residents in the survey sample, Resident #4.
The findings include:
For Resident #4 (R4), the facility staff failed to review and revise the resident's comprehensive care plan for a fall the resident sustained on 3/30/24.
A review of R4's clinical record revealed a nurse's note dated 3/30/24 that documented the resident slid out of bed. A review of R4's comprehensive care plan dated 3/13/24 failed to reveal evidence that the care plan was reviewed and revised for the 3/30/24 fall (the care plan was not revised until after R4 sustained another fall on 4/19/24).
On 5/8/24 at 10:37 a.m., an interview was conducted with RN (registered nurse) #3. RN #3 stated the care plan is a guideline for staff to be able to access and know what needs to be done for each resident. RN #3 stated the care plan should be reviewed and revised after each fall and this is usually done during the shift that a fall occurs, or the next day.
On 5/8/24 at 11:08 a.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 titled, Falls Management Program documented, Fall Occurrence: 3. A licensed nurse will review, revise, and implement interventions to the care plan based on:
-Post Fall Investigation findings
-Review of Device Assessment
-Review of Fall Risk Scoring Tool.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
3. Resident #4 (R4) fell on 3/30/24. The facility staff failed to address and/or implement interventions to prevent future falls and the resident fell again on 4/19/24.
A review of R4's clinical recor...
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3. Resident #4 (R4) fell on 3/30/24. The facility staff failed to address and/or implement interventions to prevent future falls and the resident fell again on 4/19/24.
A review of R4's clinical record revealed a nurse's note dated 3/30/24 that documented the resident slid out of bed. Further review of R4's clinical record (including the comprehensive care plan dated 3/13/24 and nurses' notes dated 3/30/24 through 4/19/24) failed to reveal the facility staff addressed and/or implemented interventions to prevent future falls. A late entry nurse's note dated 4/20/24 documented R4 was found on the floor on 4/19/24 (the resident did not sustain an injury).
On 5/8/24 at 10:37 a.m., an interview was conducted with RN (registered nurse) #3. RN #3 stated an intervention should be implemented after a resident falls and that intervention should depend on the resident's cognitive status and the circumstances of the fall.
On 5/8/24 at 11:08 a.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 titled, Falls Management Program documented, The center utilizes a systematic approach to a falls management program that facilitates an interdisciplinary approach with evidence-based interventions to develop individual care strategies .Fall Occurrence: 3. A licensed nurse will review, revise, and implement interventions to the care plan based on:
-Post Fall Investigation findings
-Review of Device Assessment
-Review of Fall Risk Scoring Tool.
Based on observation, staff interview, facility document review, it was determined the facility staff failed to provide adequate supervision and prevent accidents for three of 13 residents in the survey sample, Residents #10, 11 and #4.
The findings include:
1. For Resident #10 (R10), the facility staff failed to provide supervision for smoking per the smoking assessment.
On the most recent MDS (minimum data set) assessment, an admission assessment, with an assessment reference date of 4/15/2024, the resident scored a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. In Section J - Health Conditions, the resident was coded as using tobacco products while a resident at the facility. In Section O - Special Treatments, Procedures and Programs, the resident was coded as using oxygen while a resident at the facility.
Observation was made of R10 on 5/7/2024 at 3:24 p.m. outside on the front sidewalk to the right of the entrance. The resident was observed to be smoking a cigarette. An oxygen tank was observed on the back of the wheelchair. There were no staff members providing supervision. There was no fire extinguisher in the area. There was a receptacle for the disposal of cigarettes.
The Smoking - Safety Screen dated 5/7/2024, completed by the director of nursing, documented the resident scored a 5. The form documented a score of 0-4 = may smoke unsupervised. A score of 5 or greater = requires supervision with smoking.
The comprehensive care plan dated 5/7/2024, documented in part, Focus: the resident prefers to smoke (cigarettes, cigar, pipes, electronic delivery systems electronic cigarettes/e-cigs. vape pen, etc.). The Interventions documented in part, Educate on facility smoking policy. May smoke independently. OT (occupational therapy) referral as needed. Smoking assessment as needed.
An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 5/8/2024 at 9:00 a.m. When asked to explain the assessment process and smoking policy ASM #2 stated, the smoking assessments are completed on admission, quarterly and if a resident is observed smoking. ASM #2 was asked how she completes the assessment, ASM #2 stated she goes outside with the resident, watches them light their cigarettes, how the handle their cigarettes and how they dispose of the cigarettes. The above assessment was reviewed with ASM #2. The assessment documents the resident requires supervision with smoking. ASM #2 stated she believed that since the resident uses oxygen, that she should be supervised.
The facility policy, Smoke/Tobacco/Vapor Free Environment documented in part, Procedures: 3. The Administrator may or may not choose to designate areas outside of the building for any smoking or electronic cigarette vapor activities. 4. If designated areas are administratively established on the grounds for patients, employees or visitors of the Center, the smoking area must: a. be posted as a smoking area, b. be well ventilated, c. does not allow passive smoke or vapor emissions to recirculate into the building, d. strictly prohibit the use and/or storage of oxygen in any designated grounds smoking area. Patients who may desire to smoke in the administratively designated grounds area must be assessed by the interdisciplinary team for their ability to safely smoke in the designated areas. Patients smoking in the designated grounds areas are to be supervised as deemed appropriate through their individual Safe Smoking Assessment .5. If designated areas are administratively established on the grounds of the Center: a. Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. b. Metal containers will self-closing cover devices into which ashtrays cam be emptied shall be readily available to all areas where smoking is permitted.
ASM #1, the administrator, and ASM #2, were made aware of the above concern on 5/8/2024 at 11:07 a.m.
No further information was provided prior to exit.
2. For Resident #11 (R11), the facility staff failed to provide supervision for smoking per the smoking assessment.
On the most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 2/5/2024, the resident scored a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. In Section J - Health Conditions, the resident was coded as using tobacco products while a resident at the facility. In Section O - Special Treatments, Procedures and Programs, the resident was coded as using oxygen while a resident at the facility.
Observation was made of R11 on 5/7/2024 at 4:01 p.m. in the gazebo (the designated area for smoking), smoking a cigarette, with two other residents. The oxygen tank on the back of the wheelchair was turned off. There was no staff member present in the gazebo. A staff member came and took R11 back into the building. The resident put on his oxygen tubing and the staff member turned the oxygen tank on. The other two residents were still smoking their cigarettes.
The Admission/readmission Nursing Assessment, dated 4/11/2024 documented the resident scored a 11 on the smoking safety score. The form documented a score of 0-4 = may smoke unsupervised. A score of 5 or greater = requires supervision with smoking.
The comprehensive care plan dated, 2/27/2024 and revised on 5/8/2024, documented in part, Focus: the resident prefers to smoke (cigarettes, cigar, pipes, electronic delivery systems electronic cigarettes/e-cigs. vape pen, etc.). Resident presents with poor safety awareness. Non-compliant with instructions to not smoke with oxygen on. The Interventions documented in part, Educate on facility smoking policy. May smoke independently. OT (occupational therapy) referral as needed. Smoking assessment as needed.
An interview was conducted with ASM (administrative staff member) #2, the director of nursing, on 5/8/2024 at 9:00 a.m. When asked to explain the assessment process and smoking policy ASM #2 stated, the smoking assessments are completed on admission, quarterly and if a resident is observed smoking. ASM #2 was asked how she completes the assessment, ASM #2 stated she goes outside with the resident, watches them light their cigarettes, how the handle their cigarettes and how they dispose of the cigarettes. The above assessment was reviewed with ASM #2. The assessment documents the resident requires supervision with smoking. ASM #2 stated she believed that since the resident uses oxygen, that he should be supervised.
ASM #1, the administrator, and ASM #2, were made aware of the above concern on 5/8/2024 at 11:07 a.m.
No further information was provided prior to exit.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure a resident was free from an unnecessary medication for one of 13 residents in the su...
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Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure a resident was free from an unnecessary medication for one of 13 residents in the survey sample, Resident #1.
The findings include:
For Resident #1 (R1), the facility staff failed to hold the medication Lasix (furosemide) (1) per the physician ordered parameter of a systolic blood pressure less than 110.
A review of R1's clinical record revealed a physician's order dated 9/29/22 that documented, Check BP (blood pressure) Prior to Lasix administration one time a day for hypotension (low blood pressure) hold medication for SBP (systolic blood pressure) less than 110. This was scheduled on the MAR (medication administration record) to be done at 9:00 a.m. Further review of R1's clinical record revealed a physician's order dated 11/16/23 for furosemide 20 milligrams- three tablets by mouth two times a day for edema. A review of R1's February 2024 MAR and April 2024 MAR revealed the resident was administered furosemide on 2/15/24 at 9:00 a.m. although the resident's systolic blood pressure was 103 and was administered furosemide on 4/16/24 at 9:00 a.m. although the resident's systolic blood pressure was 99 (as evidenced by check marks on the MARs).
On 5/8/24 at 10:37 a.m., an interview was conducted with RN (registered nurse) #3. RN #3 stated nurses evidence medication administration by checking the medication off on the MAR. RN #3 stated nurses should hold a medication per the parameter ordered by the physician and nurses should note the medication was held on the MAR. R1's February 2024 and April 2024 MARs were reviewed with RN #3. RN #3 stated that on 2/15/24 and 4/16/24, the resident's furosemide should have been held and it looked like the medication was signed off as being administered.
On 5/8/24 at 11:08 a.m., ASM (administrative staff member) #1 (the administrator), and ASM #2 (the director of nursing) were made aware of the above concern.
The facility pharmacy policy titled, General Guidelines for Medication Administration documented, II. 2. Medications are administered in accordance with written orders of the prescriber.
Reference:
(1) Lasix (furosemide) is used to treat high blood pressure and edema. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682858.html
Dec 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide care and services in accordance with professional standards for 1 resident, Resident #13, in a survey sample of 16 residents.
The findings included:
For Resident #13, facility staff failed to administer medications as ordered by the physician on 11/23/23.
On 12/6/23, Resident #13's clinical record was reviewed and revealed physician orders and medication administration times as follows:
-Glipizide Oral Tablet, 10mg, give 1 tablet by mouth two times a day--ordered on 11/23/23, documented as given on 11/24/23
-Synjardy Oral Tablet, 5-1000mg (Empagliflozin-Metformin HCl), give 1 tablet by mouth in the evening--ordered on 11/23/23, documented as given on 11/24/23
-Tamsulosin HCl Oral Capsule, 0.4mg, give 1 capsule by mouth one time a day--ordered on 11/23/23, documented as given on 11/24/23
On 12/6/23 at approximately 1:30 PM, an interview was conducted with the Director of Nursing (DON) who confirmed the findings and stated that medications are expected to be given as ordered by the physician. She verified Resident #13 was admitted on [DATE] and stated, I do not know why he [Resident #13] did not get these meds on time, it is my expectation that if there is a question about medications then the nurse should contact the doctor for clarification and document it in a note.
LPN C (licensed practical nurse-C) was Resident #13's assigned nurse on 11/23/23 and 11/24/23, however was unavailable for interview. The DON stated that the facility's professional nursing standards reference was [NAME]. A facility policy on medication administration was requested and received.
Review of the facility policy entitled, General Guidelines for Medication Administration, revised 08-2020, heading Policy read, Medications are administered as prescribed in accordance with good nursing principles and practices .
According to [NAME] Nursing Procedures, Seventh Edition, 2016, section entitled, Oral Drug Administration, steps in the implementation of medication administration included but were not limited to: Verify the medication is being administered at the proper time .to reduce the risk of medication errors.
On 12/6/23 at the end of day meeting, the Facility Administrator and DON were updated on the findings. No further information was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide oxygen therapy consistent with infection control practices for 1 ...
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Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide oxygen therapy consistent with infection control practices for 1 resident, Resident #15, in a survey sample of 16 residents.
The findings included:
For Resident #15, facility staff failed to label and date the oxygen tubing, humidification bottle, and nebulizer mask with tubing in accordance with infection control standards of practice.
On 12/6/23 at approximately 10:50 AM, Surveyor B observed an oxygen concentrator with a humidification bottle attached along with a nasal cannula in Resident #15's room. Resident #15 was not in her room. A facemask with a medication reservoir was attached to a nebulizer unit at her bedside. There were no labels or dates observed on any of the oxygen tubing or on the humidification bottle. The facemask attached to the nebulizer unit was not contained in a bag and was not labeled/dated.
On 12/6/23, immediately following the observations, an interview was conducted in Resident #15's room, with LPN B [licensed practical nurse B] and the ADON [Assistant Director of Nursing], both of whom confirmed the findings. LPN B stated, I do not see any date label on the [oxygen] tubing, the water bottle [humidification bottle], or the facemask, it is supposed to be changed weekly on Sundays, When asked about the importance of changing the oxygen tubing weekly, LPN B stated, It needs to be changed weekly to prevent the spread of infections. The ADON concurred with LPN B's statements and added, Without any labeling to note the date of last change, it is anybody's guess as to when it was last done, if at all.
Review of Resident #15's clinical record revealed a physician's order that read, Oxygen Therapy--Oxygen at 3 liters per minute via nasal cannula and Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3)MG/3ML [nebulizer treatments].
Review of the facility's policy entitled, Respiratory/Oxygen Equipment revision date 3/13/2023, subheading Medicated Nebulizer Treatment, item 5 read, Rinse out nebulizer reservoir with tap water, dry, and place in plastic bag when not in use. Nebulizers and bags should be changed weekly. Subheading Oxygen Therapy via Nasal Cannula, Simple Mask, Venturi Mask, and Oximizer, item 6 read, Nasal cannulas, Simple masks, Venturi mask, and Oximizer and tubings should be changed weekly and item 7 read, .Humidifier bottles are to be changed weekly.
On 12/6/23 during the end of day conference, the Facility Administrator and Director of Nursing were informed of the findings. No further information was provided.
Oct 2023
33 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Abuse Prevention Policies
(Tag F0607)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff fail...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to implement their abuse policy affecting 2 residents (#53 and #85), resulting in harm for Resident #53.
Immediate Jeopardy (IJ) was identified on 09/27/2023 at 5:25 p.m., at which time the facility Administrator and Director of Nursing were made aware. Following verification of the removal of immediacy, the facility abated IJ on 10/04/2023 at 10:45 a.m. The scope and severity was lowered to a level 3, pattern.
The findings included:
1. The facility staff failed to implement their abuse policy by permitting facility staff to work when their criminal background status was unknown.
On 09/27/2023, a review was conducted of a sample of employee files which revealed the following:
a. Staff #4 was hired 03/17/2022 and terminated employment on 10/01/2022. Staff #4's employee record had no evidence that a criminal background check had been obtained. Therefore, from 03/17/2022 - 10/01/2022, facility staff were unaware of Staff #4's criminal background status, and the staff member provided direct resident care during this time.
b. Staff #10 was hired on 10/31/2022 and terminated employment on 01/10/2023. There was no evidence provided to indicate that Staff #3 had a criminal background check performed. Therefore, from 10/31/2022 - 01/10/2023, facility staff were unaware of Staff #10's criminal background status and was permitted to provide direct care to residents.
c. Staff #13 was hired 07/5/2022 and terminated employment on 10/08/2022. Staff #13's employee record had no evidence of a criminal background check on file. Therefore, from 07/05/2022 - 10/08/2022, facility staff were unaware of Staff #13's criminal background status and was permitted to provide direct care to residents.
d. Staff #24 was hired 03/08/2023. Staff #24's criminal background check was requested on 03/07/2023 and noted to read, Transaction is being processed and the final report was not on file. Therefore, from 03/08/2023 until the time of survey, the facility staff were unaware of Staff #24's criminal background status and the employee was permitted to continue to work without knowing if the employee was guilty of a barrier crime.
On 09/27/2023 at approximately 1:00 p.m., an interview was conducted with the Human Resources Director (HRD) who stated, We get criminal background checks on every applicant. For the Virginia State Police, we wait 30 days, and they can work with another employee while we wait for it.
The HRD verified that Staff #4, #10, #13, and #24 did not have a criminal background report within 30 days of their respective hire dates.
A review of the facility's policy entitled, Abuse/Neglect/Misappropriation/Crime Prevention/Screening/Training, dated 01/23/2020, subtitle, Procedure, item 1 read, Criminal background and reference checks are performed on all employees.
Prior to conclusion of the survey, the facility staff provided the survey team with a facility policy entitled, Onboarding/Virginia, with an effective date of 10/01/2023, which was reviewed. This policy read, The company will comply with all local and state regulations and guidelines as required for all employees who are employed in the Commonwealth of Virginia. 1. A complete and accurate personnel file, as outlined in Policy #207 and in accordance with 12VAC5-371-140-E of the Administrative Code of Virginia, will be created for each new employee which contains the basic demographic and indicative data needed for employment, as well as: a. A criminal history check of the Central Criminal Records Exchange conducted via Virginia State Police Non-Criminal Justice Interface (NCJI) in accordance with 32.1-126.01 of the Code of Virginia .
2. For Resident #53, the facility staff failed to prevent the resident from being abused by a staff member. After being made aware of the allegation, the facility staff failed to take measures to protect the Resident #53 from their alleged perpetrator, which permitted the staff member to abuse the resident again.
On 09/26/2023, during a clinical record review of Resident #53's clinical chart, the following was noted:
a. Resident #53 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact.
b. A progress note dated 08/10/2023 at 5:06 p.m. stated, Patient sent to Saint Mary's for evaluation r/t [related to] alleged assault, MD [medical doctor] made aware. Patient verbalized understanding the reason for transfer.
c. Another progress note dated 08/10/2023 at 5:15 p.m. read, Patient made a statement in regard to an assault that took place this morning, a statement was given from patient to myself dictated at 2:11 PM at the south unit nursing station. Phone call placed to nonemergency services so patient could give an official statement and press charges.
On 09/27/2023, a review was conducted of the facility's documentation regarding the events involving Resident #53. There was a written statement taken from Resident #53 that read, Statement of [Resident #53's name redacted] patient stated that while he was asleep, he was awakened by a washcloth being placed on his face, he then heard a voice say, can you see me? Patient then says in return, I am not blind. Patient states the CNA [certified nursing assistant/CNA C] then pulled off his sheets and undid his brief and began flicking his penis back and forth. Patient states the CNA then stated he was going to shave his pubic hairs. Patient stated he began to yell out for help, which caused the CNA to abruptly stop, then pick the patient up and throw him in the chair. Patient then restated all of the above details to the speech therapist.
On 09/27/2023 at 11:26 a.m., an interview was conducted with the facility Director of Nursing (DON), with the Administrator and survey team present. The DON was asked about the incident involving Resident #53 and CNA C. The DON reported, On 8/10 when I came in the speech therapist (SLP) came and talked with me 8:30 a.m., and gave me a service concern and said she saw Resident #53 and he reported that a CNA had touched him inappropriately. I went and talked with him [Resident #53] and he said when he did foley care it was discomfort. Then at noon he said the CNA had put a washcloth over his face and he was flicking his penis back and forth. He could not give a name or describe the person, we had one male CNA working that day, she identified as [CNA C's name redacted]. I asked him [Resident #53] if he wanted to be sent out, he said yes. The DON stated she had CNA C sent home prior to her arrival at the facility early that morning due to performance issues, prior to her knowledge of the allegation involving Resident #53. However, it was later determined that CNA C had not been removed from the premises until over 5 hours following the initial incident.
On 09/27/2023 at 12:10 p.m., an interview was conducted with Employee M, the Speech Language Pathologist (SLP). The SLP reported on 08/10/2023, she arrived to work at 7:50 a.m., and as she walked down the hall, Resident #53 got her attention and reported, the aide [CNA C] had put a washcloth on his face and he had touched his penis. I told the nurse. The SLP stated at about 9:30 a.m. in the dining room, she saw Resident #53 being fed by the CNA who had allegedly abused the resident earlier that morning. The SLP said, I saw his [Resident #53] mouth was stuffed full of food, and I saw that was way too much and he [CNA C] was getting ready to put more in his mouth. I had the Resident spit it out and said that's why too much and it was the wrong diet texture, he [CNA C] said that's what they sent. I had to take over feeding the Resident. The SLP reported that she reported this incident to nursing leadership and her immediate supervisor. Later that day, she saw CNA C still in the facility/in passing in the hall. She was not sure of the time. The SLP said she reported the events to the Director of Nursing and wrote a statement regarding the events involving Resident #53 and CNA C. On 9/27/23, Surveyors D and F attempted to interview Resident #53, but the resident was not available for interview.
On 09/28/2023 at 3:00 p.m., Surveyors D and F visited Resident #53 in his room. Resident #53 gave the same accounting of events that were in the written statement referenced earlier. There was no change in his report. The resident became very tearful and stated he was so afraid and that CNA C laid me flat in the chair on my back and was trying to silence me and say I choked on food. Resident #53 said, [Employee M's name redacted] took a picture. The resident stated that following this incident he was afraid to sleep, kept looking around, and had to be prescribed Trazadone so he could sleep. When asked how all of this made him feel, Resident #53 said, Like I wanted to leave here, I was scared, I can't move, I was afraid I was going to choke, he was trying to silence me so he could say I choked. I watched all the time. This was harm.
An additional review of the clinical record revealed that Resident #53 was ordered Trazodone 50 mg tablet to be given at bedtime for sleep aid on 08/23/2023.
On the afternoon of 09/29/2023, an interview was conducted with the scheduler, who stated on the afternoon of 08/10/2023, she was told by the Director of Nursing to send CNA C home, due to complaints and work performance. Review of payroll records revealed that CNA C did not clock out and leave the premises on 08/10/2023 until 1:17 p.m.
A review was conducted of the facility's abuse policy titled, Abuse/Neglect/Misappropriation/Crime/Administrative Reference Guide. Excerpts from this policy read, 1. Physical abuse: b. physical contact intentionally or through recklessness that results in, or is likely to result in, death, physical injury, pain, or psychological harm to the patient. Indications of psychological harm include a noticeable level of fear, anxiety, agitation, or emotional distress in the patient. 3. Sexual Abuse: a. sexual harassment, inappropriate touching.
The policy titled, Abuse/Neglect/Misappropriation/Crime/ Patient Protection, was reviewed. This policy read, There is a zero tolerance for mistreatment, abuse, neglect, misappropriation of property, or any crime against a patient of the Health and Rehabilitation Center. 1. Patients of the center have the legal right to be free from verbal, sexual, mental, and physical abuse, corporal punishment. 2. Any employee and/or covered agent of the Center, who willfully abuses . or participates in any criminal activity against any patient of the center will be immediately subjected to corrective action.
3. For Resident #53, the facility staff failed to report and investigate allegations of abuse.
On 09/27/2023, a review was conducted of the facility's documentation of the allegation and actions taken regarding Resident #53 and the incidents with CNA C. There was a written statement taken from Resident #53. There was also a written statement from Employee M, the Speech Language Pathologist (SLP). Lastly there was evidence the state survey agency/Office of Licensure and Certification (OLC) and Adult Protective Services (APS) were faxed a report of the incident on 08/10/2023 at 7:10 p.m. There was no evidence that an investigation into the allegations was conducted.
The report submitted to the OLC and APS lacked significant information regarding Resident #53's allegations involving CNA C. The details of being awakened by a washcloth being put across his face, saying he was going to shave the resident's pubic hair, and the details of the aggressive feeding were all omitted from the report.
On 09/27/2023 at 11:26 a.m., an interview was conducted with the facility's Director of Nursing (DON), with the Administrator and survey team present. The DON was asked about the incident involving Resident #53 and CNA C. The DON reported, On 8/10 when I came in the speech therapist (SLP) came and talked with me 8:30 a.m. and gave me a service concern and said she saw Resident #53 and he reported that a CNA had touched him inappropriately. I went and talked with him [Resident #53] and he said when he did foley care it was discomfort. Then at noon he said the CNA had put a washcloth over his face and he was flicking his penis back and forth. He could not give a name or describe the person, we had one male CNA working that day, which she identified as [CNA C's name redacted]. I asked him [Resident #53] if he wanted to be sent out, he said yes. The DON stated that she had CNA C sent home prior to her arrival at the facility early that morning due to performance issues, prior to her knowledge of the allegation involving Resident #53.
During the above interview, the DON was asked to explain what steps were taken to investigate the allegation and if she had any additional documentation regarding an investigation. The DON stated she had interviewed other residents and reviewed the hospital records of Resident #53. Because there was no forensic evidence, she unsubstantiated the allegation. The DON was asked to provide evidence of the resident interviews she conducted, and she said she had nothing to provide.
When asked if staff, including but not limited to CNA C, were interviewed, the DON indicated none of the staff were interviewed. The facility had no evidence of any investigation being conducted.
A review was conducted of the facility's abuse policy titled, Abuse/Neglect/Misappropriation/Crime/Reporting Requirements/Investigations. Excerpts from this policy read, 2. The Administrator and/or Director of Nursing will immediately initiate a thorough internal investigation of the alleged/suspected occurrence. The investigation protocol will include, but not be limited to, collecting evidence, interviewing alleged victims and witnesses, and involving other appropriate individuals, agents, or authorities to assist in the process and determinations.
Immediate Jeopardy (IJ) was identified on 09/27/2023 at 5:25 p.m., at which time the facility's Administrator and Director of Nursing were made aware.
On 10/02/2023 at 3:30 p.m., the facility submitted an accepted IJ removal plan and on 10/04/2023, submitted a revised plan which read as follows:
1. 9/27/23: Resident #103 reported an allegation of abuse on 8/10/2023 and FRI submitted regarding resident #85.
2. 9/27/23: FRI submitted for an allegation of abuse on 8/10/2023 involving resident #53 and #85. Physician, responsible party, and police notified, and case assigned to detective [NAME].
3. The identified CNA, [Name redacted], removed from schedule on 8/10/2023 and no longer permitted in the center.
4. 9/28/2023: [Name redacted] license (CNA) reported to the board of nursing.
5. 9/28/2023: Facility personnel educated on the abuse policy to identify, protect, report, and investigate allegations of abuse prior to working.
6. 9/27/2023: New hires educated on abuse policy prior to working.
7. 9/27/2023: Regional Director of Human Resources reviewed all personnel files to verify Virginia State Police (VSP) background checks.
8. 10/2/2023: Employees with pending VSP background check clearances removed from the schedule.
9. 9/27/2023: Regional Human Resources educated Administrator and managers on screening employees and VSP background checks clearance.
10. 9/27/2023: The facility educated all personnel on protecting, reporting, investigation, screening employees, and adhering to a mandated reporting procedure.
11. 9/27/2023: The facility interviewed residents to determine if there was any other allegation of abuse.
12. 9/27/2023: skin checks completed on residents who could not be interviewed to determine any signs of abuse.
13. 9/27/2023: The facility completed a comprehensive audit of all FRIs and service concerns that occurred from January 2023 up to the present to ensure no other case of abuse existed.
14. 9/27/2023: The facility identified an allegation of abuse involving a receptionist, and resident #103.
15. Receptionist suspended pending an investigation. A FRI sent to the Office of Licensure and Certification on 9/26/2023.
16. The implementation deadline of this immediacy removal plan is October 2, 2023, by 3:20 PM.
On 10/02/2023, the facility's administration submitted to the survey team credible evidence of the IJ immediacy removal plan. Included in the documents was documentation of Direct Supervision, which indicated that employees without a criminal background check clearance would be permitted to work under the direct supervision of a staff member with a criminal background clearance. The survey team notified the facility's administration that this was not permissible, and that each employee had to have a criminal background check clearance to work beyond 30 days of employment.
On 10/03/2023, the survey team attempted again to verify the facility staff had implemented their approved IJ immediacy removal plan. Staff interviews were conducted with facility staff from various departments to ensure they were aware of what abuse is, how to respond and protect residents in the event of abuse, and that they were mandated reporters.
The survey team obtained a resident census listing and cross checked to ensure that residents who could be interviewed had been interviewed, and residents who could not be interviewed had a head-to-toe assessment. There was one resident identified that had not been interviewed or assessed for signs of abuse.
The survey team reviewed the employee audits and identified that the contracted dietary, housekeeping, and laundry staff had not been audited to ensure they had a criminal background check from the Virginia State Police that indicated they were free from any barrier crimes.
On 10/03/23 at 4:40 p.m., the facility Administrator and corporate staff were made aware that the survey team had been unable to verify abatement.
On 10/04/2023, the survey team returned to the facility for them to attempt to abate IJ. The facility staff provided the survey team with a head-to-toe assessment for the resident that had previously not been assessed for signs and symptoms of abuse. Additionally, the team reviewed the employee record audit and noted that the contracted staff were now listed. However, the audit indicated that Staff #24, who was a cook, was noted as having had a criminal background check. It had previously been noted as recently as 10/03/2023, Staff #24 did not have a criminal background check on-file at the facility and his status regarding barrier crimes and his criminal record remained unknown. In addition, 2 agency staff members were noted on the current working schedule for the day and there was not any evidence provided to indicate they had been screened for criminal records.
On 10/04/2023 at approximately 10:00 a.m., the facility's Administrator was again made aware that they were unable to abate IJ.
On 10/04/2023 at 10:40 a.m., the facility's Administrator returned with a revised audit which correctly reflected that Staff #24 did not have a criminal record on file. The audit verified that employees without a criminal background check had been removed from the schedule and were not currently working. The facility's administration also provided a criminal background that was free from barrier crimes for the 2 agency staff working. The survey team confirmed IJ was abated on 10/04/2023 at 10:45 a.m.
4. For Resident #85, the facility staff failed to implement the abuse policy by reporting an allegation of sexual abuse.
On or about 08/10/2023, an allegation that a CNA shaved the pubic hair of Resident #85, who is cognitively impaired and unable to be interviewed. The allegation was reported by the CNA who cares for her and the roommate of Resident #85.
On 09/26/2023, an interview was conducted with Resident #103, who stated she knew that Resident #85 had been molested by a male CNA. She allowed the surveyors to listen to an audio recording of CNA E questioning Resident #85. According to the audio recording, CNA E could be heard saying, Why did you let that man shave you down there. Resident #85 has a Brief Interview of Mental Status (BIMS) score of 99, and stated she did not let anyone shave her to which you can hear the CNA reply, You are mighty bald down there. You got less hair than me and I was waxed. On 09/27/2023 at 1:00 p.m., an interview was conducted with CNA E who admitted that she had knowledge of the incident and that she made the nurse and the former DON aware of the incident; however, she did not report it as abuse at that time.
On 09/26/2023, an interview was conducted with the DON, who was asked if she reported the allegation of sexual abuse, and she stated that she did not find it was abuse. She stated she heard about it from Resident #103, and she did not consider it abuse. The DON stated, Coming from (Resident #103 name redacted) I don't believe it. When asked again if she followed the abuse policy, and reported to the appropriate parties, she stated she did not think it was abuse so she did not report it.
A review of the Abuse Policy read:
All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.
On 10/04/2023 during the end of day meeting, the Administrator was made aware of the findings.
No further information was provided.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility failed to protect the residents' right to be free from physical abuse and sexual a...
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Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility failed to protect the residents' right to be free from physical abuse and sexual abuse by a staff member and failed to protect the residents from continued abuse by their perpetrator, affecting 2 residents (Resident #53 and #85) in a survey sample of 48 residents, which resulted in psychosocial harm for Resident #53.
The findings included:
1. For Resident #53, the facility staff failed to protect the resident from enduring physical and sexual abuse, which resulted in psychosocial harm for the resident.
On 09/26/2023, during a clinical record review of Resident #53's clinical chart the following was noted:
a. Resident #53 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact.
b. A progress note dated 08/10/2023 at 5:06 p.m., stated, Patient sent to Saint Mary's for evaluation r/t [related to] alleged assault, MD [medical doctor] made aware. Patient verbalized understanding the reason for transfer.
c. Another progress note dated 08/10/2023 at 5:15 p.m., read, Patient made a statement in regard to an assault that took place this morning, a statement was given from patient to myself dictated at 2:11 PM at the south unit nursing station. Phone call placed to nonemergency services so patient could give an official statement and press charges.
On 09/27/2023, a review was conducted of the facility's investigation that had been performed. There was a written statement that was taken from Resident #53 that read as follows: Statement of [Resident #53's name redacted] patient stated that while he was asleep, he was awakened by a washcloth being placed on his face, he then heard a voice say, can you see me? Patient then says in return, I am not blind. Patient states the CNA [certified nursing assistant/CNA C] then pulled off his sheets and undid his brief and began flicking his penis back and forth. Patient states the CNA then stated he was going to shave his pubic hairs. Patient stated he began to yell out for help, which caused the CNA to abruptly stop, then pick the patient up and throw him in the chair. Patient then restated all of the above details to the speech therapist.
On 09/27/2023 at 11:26 a.m., an interview was conducted with the facility Director of Nursing (DON), with the Administrator and survey team present. The DON was asked about the incident involving Resident #53 and CNA C. The DON reported, On 8/10 when I came in, the speech therapist (SLP) came and talked with me 8:30 a.m., and gave me a service concern and said she saw Resident #53 and he reported that a CNA had touched him inappropriately. I went and talked with him [Resident #53] and he said when he did foley care it was discomfort. Then at noon he said the CNA had put a washcloth over his face and he was flicking his penis back and forth. He could not give a name or describe the person, we had one male CNA working that day, she identified as [CNA C's name redacted]. I asked him [Resident #53] if he wanted to be sent out, he said yes. The DON stated that she had CNA C sent home prior to her arrival at the facility early that morning due to performance issues, prior to her knowledge of the allegation involving Resident #53.
On 09/27/2023 at 12:10 p.m., an interview was conducted with Employee M, the Speech Language Pathologist (SLP). The SLP reported on 08/10/2023, she arrived to work at 7:50 a.m., and as she walked down the hall, Resident #53 got her attention and reported, the aide [CNA C] had put a washcloth on his face and he had touched his penis. I told the nurse. The SLP also stated that at about 9:30 a.m., she saw Resident #53 in the dining room being fed by the CNA who had allegedly abused Resident #53 earlier that morning. The SLP said, I saw his [Resident #53] mouth was stuffed full of food, and I saw that was way too much and he [CNA C] was getting ready to put more in his mouth. I had the resident spit it out and said that's why too much and it was the wrong diet texture, he [CNA C] said that's what they sent. I had to take over feeding the resident. The SLP reported that she reported this incident to nursing leadership and her immediate supervisor. Later that day she saw CNA C still in the facility/in passing in the hall. She was not sure of the time. The SLP said she reported the events to the Director of Nursing (DON) and wrote a statement regarding the events involving Resident #53 and CNA C. Surveyors D and F attempted to interview Resident #53 the same day, but the resident was not available for interview.
On 09/28/2023 at 3:00 p.m., Surveyors D and F visited Resident #53 in his room. Resident #53 gave the same accounting of events that were in the written statement referenced earlier. There was no change in his report. The resident became very tearful and stated he was so afraid and that CNA C laid me flat in the chair on my back and was trying to silence me and say I choked on food. Resident #53 said, [Employee M's name redacted] took a picture. The resident stated that following this incident he was afraid to sleep, kept looking around, and had to be prescribed Trazadone so he could sleep. When asked how all of this made him feel, Resident #53 said, Like I wanted to leave here, I was scared, I can't move, I was afraid I was going to choke, he was trying to silence me so he could say I choked. I watched all the time. This was harm.
An additional review of the clinical record revealed that Resident #53 was ordered Trazodone 50 mg tablet to be given at bedtime for sleep aid on 08/23/2023.
On the afternoon of 09/29/2023, an interview was conducted with the scheduler, who stated that on the afternoon of 08/10/2023, she was told by the Director of Nursing to send CNA C home, due to complaints and work performance. Review of payroll records revealed that CNA C did not clock out and leave the premises on 08/10/2023 until 1:17 p.m.
A review was conducted of the facility's abuse policy titled, Abuse/Neglect/Misappropriation/Crime/Administrative Reference Guide. Excerpts from this policy read, 1. Physical abuse: b. physical contact intentionally or through recklessness that results in, or is likely to result in, death, physical injury, pain, or psychological harm to the patient. Indications of psychological harm include a noticeable level of fear, anxiety, agitation, or emotional distress in the patient. 3. Sexual Abuse: a. sexual harassment, inappropriate touching.
The policy titled, Abuse/Neglect/Misappropriation/Crime/ Patient Protection, was reviewed. This policy read, There is a zero tolerance for mistreatment, abuse, neglect, misappropriation of property, or any crime against a patient of the Health and Rehabilitation Center. 1. Patients of the center have the legal right to be free from verbal, sexual, mental, and physical abuse, corporal punishment. 2. Any employee and/or covered agent of the Center, who willfully abuses or participates in any criminal activity against any patient of the center will be immediately subjected to corrective action.
On 09/27/2023 and 09/28/2023, the facility Administrator and corporate staff were made aware of the above findings. On 09/27/2023, the corporate staff notified the survey team they would be re-opening the investigation into the events involving Resident #53 and CNA C.
No further information was provided.
2. For Resident #85, the facility staff failed to ensure the resident's right to be free from sexual abuse.
On 09/26/2023, an interview was conducted with Resident #103, who stated she knew that on 08/10/2023 Resident #85 had been molested by a male CNA. She allowed the surveyors to listen to an audio recording of CNA E questioning Resident #85. According to the audio recording, CNA E could be heard saying, Why did you let that man shave you down there. Resident #85 stated that she did not let anyone shave her to which you can hear the CNA reply You are mighty bald down there. You got less hair than me and I was waxed.
On 09/27/2023 at 1:00 p.m., an interview was conducted with CNA E who admitted that she had knowledge of the incident and that she made the nurse on duty and the DON aware of the incident.
On 09/27/2023 an interview was conducted with the DON who stated she did not view it as abuse and stated. Coming from [Resident #103] she was not inclined to believe her. When asked what she was supposed to do with allegations of abuse, she stated she should investigate them. When asked what she should do first, she repeated Investigate them. The DON was advised that facilities are to report first and complete the investigation is second. The DON was also advised to review the facility's policy and the State Operations Manual (SOM) on abuse reporting.
The incident was not reported nor investigated until 09/27/2023 (2 days after the survey began). The incident was reported to the Office of Licensure and Certification, Adult Protective Services, the Department of Health Professions, and the Police by the Regional Director of Clinical Services.
On 10/04/2023 during the end of day meeting, the Administrator was made aware of the concerns.
No further information was provided.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0699
(Tag F0699)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and facility documentation, the facility staff failed to ensure that re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and facility documentation, the facility staff failed to ensure that residents who are trauma survivors receive trauma-informed care to mitigate triggers for 2 residents (Residents #22 and #53) in a survey sample of 48 residents.
The findings included:
1. For Resident #53, the facility staff failed to provide trauma-informed care for a resident who has experienced sexual assault by CNA C at the facility.
Resident #53 was admitted to the facility on [DATE] with diagnoses that include but are not limited to schizoaffective disorder, hemiplegia after CVA (Cerebrovascular Accident or stroke) right sided, HIV (Human Immunodeficiency Virus), Hepatitis C, and Hypertension.
A review of the clinical record revealed the following:
8/10/2023 5:06 pm Transfer to Hospital Summary Note Text: Patient sent to [Hospital Name redacted] for evaluation r/t alleged assault, MD made aware. Patient verbalized understanding the reason for transfer.
8/10/2023 - 5:15 pm Health Status Note Text: Patient made a statement in regard to an assault that took place this morning, a statement was given from patient to myself dictated at 2:11 pm at the south unit nursing station. Phone call placed to nonemergent services so patient could give an official statement and press charges.
8/12/2023 4:51 - Alert Note Text: Due to safety concerns r/t behavioral issues; constant yelling and threatening staff to throw himself out of the bed when in room/bed. Administration made aware to possibly consider moving room closer to nurses' station.
8/15/2023 2:41 pm COMMUNICATION - with Resident Note Text: [name redacted] and [name redacted] spoke with [Resident #53] about his feelings today 8/15/23. Therapy reported that [Resident #53] wants to harm self, to which [Resident #53] admitted . [Resident #53] says that he can come up with a plan to harm himself [name redacted] made Dr. [name redacted] (psych) aware.
8/17/2023- 5:50 AM - Health Status Note-Note Text: Per reports, resident was suicidal during the day shift. Hourly checks done on resident throughout the shift, resident stated he had no plan or intention to commit suicide. During multiple encounter, resident was noted to be impatient, combative towards staff such as throwing water at care staff or yelling for not providing him with his needs as soon as he asked for them. Nurse provided education that he needs to give staff time to respond, also he needs to communicate with his words rather than violently/physically attempting to hit staff. Incontinent care provided every 2 hours and as needed, fall precautions followed and maintained, he is stable and resting in bed at this time.
On 09/27/2023 and interview was conducted with the DON who was asked if they have psych services in the building and she stated that they did. When asked if she thought it would be beneficial for Resident #53 to have seen psych services after such an incident, she stated that she thought he did and would supply the notes from psych services.
A review of the clinical record revealed that Resident #53 had an order dated 08/01/2023 that read, Psych Consult as needed however, was not seen by psych services until 08/23/2023. The visit on 08/23/2023 was not prompted by the sexual assault. A review of the psych notes revealed the following:
Resident was referred today for stabilization in depressed mood. Per nurses' notes and report, resident is reported to be verbally abusive to staff, and refusing care sometimes, Resident was met in his room, in bed, calm, alert, speech clear and engaged. Resident reported in on multiple psychotropic medications to include Lithium, Haldol, Risperidone, Diazepam, Ativan, Methadone, Seroquel, Hydroxyzine and Trazadone. Reported he has not been sleeping well a night. I stay awake the whole night; I cannot sleep. Resident also reported he feels sad and depressed.
On 08/23/2023 after the psych visit, the order was given for Trazadone 50mg for insomnia.
On 09/28/2023 at 11:00 a.m., an interview was conducted with the Staff Development Coordinator who was asked about training for PTSD, she stated they do not tell me to train on that subject. When asked if she trained on trauma-informed care, she stated that she did not. When asked if she trained on behavioral healthcare needs related to substance abuse, she stated that she did not. When asked does your staff care for residents in this facility with any or all those issues and she stated that they do.
On 10/04/2023 during the end of day meeting, the Administrator was made aware of the concerns.
No further information was provided.
2. For Resident #22, the facility staff failed to provide trauma-informed care for a resident diagnosed with Post Traumatic Stress Disorder (PTSD).
Resident #22 was admitted to the facility on [DATE] with diagnoses that include but are not limited to incomplete paraplegia, PTSD, peripheral neuropathy, anxiety, history of substance abuse and smoking.
On 09/25/2023 at approximately 1:00 p.m., an interview was conducted with Resident #22 who stated the facility Does not know how to deal with us, I have PTSD and they don't know how to talk to me. When asked to elaborate, he stated the facility staff are loud and rude and that triggers him to become aggressive. When asked if he has told anyone about this, he stated he has spoken to the DON and the Administrator about it, but nothing is done. Resident #22 also stated he had a substance abuse problem prior to coming to the facility and that the facility staff use that information against me. When asked what he meant by that, he stated the facility staff downplay his pain because he had a substance abuse issue prior to coming to the facility. He stated the staff have labeled him as drug seeking.
On 09/28/2023 at 11:00 a.m., an interview was conducted with the Staff Development Coordinator who was asked about training for PTSD, she stated they do not tell me to train on that subject. When asked if she trained on trauma-informed care, she stated that she did not. When asked if she trained on behavioral healthcare needs related to substance abuse, she stated that she did not. When asked does your staff care for Residents in this facility with any or all those issues and she stated that they do.
On 10/04/2023 during the end of the day debriefing, the Administrator was made aware of the concerns.
No further information was provided.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0726
(Tag F0726)
A resident was harmed · This affected 1 resident
Based on resident interview, staff interview, and facility documentation review, the facility failed to ensure 5 of 5 nursing staff members (Staff #6, Staff #21, Staff #22, Certified Nursing Assistant...
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Based on resident interview, staff interview, and facility documentation review, the facility failed to ensure 5 of 5 nursing staff members (Staff #6, Staff #21, Staff #22, Certified Nursing Assistant [CNA]-H and CNA-K) in the sample were competent to provide care to the facility's resident population, resulting in psychological harm for Resident #22.
Findings included:
The facility staff failed to ensure nursing staff had the competencies including knowledge, skills, and abilities, necessary to meet the resident's needs when diagnosed with trauma/Post-traumatic Stress Disorder (PTSD) in accordance with the facility assessment, resulting in expression of psychological harm for Resident #22.
During the initial tour of the facility on 09/25/2023 at 11:50 a.m., Resident #22 approached the surveyors (Surveyor C and Surveyor D) and stated he had PTSD, and the facility staff did not know how to take care of people diagnosed with PTSD. Resident #22 stated he was upset about it. He stated he really was diagnosed with PTSD. They (facility staff) act like they don't know how to handle it (PTSD). Resident #22 stated the staff treated him as if he was pretending. Resident #22 stated this is serious. The resident stated he did not feel understood by the staff. Resident #22 discussed his feelings more in depth with Surveyor D during the survey.
On 09/26/2023 at 9:05 a.m., an interview was conducted with Licensed Practical Nurse B who stated there were residents in the facility who had diagnoses of PTSD and other behavioral health conditions. LPN-B stated she had not received specialized training on caring for residents with trauma/PTSD.
On 09/27/2023 at 12:55 p.m., an interview was conducted with Certified Nursing Assistant-L who stated she had not received any special training on caring for residents with trauma/PTSD.
Review of the Facility Assessment revealed a review date of 08/31/2023. The facility assessment, Part 2. Services and Care Offered Based on Resident Needs (on page 1 of 2) Section 2.1 General Care and Specific Care or Practices listed the general care area of Mental Health and Behavior and under Specific Care or Practices was written, Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with .trauma/PTSD, other psychiatric diagnoses .
On 09/27/2023 at 2:15 p.m., an interview was conducted with the Staff Development Coordinator who stated she provided in-service education and training to the facility staff members. The Staff Development Coordinator stated staff members also complete computer-based training on required subjects. She stated she was aware the facility accepted residents for admission who were diagnosed with behavioral health issues to include but not limited to mental, psychosocial, or substance use disorder, a history of trauma and/or post-traumatic stress disorder, or other behavioral health condition and dementia according to the facility assessment. The Staff Development Coordinator stated the facility assessment was utilized to ensure residents could receive the care and services necessary for their well-being. The Staff Development Coordinator stated she was not told to include trauma/PTSD in the training topics but would immediately begin to train on that topic.
Review of the 5 sampled employee training records revealed no documentation of training on trauma/PTSD. All 5 staff members were hired in 2022 or 2023 (Staff #6 LPN hired in 2023, Staff #21 hired in 2022, Staff #22 hired in 2022, CNA-H hired in 2023 and CNA-K hired in 2022).
During the end of day debriefing on 09/27/2023, the facility Administrator, Director of Nursing, and Corporate Nurse Consultant were informed of the findings of no behavioral health training on trauma/PTSD. They were informed that none of its staff members had received any training/education or met competencies regarding the provision of care to residents diagnosed with trauma/PTSD. The residents' needs were not being met in order for them to reach their highest potential.
On 09/28/2023, the Staff Development Coordinator provided a copy of the training curriculum including topics covered during orientation and training sessions. Review of the curriculum revealed there was no documentation of the topic of trauma/PTSD (Post-traumatic Stress Disorder.
During the end of day debriefing on 10/03/2023, the facility Administrator, Director of Nursing, Corporate Nurse Consultant, and [NAME] President of Operations were informed of the findings. They were informed by Surveyor D that one resident expressed feelings of psychosocial harm.
No further information was provided.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0742
(Tag F0742)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and facility documentation, the facility staff failed to ensure residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and facility documentation, the facility staff failed to ensure residents who display or are diagnosed with mental disorder, or history of Post-traumatic Stress Disorder (PTSD) receives appropriate treatment and services to attain the highest practical mental and psychosocial well-being for 1 resident (Resident #53) in a survey sample of 48 residents.
The findings included:
For Resident #53, the facility staff failed to ensure the resident received appropriate services post sexual assault by a staff member at the facility.
Resident #53 was admitted to the facility on [DATE] with diagnoses that include but are not limited to schizoaffective disorder, hemiplegia after CVA (Cerebrovascular Accident or stroke) right sided, HIV (Human Immunodeficiency Virus), Hepatitis C, and Hypertension.
A review of the clinical record revealed the following:
8/10/2023 5:06 pm Transfer to Hospital Summary Note Text: Patient sent to [hospital Name redacted] for evaluation r/t alleged assault, MD made aware. Patient verbalized understanding the reason for transfer.
8/10/2023 - 5:15 pm Health Status Note Text: Patient made a statement in regard to an assault that took place this morning, a statement was given from patient to myself dictated at 2:11 pm at the south unit nursing station. Phone call placed to nonemergent services so patient could give an official statement and press charges.
8/12/2023 4:51 -Alert Note Text: Due to safety concerns r/t behavioral issues; constant yelling and threatening staff to throw himself out of the bed when in room/bed. Administration made aware to possibly consider moving room closer to nurses' station.
8/15/2023 2:41 pm COMMUNICATION - with Resident Note Text: [name redacted] and [name redacted] spoke with [Resident #53] about his feelings today 8/15/23. Therapy reported that [Resident #53] wants to harm self, to which [Resident #53] admitted . [Resident #53] says that he can come up with a plan to harm himself [name redacted] made Dr. [name redacted] (psych) aware.
8/17/2023- 5:50 AM -Health Status Note-Note Text: Per reports, resident was suicidal during the day shift. Hourly checks done on resident throughout the shift, resident stated he had no plan or intention to commit suicide. During multiple encounter, resident was noted to be impatient, combative towards staff such as throwing water at care staff or yelling for not providing him with his needs as soon as he asked for them. Nurse provided education that he needs to give staff time to respond, also he needs to communicate with his words rather than violently/physically attempting to hit staff. Incontinent care provided every 2 hours and as needed, fall precautions followed and maintained, he is stable and resting in bed at this time.
On 09/27/2023, an interview was conducted with the DON who was asked if they have psych services in the building and she stated they did. When asked if she thought it would be beneficial for Resident #53 to have seen psych services after such an incident, she stated she thought he did and would supply the notes from psych services.
A review of the clinical record revealed that Resident #53 had an order dated 08/01/2023 that read Psych Consult as needed; however, the resident was not seen by psych services until 08/23/2023. The visit on 08/23/2023 was not prompted by the sexual assault. A review of the psych notes revealed the following:
Resident was referred today for stabilization in depressed mood. Per nurses' notes and report, resident is reported to be verbally abusive to staff, and refusing care sometimes, Resident was met in his room, in bed, calm, alert, speech clear and engaged. Resident reported in on multiple psychotropic medications to include Lithium, Haldol, Risperidone, Diazepam, Ativan, Methadone, Seroquel, Hydroxyzine and Trazadone. Reported he has not been sleeping well a night. I stay awake the whole night; I cannot sleep. Resident also reported he feels sad and depressed.
On 08/23/2023 after the psych visit, the order was given for Trazadone 50mg for insomnia.
On 09/28/2023 at approximately 3:00 p.m., Resident #53 was interviewed about the incident on 08/10/2023 involving the sexual assault by CNA C. Resident #53 stated that he was afraid to have male staff anymore. He stated he was unable to sleep at all after the incident and was prescribed Trazadone as a result. Resident #53 was in tears when explaining how the incident made him feel helpless and fearful because he has contractures that prevent him from defending himself. Resident #53 stated he was aware the CNA would no longer be in the building but still did not want any male CNA staff to work with him. When asked if he was provided with emotional support or psych services immediately following the incident, he stated that he did not.
On 10/04/2023 during the end of day meeting, the Administrator was made aware of the concerns.
No further information was provided.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0838
(Tag F0838)
A resident was harmed · This affected 1 resident
Based on resident interview, staff interview, and facility documentation review, the facility staff failed to update the facility assessment to assess the needs of its resident population, the require...
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Based on resident interview, staff interview, and facility documentation review, the facility staff failed to update the facility assessment to assess the needs of its resident population, the required resources to provide the care and services the residents need resulting in expression of psychological harm by one resident (Resident #22) in the survey sample of 46 residents.
Findings included:
The facility failed to develop and implement a plan to provide care and services to include education, training, and competencies related to the care of residents diagnosed with Post-traumatic Stress Disorder (PTSD) resulting in one resident (Resident # 22) expressing psychological harm.
On 09/25/2023 at 11:50 a.m. during the initial tour of the facility, Resident #22 approached the surveyors (Surveyor C and Surveyor D) and stated he had Post-traumatic Stress Disorder (PTSD), and the facility staff Did not know how to take care of people diagnosed with PTSD. Resident #22 stated he was upset about it. He stated he really was diagnosed with PTSD. They (facility staff) act like they don't know how to handle it (PTSD). Resident #22 stated the staff treated him as if he was pretending. Resident #22 stated, this is serious. Resident #22 stated he did not feel understood by the staff. The resident discussed his feelings more in depth with Surveyor D during the survey.
On 09/26/2023, the Facility Assessment was reviewed by Surveyor C. Review of the Facility Assessment revealed the Assessment was updated on 08/31/2023 and reviewed with Quality Assurance Assessment/Quality Assurance Performance Improvement (QAA/QAPI) committee on 09/26/2023.
On 09/27/2023, an interview was conducted with the Staff Development Coordinator who stated she was responsible for the education of the employees. The Staff Development Coordinator stated she did not provide any training on behavioral health to include Post-traumatic Stress Disorder because she was not aware of the requirement to provide that training to the staff members. She stated she had not been told that particular training was required. When asked if staff members were expected to know how to provide care for the residents accepted in the facility, the Staff Development coordinator stated yes.
Resident #22 reported the facility staff did not know how to take care of him with his diagnosis of PTSD. Resident #22 reported experiencing undue stress related to the staff not taking him seriously.
During the end of day debriefing on 09/27/2023, the Facility Administrator, Director of Nursing, and Corporate Nurse Consultant were informed that the Facility Assessment stated the facility accepted residents with behavioral health diagnoses. The Facility Assessment did not address education/training and competencies resources for behavioral health to include Post-traumatic Stress Disorder.
On 10/03/2023 during the end of day debriefing, the Facility Administrator, Director of Nursing, Corporate Nurse Consultant, and Regional [NAME] President of Operations were informed of the findings.
No further information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0553
(Tag F0553)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff fail...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure the residents' right to participate in care planning for 1 resident, Resident #48, in a survey sample of 48 residents.
The findings included:
For Resident #48, the facility staff failed to provide the opportunity for her to participate in her own care planning.
On 09/26/2023 at approximately 9:30 a.m., an interview was conducted with Resident #48, and she was asked if she participated in the planning of her care at the facility, to which Resident #48 replied, I have never been asked or invited to attend any meetings about my care here, I would like to be involved.
On 09/28/2023 at approximately 11:30 a.m., a review of Resident #48's clinical record was performed and revealed the most recent Minimum Data Set (MDS), a quarterly review with an Assessment Reference Date (ARD) of 08/24/2023, coded Resident #48 with a Brief Interview of Mental Status (BIMS) score of 12 out of 15, indicating moderate cognitive impairment. Resident #48 was documented as her own Responsible Party.
Review of the clinical record also revealed a comprehensive care plan for Resident #48; however, there was no documentation indicating that Resident #48 was invited to participate with care plan meetings. There was an admission note dated 04/18/2023 that read, Family notified about jumpstart [care plan] meeting, she [family member] said that she would be unable to attend .
On 10/2/2023 at approximately 1:30 p.m., an interview was conducted with the Facility Administrator and Regional Clinical Nurse (RCN) which included a review of Resident #48's clinical record. The RCN verified there was no evidence that Resident #48 had been invited to participate in her care planning since her admission on [DATE]. The Facility Administrator stated, [Name redacted, Resident #48] should have been invited to attend any meetings about her plan of care, I expect those efforts to be documented in her clinical record and that has not been done. A facility policy was requested and received.
The facility policy entitled, Resident Assessment & Care Planning, effective date 11/01/2019, subheading Procedure, item 7, read, The MDS Coordinator or designee will be responsible for inviting the patient and the family to the conference utilizing the MFA Resident Care Planning Invitation form . and item 9 read, Notes will be kept for each patient's care plan discussed at the conference. A designated staff member attending the conference will include an electronic progress note summarizing the conference and stating all who attended, including the patient and any family members who were present.
On 10/02/2023, the Facility Administrator was made aware of the findings. No further information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
Based on interview, clinical record review, and facility documentation the facility staff failed to ensure the resident's right to choose healthcare providers, for 1 resident, Resident #22, in a surve...
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Based on interview, clinical record review, and facility documentation the facility staff failed to ensure the resident's right to choose healthcare providers, for 1 resident, Resident #22, in a survey sample of 48 residents.
The findings included:
For Resident #22, the facility staff failed to schedule an appointment with the Pain Management Clinic as requested by the resident and ordered by the physician.
On 09/25/2023 at approximately 3:00 p.m., Resident #22 requested to speak to this surveyor. Resident #22 had previously been interviewed about issues at the facility and wanted to add one more thing. The resident stated he had inquired with the Medical Director about pain medicine (Oxycodone) that he used to take and was discontinued, and wanting to restart that medication. Resident #22 stated the Medical Director told him it would be better if he would see a pain management clinic and wrote a referral to the pain management clinic in the chart. Resident #22 stated this happened months ago, and he still has not been told about an appointment. A review of the clinical record revealed this was written in the progress notes by the physician on 07/28/2023.
A review of the clinical record revealed the following progress note:
9/15/2023 2:57 pm -COMMUNICATION- Note Text: Spoke with resident and the MD explained to him that his paperwork had been faxed over to a pain management clinic on 9/11/23 and that I was waiting for a return call. I called on 9/15/23 to the pain management clinic and spoke with them and I was made aware that the paperwork had been received and that it is still under review, and they will call patient once the review is completed.
On 09/26/2023 at approximately 10:30 a.m., an interview was conducted with Employee R, who schedules appointments for residents. She stated it was documented in her book where the appointment was requested on 09/11/2023. She stated she was aware that the appointment was requested in July; however, she had been out of work and did not get the original referral. Also, she did not know of the request until 09/11/2023 and she called the pain management clinic at that point.
On 10/04/2023 during the end of day meeting, the Administrator was made aware of the concerns. No further information was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and facility documentation, the facility staff failed to act promptly u...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and facility documentation, the facility staff failed to act promptly upon the grievances arising from Resident Council.
The findings included:
Resident council continues to have complaints of the same nature with no improvement month after month. The facility has not effectively addressed the concerns of the residents regarding quality of food, timeliness of medication administration, timely incontinence care, poor staff attitudes, and cleanliness of the building.
A review of the Resident Council minutes revealed the following:
March 2023 - Residents complained that staff have bad attitudes, medication not given in a timely manner, CNAs not providing care to dependent residents routinely during the day and night.
April 2023 - Staff are rude, staff are loud at night, staff are using cell phones while providing incontinent or ADL care, diets are not being followed, and the dietary staff are rude.
May 2023 - Floors, bathrooms, and sinks are not cleaned properly, alternate meals and/or sandwiches not offered, staff continue to be rude, no snacks offered at night, and retaliation of staff.
June 2023 - Staff are loud at night, staff not checking/changing dependent residents, CNAs and nurses respond with I don't have you when asking for something, snacks not available at night, and CNAs not rounding.
July 2023 - Food has not improved, staff continue to be rude, medications are unavailable or not ordered timely, and tray tickets do not match tray items.
August 2023 - Medication times, rude staff, using phone while providing care, food items on tray do not match ticket, wrong diets served, and rooms and bathrooms had not been cleaned.
On the afternoon of 09/28/2023, an interview was conducted with Employee S (Activities Director) who stated that each department is given the feedback from Resident Council to address within their department. When asked if she noticed the same issues keep arising month after month, she stated she did see a pattern. She also stated that all staff have been having education on customer service.
The following are excerpts from a Facility Reported Incident that occurred on 04/27/2023. The incident was reported to the Office of Licensure and Certification by the facility Administrator:
[Resident name redacted] is an [AGE] year old resident with a BIMS [Brief Interview of Mental Status] of 15 [indicating no cognitive impairment]. H admitted to the facility on [DATE]
[Resident name redacted] alleged that CNA [name redacted] cursed at him saying Kiss my ass! after answering his call bell, left the room then returned repeating the same verbal allegation.
Based on the findings of the allegations regarding abuse/mistreatment regarding [Resident name redacted] and [CNA name redacted] substantiated. CNA [Name redacted] has been terminated. Staff will be educated on abuse and neglect.
On 10/04/2023 during the end of day meeting, the Administrator was made aware of the concerns. No further information was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on clinical record review, staff interview, and facility documentation review, the facility staff failed to notify the responsible party of a change in condition for 1 Resident, Resident #362, i...
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Based on clinical record review, staff interview, and facility documentation review, the facility staff failed to notify the responsible party of a change in condition for 1 Resident, Resident #362, in a sample size of 48 Residents.
The findings included:
For Resident #362, facility staff failed to notify the responsible party/family of a change in his condition on 07/20/2023.
On 10/02/2023 at approximately 3:00 p.m., Resident #362's clinical record was reviewed in its entirety with particular attention given to physician's orders, nursing assessments, and progress notes. A progress note dated 07/20/2023 at 7:34 p.m. documented, Resident's daughter [name redacted] upset upon arrival to visit her father, nurse informed her residents blood pressure was elevated approx. noon time today, Resident pcp notified of elevation and medicated as directed, family was not notified of change in condition, daughter request that resident be transferred to hospital for evaluation, pcp notified of request, resident was taken to the ER via EMS.
On 10/02/2023 at 4:15 p.m., the Clinical Nurse Consultant (CNC) was interviewed and stated, It is my expectation and facility policy that both the doctor and family are notified if a resident experiences a change in their condition, always.
Review of the facility policy titled, Significant Change in Condition, with an effective date of 11/01/2019, Procedure, item 4 read, Responsible party will also be notified of a change in condition and item 9, Notification of responsible party shall be documented in the progress notes including time and name of person informed.
On 10/02/2023 at the end of day meeting, the Facility Administrator and CNC were updated on the findings. No further information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to issue appropriate notices when skilled services were ending for 1 resident (Resident #...
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Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to issue appropriate notices when skilled services were ending for 1 resident (Resident #87) in a survey sample of 3 residents, which were all reviewed for such notices.
The findings included:
For Resident #87, the facility staff failed to issue an Advance Beneficiary Notice (ABN) when skilled services were ending.
On 09/25/2023, the facility Administrator was asked to provide a listing of residents who were discharged from Medicare Part A services. From this listing, a sample was selected which included Resident #87. The notices issued to these residents were reviewed and revealed the following:
For Resident #87, the facility staff failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) notice prior to skilled care services ending. Only a Notice of Medicare Non-Coverage (NOMNC) was issued. Resident #87 was under skilled care with Medicare Part A as the primary payer from 06/11/2023 - 07/02/2023. Upon skilled care ending, Resident #87 remained a resident of the facility; therefore, should have been issued a SNF ABN in addition to the NOMNC.
On 09/26/2023 at approximately 4:30 p.m., an interview was conducted with Employee O, the Discharge Planner. When asked to explain the purpose of the forms and when they are issued, Employee O said, They are issued before insurance is cut, to let them know when insurance is going to stop and when copays will start. Employee O further explained that when a resident stays long-term care, both the NOMNC and ABN are issued.
Employee O reviewed the notice for Resident #87 and confirmed that an Advance Beneficiary Notice should have been issued but was not.
The facility policy titled, Advanced Beneficiary Notice (ABN) was reviewed. The policy read, The Advanced Beneficiary Notice will be used to properly notify a Medicare Part A or Medicare Part B patient and/or responsible party of the clinical determination that the patient no longer meets the Medicare criteria for skilled services . 2. The Social Worker and Discharge Planner or designee issues the notice to the beneficiary or their representative in person or by telephone of the upcoming non-coverage status based on clinical team recommendations. a. This notification must be made at least 2 days in advance of non-coverage status for Part A recipients .
In the CMS document, Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN), the instruction sheet reads, .The SNFABN provides information to the beneficiary so that s/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. SNFs must use the SNFABN when applicable for SNF Prospective Payment System services (Medicare Part A) . Accessed online at: https://www.cms.gov/Medicare/Medicare-General-Information/BNI/FFS-SNF-ABN-
On 09/26/2023 during the end of day meeting, the facility's Director of Nursing and Corporate staff were made aware of the above findings.
No further information was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility failed to report allegations of abuse by a staff member involving 2 residents (Res...
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Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility failed to report allegations of abuse by a staff member involving 2 residents (Residents #53 and #85) in a survey sample of 48 residents.
The findings included:
1. For Resident #53, the facility staff failed to complete a timely and accurate report of an allegation of physical and sexual abuse by CNA C to the state survey agency, adult protective services, and law enforcement.
On 09/26/2023, during a clinical record review of Resident #53's clinical chart, the following were noted:
a. A progress note dated 08/10/2023 at 5:06 p.m. read, Patient sent to saint Mary's for evaluation r/t [related to] alleged assault, MD [medical doctor] made aware. Patient verbalized understanding the reason for transfer.
b. Another progress note dated 08/10/2023 at 5:15 p.m., stated, Patient made a statement in regard to an assault that took place this morning, a statement was given from patient to myself dictated at 2:11 PM at the south unit nursing station. Phone call placed to nonemergency services so patient could give an official statement and press charges.
On 09/27/2023, a review was conducted of the facility's documentation of the allegation and actions taken. There was a written statement that was taken from Resident #53 that read as follows: Statement of [Resident #53's name redacted] patient stated that while he was asleep, he was awakened by a washcloth being placed on his face, he then heard a voice say, can you see me? Patient then says in return, I am not blind. Patient states the CNA [certified nursing assistant/CNA C] then pulled off his sheets and undid his brief and began flicking his penis back and forth. Patient states the CNA then stated he was going to shave his pubic hairs. Patient stated he began to yell out for help, which caused the CNA to abruptly stop, then pick the patient up and throw him in the chair. Patient then restated all of the above details to the speech therapist.
There was evidence the state survey agency/Office of Licensure and Certification (OLC) and Adult Protective Services (APS) were faxed a report of the incident on 08/10/2023 at 7:10 p.m., almost 12 hours after facility management were made aware of the initial abuse allegation. Additionally, the report submitted grossly misrepresented the allegation(s) made. The report read, It was reported to Speech therapist and floor nurse by [Resident #53's name redacted], BIMS [brief interview for mental status score] 14, that the aide who took care of him touched him inappropriately, cannot give date but states not today or yesterday but the same one that worked this morning. Aide immediately sent home upon knowledge pending investigation. During Surveyor F's investigation of this incident, payroll records revealed CNA C did not leave the facility on the day of the allegations until 1:17 p.m.
On 09/27/2023 at 11:26 a.m., an interview was conducted with the facility's Director of Nursing (DON), with the Administrator and survey team present. The DON was asked about the incident involving Resident #53 and CNA C. The DON reported, On 8/10 when I came in the speech therapist (SLP) came and talked with me 8:30 a.m. and gave me a service concern. She said she saw Resident #53 and he reported that a CNA had touched him inappropriately. I went and talked with him [Resident #53] and he said when he did foley care it was discomfort. Then at noon he said the CNA had put a washcloth over his face and he was flicking his penis back and forth. He could not give a name or describe the person, we had one male CNA working that day, she identified as [CNA C's name redacted] I asked him [Resident #53] if he wanted to be sent out, he said yes. The DON stated she had CNA C sent home prior to her arrival at the facility early that morning due to performance issues, prior to her knowledge of the allegation involving Resident #53.
During the above interview, the DON was asked about the reporting of the incident. The DON was able to verbalize that reports regarding allegations of abuse are to be reported within 2 hours. When questioned about the timing of the report involving Resident #53, she did not respond as to why it was delayed.
The DON was asked about the lack of details regarding Resident #53's allegations involving CNA C, in the report submitted. The details of being awakened by a washcloth being put across his face, saying he was going to shave the resident's pubic hair and the details of the aggressive feeding were all omitted from the report. Again, the DON did not give an answer as to why those details were omitted.
When asked if the allegations against CNA C were reported to the Board of Nursing, which is the agency that certified CNA C to practice as a nursing assistant, the DON said yes, but was unable to provide any credible evidence it was reported.
On 09/27/2023 at 12:10 p.m., an interview was conducted with Employee M, the speech language pathologist (SLP). The SLP confirmed Resident #53's report of abuse was reported to her on 08/10/2023, when she arrived to work at 7:50 a.m. She also stated she immediately reported the allegation to her departmental supervisor, the nursing unit manager, and then to the Director of Nursing. On 09/27/2023, Surveyors D and F attempted to interview Resident #53, but the resident was not available for interview.
On 09/28/2023 at 3:00 p.m., Surveyors D and F visited Resident #53 in his room. Resident #53 gave the same accounting of events that were in the written statement referenced earlier. There was no change in his report. Resident #53 became very tearful, said he was so afraid, and that CNA C laid me flat in the chair on my back and was trying to silence me and say I choked on food. Resident #53 said, [Employee M's name redacted] took a picture. The resident stated following this incident he was afraid to sleep, kept looking around, and had to be prescribed Trazadone so he could sleep. When asked how all of this made him feel, Resident #53 said, Like I wanted to leave here, I was scared, I can't move, I was afraid I was going to choke, he was trying to silence me so he could say I choked. I watched all the time.
A review was conducted of the facility's abuse policy titled, Abuse/Neglect/Misappropriation/Crime/Reporting Requirements/Investigations. Excerpts from this policy read, 1. Immediately upon notification of any alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, the Administrator will immediately report to the State Agency, but not later than 2 hours after the allegation is made, if the events that caused the allegation involves abuse or results in serious bodily injury. b. Notify the Adult Protective Services Agency, the local Ombudsman, and the appropriate local law enforcement authorities (police, sheriff's office, and/or medical examiner as deemed appropriate) for any incident of patient abuse, mistreatment, neglect, or misappropriation of personal property or other reasonable suspicion of a crime. c. Notify within 24 hours the Department of Health Professions (DHP) for incidences involving nurse aides, RNs, LPNs, Physicians, or others licensed or certified by DHP.
On 09/27/2023 and 09/28/2023, the facility's Administrator and corporate staff were made aware of the above findings.
On 09/27/2023, the corporate staff notified the survey team they would be re-opening the investigation into the events involving Resident #53 and CNA C and had made an accurate report of the allegations to the required agencies/authorities.
No further information was provided.
2. For Resident #85, the facility staff failed to ensure allegations of abuse are reported within 24 hours for allegations that do not result in serious bodily injury.
On or about 08/10/2023, an allegation that a CNA shaved the pubic hair of Resident #85 who is cognitively impaired and unable to be interviewed. The allegation was reported by the CNA who cares for her and the roommate of the resident.
On 09/26/2023, an interview was conducted with Resident #103 who stated she knew that Resident #85 had been molested by a male CNA. She allowed the surveyors to listen to an audio recording of CNA E questioning Resident #85, Why did you let that man shave you down there. Resident #85 has a Brief Interview of Mental Status (BIMS) score of 99 and stated that she did not let anyone shave her, to which you can hear the CNA reply You are mighty bald down there. You got less hair than me and I was waxed. On 09/27/2023 at 1:00 p.m., an interview was conducted with CNA E who admitted that she had knowledge of the incident and that she made the nurse aware of the incident and the former DON was also made aware, however she did not report it as abuse at that time.
On 09/26/2023, an interview was conducted with the DON who was asked if she reported the allegation of sexual abuse and she stated that she did not find it was abuse. She stated she heard about it from Resident #103, and she did not consider it abuse. The DON stated, Coming from (Resident #103 name redacted) I don't believe it. When asked again if she followed the Abuse Policy and reported the incident to the appropriate parties, she stated she did not think it was abuse, so she did not report it.
A review of the Abuse Policy read:
All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.
The incident was not reported nor investigated until 09/27/2023 2 days after the survey began. The incident was reported to the Office of Licensure and Certification, Adult Protective Services, the Dept of Health Professions, and the Police by the Regional Director of Clinical Services on 09/27/2023.
On 10/04/2023 during the end of day meeting, the Administrator was made aware of the findings.
No further information was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility failed to conduct investigations of allegations of abuse by a staff member involvi...
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Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility failed to conduct investigations of allegations of abuse by a staff member involving 2 residents (Residents #53 and #85) in a survey sample of 48 residents.
The findings included:
1. For Resident #53, who reported an allegation of physical and sexual abuse by CNA C, the facility staff failed to conduct an investigation and take measures to prevent further abuse while an investigation was conducted.
On 08/10/2023, Resident #53 reported an allegation of abuse to facility staff.
On 09/26/2023, during a clinical record review of Resident #53's clinical chart the following was noted:
a. A progress note dated 08/10/2023 at 5:06 p.m., read, Patient sent to saint Mary's for evaluation r/t [related to] alleged assault, MD [medical doctor] made aware. Patient verbalized understanding the reason for transfer.
b. Another progress note dated 08/10/2023 at 5:15 p.m., stated, Patient made a statement in regard to an assault that took place this morning, a statement was given from patient to myself dictated at 2:11 PM at the south unit nursing station. Phone call placed to nonemergency services so patient could give an official statement and press charges.
On 09/27/2023, a review was conducted of the facility's documentation of the allegation and actions taken. There was a written statement that was taken from Resident #53 that read as follows: Statement of [Resident #53's name redacted] patient stated that while he was asleep, he was awakened by a washcloth being placed on his face, he then heard a voice say, can you see me? Patient then says in return, I am not blind. Patient states the CNA [certified nursing assistant/CNA C] then pulled off his sheets and undid his brief and began flicking his penis back and forth. Patient states the CNA then stated he was going to shave his pubic hairs. Patient stated he began to yell out for help, which caused the CNA to abruptly stop, then pick the patient up and throw him in the chair. Patient then restated all of the above details to the speech therapist.
There was also a written statement from Employee M, the Speech Language Pathologist (SLP). Lastly, there was evidence the state survey agency, Office of Licensure and Certification (OLC), and Adult Protective Services (APS) were faxed a report of the incident on 08/10/2023 at 7:10 p.m. There was no evidence an investigation into the allegations was conducted.
During Surveyor F's investigation of this incident, payroll records revealed CNA C did not leave the facility on the day of the allegations until 1:17 p.m., despite the initial report being made at approximately 7:50 a.m. Following that initial incident of physical and sexual abuse, CNA C then continued to provide care for Resident #53 and at 9:30 a.m., was seen aggressively feeding the resident, to the point the SLP had to intervene for the resident's safety and welfare.
On 09/27/2023 at 11:26 a.m., an interview was conducted with the facility's Director of Nursing (DON), with the Administrator and survey team present. The DON was asked about the incident involving Resident #53 and CNA C. The DON reported, On 8/10 when I came in the speech therapist (SLP) came and talked with me 8:30 AM and gave me a service concern and said she saw Resident #53 and he reported that a CNA had touched him inappropriately. I went and talked with him [Resident #53] and he said when he did foley care it was discomfort. Then at noon he said the CNA had put a washcloth over his face and he was flicking his penis back and forth. He could not give a name or describe the person, we had one male CNA working that day, which she identified as [CNA C's name redacted]. I asked him [Resident #53] if he wanted to be sent out, he said yes. The DON stated she had CNA C sent home prior to her arrival at the facility early that morning due to performance issues, prior to her knowledge of the allegation involving Resident #53.
During the above interview, the DON was asked to explain what steps were taken to investigate the allegation and if she had any additional documentation regarding the investigation. The DON stated she had interviewed other residents and reviewed the hospital records of Resident #53, and because there was no forensic evidence, she unsubstantiated the allegation. The DON was asked to provide evidence of the residents' interviews she conducted, and she said she had nothing to provide.
When asked if staff, including but not limited to CNA C, were interviewed, the DON indicated no. The facility had no evidence of any investigation being conducted.
On 09/27/2023 at 12:10 p.m., an interview was conducted with Employee M, the speech language pathologist (SLP). The SLP confirmed Resident #53's report of abuse reported to her on 08/10/2023, when she arrived to work at 7:50 a.m. She also stated she immediately reported the allegation to her departmental supervisor, the nursing unit manager, and then to the Director of Nursing. On 09/27/2023, Surveyors D and F attempted to interview Resident #53, but the resident was not available for interview.
On 09/28/2023 at 3:00 p.m., Surveyors D and F visited Resident #53 in his room. Resident #53 gave the same accounting of events that were in the written statement referenced earlier. There was no change in his report. Resident #53 became very tearful, said he was so afraid, and that CNA C laid me flat in the chair on my back and was trying to silence me and say I choked on food. Resident #53 said, [Employee M's name redacted] took a picture. The resident also stated that following this incident, he was afraid to sleep, kept looking around, and had to be prescribed Trazadone so he could sleep. When asked how all of this made him feel, Resident #53 said, Like I wanted to leave here, I was scared, I can't move, I was afraid I was going to choke, he was trying to silence me so he could say I choked. I watched all the time.
A review was conducted of the facility's abuse policy titled, Abuse/Neglect/Misappropriation/Crime/Reporting Requirements/Investigations. Excerpts from this policy read, 2. The Administrator and/or Director of Nursing will immediately initiate a thorough internal investigation of the alleged/suspected occurrence. The investigation protocol will include, but not be limited to, collecting evidence, interviewing alleged victims and witnesses, and involving other appropriate individuals, agents, or authorities to assist in the process and determinations.
On 09/27/2023 and 09/28/2023, the facility Administrator and corporate staff were made aware of the above findings. The corporate staff notified the survey team they would be re-opening the investigation into the events involving Resident #53 and CNA C.
No further information was provided.
2. For Resident #85, the facility staff failed to thoroughly investigate an allegation of sexual abuse at the time it occurred.
On or about 08/10/2023, an allegation that a CNA shaved the pubic hair of Resident #85 who is cognitively impaired and unable to be interviewed. The allegation was reported by the CNA who cares for her and the roommate of the resident.
On 09/26/2023, an interview was conducted with Resident #103 who stated she knew that Resident #85 had been molested by a male CNA. She allowed the surveyors to listen to an audio recording of CNA E questioning Resident #85. According to the audio recording, CNA E stated, Why did you let that man shave you down there? Resident #85 has a Brief Interview of Mental Status (BIMS) score of 99, and stated that she did not let anyone shave her to which you can hear the CNA reply, You are mighty bald down there. You got less hair than me and I was waxed. On 09/27/2023 at 1:00 p.m., an interview was conducted with CNA E who admitted she had knowledge of the incident and that she made the nurse and the former DON aware of the incident; however, she did not report it as abuse at that time.
On 09/26/2023, an interview was conducted with the DON who was asked if she reported the allegation of sexual abuse and she stated that she did not find it was abuse. She stated she heard about it from Resident #103, and she did not consider it abuse. The DON stated, Coming from (Resident #103 name redacted) I don't believe it. When asked again if she followed the abuse policy and reported it to the appropriate parties, she stated she did not think it was abuse, so she did not report it.
A review of the Abuse Policy read:
All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.
The incident was not reported nor investigated until 09/27/2023, 2 days after the survey began. The incident was reported to the Office of Licensure and Certification, Adult Protective Services, the Department of Health Professions, and the Police by the Regional Director of Clinical Services on 09/27/2023.
On 10/04/2023 during the end of day meeting, the Administrator was made aware of the findings.
No further information was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to complete a comprehensive assessment after sign...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to complete a comprehensive assessment after significant change in a timely manner for one resident (Resident #19) in a survey sample of 48 residents.
For Resident #19, the facility staff failed to perform a significant change in status assessment after 2 areas of decline in pressure ulcer formation after hospitalization, and significant weight loss prior to and after hospitalization within 14 days of knowing about the 2 declines.
The findings included:
For Resident #19, the facility staff did not intervene during the significant weight loss of a resident with known dysphagia following a stroke, insulin dependent Diabetes Mellitus, and 3 wounds.
Resident #19 was admitted to the facility on [DATE], and most recently readmitted after hospitalization on 09/19/2023 with diagnoses including; encephalopathy, urinary tract infection, oral cadidiasis, and COVID-19. Resident #19 had a medical history including, stroke, diabetes, and acute gastrointestinal bleeding with resulting acute post hemorrhagic anemia and weakness from the 12/26/2022 admission.
Resident #19's most recent quarterly Minimum Data Set (MDS) assessment was dated with an assessment reference date of 06/21/2023, and coded the resident as moderately cognitively impaired, required extensive assistance with feeding, coded no wounds nor skin problems, at risk for malnutrition, weight 148.0 lbs (pounds), and no swallowing issues. The assessment was in error as the resident had 2 ongoing long standing foot wounds from an original admission known for years.
It is notable to add that no significant change to the MDS assessment was completed from Resident #19's readmission from the hospital on [DATE] through the time of survey ending 10/04/2023 (15 days after readmission). Resident #19 had a known significant weight loss before hospitalization, and a new pressure sore on Resident #19's right buttock found on the day of readmission at unstageable due to slough in the wound bed. These issues would require further nutritional support for wound healing and significant weight loss. According to the regulation, a significant change assessment should be conducted within 14 days of a known decline in 2 or more areas such as unplanned weight loss and a new unstageable pressure wound.
On 01/02/2023, the Registered Dietician (RD) evaluated Resident #19, and documented Nutrition Assessment (A) Diagnoses .regular diet level 4 pureed texture, regular liquids consistency. Po (oral) intake 25-75% of most meals, supplement none, .pressure wound, medications named .Nutrition Prescription/interventions (1) add multivitamin with minerals to aid in wound healing (2) Add ensure compact 4 ounces by mouth due to variable oral intake, increased needs for wound healing, malnutrition prevention, advanced age Monitor/Evaluation (M/E): Monitor weights, meal intake and provide follow up per protocol.
On 06/20/2023, the last RD evaluation document was completed in the clinical record and stated, Nutrition Assessment (A) quarterly ARD 6-21-23 .Diagnoses .regular diet regular texture, thin liquids consistency. Po (oral) intake 50-100% of most meals, supplement med plus 2.0 at 120 milliliters by mouth with (hs) bedtime labs, medications named .continue current interventions Monitor/Evaluation (M/E): Monitor weights, meal intake and provide follow up per protocol. weight 148.3 lbs (pounds).
On 09/07/2023 and 09/14/2023, dietary notes indicated significant weight loss was identified; however, no new interventions nor orders were added.
The facility inspection/survey began 09/25/2023 and ended on 10/04/2023. Resident #19's weight document was reviewed and revealed the following:
1. 07/03/2023 - 145.0 pounds
2. 08/07/2023 - 140.2 pounds (5 pound weight loss in one month begins)
3. 09/06/2023 - 131.6 pounds (now a 14 pound (10 % ) weight loss in 2 months)
4. 09/11/2023 - 129.0 pounds (now a 16 pound weight loss 9 weeks) Resident #19 went out to the hospital on [DATE], and returned on 09/19/2023.
5. 09/19/2023 - 135.0 (a 6 pound weight gain during hospitalization)
6. 09/25/2023 - 126.0 pounds (a 9 pound weight loss begins again)
7. 09/27/2023 - 119.4 pounds (now almost 20% weight loss in less than 4 months) and weight loss continues.
Physician and RD orders were reviewed, and revealed that from 01/03/2023, multivitamin was ordered and discontinued on 06/30/2023, the regular diet was discontinued on 06/30/2023, and the Ensure Compact supplement was discontinued on 06/01/2023. The Med Plus 2.0 supplement was started on 06/01/2023, and discontinued on 06/30/2023.
There were no orders for supplements after the 06/30/2023 discontinuance until 09/19/2023, after a significant weight loss had occurred and been ongoing for months. The multivitamin, and Med Plus 2.0 were restarted on 09/19/2023; however, the Med Plus 2.0 supplement was discontinued nine days later on 09/28/2023 by a physician's order. Weekly weights were obtained beginning 09/06/2023, indicating knowledge of the significant weight loss (10 days) before hospitalization on 09/16/2023 for Resident #19; however, no interventions were added for the weight loss.
The medication administration record (MAR) documented that the Med plus 2.0 was given daily after 09/28/2023, even after being discontinued, and on 09/28/2023, the diet was changed to mechanically altered which dietary staff indicated meant chopped.
Resident #19 did not receive supplements from 06/30/2023 through 09/19/2023 during a significant weight loss, and the RD did not evaluate nor intervene during a significant weight loss.
Resident #19's nutrition care plan, completed and initiated on 01/02/2023, was canceled on 09/18/2023 by the RD. No new nutrition care plan nor any other care plan had been completed at the time of survey on 09/25/2023, nor through 09/27/2023 (9 days after readmission) when documents were obtained. The new readmission care plan was in development according to staff nurses when asked to review the care plan in the electronic clinical record.
Resident #19 did not have a dehydration care plan even though the resident had experienced dehydration in the facility and received Clysis fluid resuscitation instilled subcutaneously on several occasions. Resident #19 did not receive diuretic medications which assists with removing fluid from the body.
Activities of Daily Living records (ADLs) were reviewed and revealed Resident #19 needed to be assisted and received extensive assistance. The resident consumed varying amounts of meals from 0% to 75%.
Family interviews to include the resident's daughter, and granddaughter, who stated she was a Licensed Practical Nurse (LPN), revealed that Resident #19 had to be fed and will, at times, accept things in her hands to eat, such as sandwiches. However, she must be cued to eat them. The family was very involved with the resident's care and were in the facility almost daily. The family stated they had not received a baseline care plan nor had they been invited to a care plan meeting since Resident #19 was readmitted on [DATE], and they were concerned about the resident's weight loss.
Staff interviews revealed that Resident #19 had to be fed, and that she would stop eating if not fed.
Observations conducted on 09/29/2023 at 12:00 p.m., revealed Resident #19 in the communal dining room on the nursing unit. The resident was sitting at a table with 3 other residents with meal trays in front of them, and they were being assisted by one staff member to set-up, and feed the residents at the table. Resident #19's tray was observed to have 1/2 inch cubed turkey meat, 1/2 inch chopped cubes of cabbage, mashed potatoes and gravy. The resident was not eating and Certified Nursing Assistant (CNA) D, who was sitting with the residents, stated she would be feeding Resident #19.
Observations were continued and only one teaspoonful of potatoes was placed up to the mouth of Resident #19, of which, the resident took half into her mouth and swallowed. At 1:00 p.m., all trays were loaded onto the cart to return to the kitchen. Resident #19's tray was observed to have 1/2 spoonful of mashed potatoes consumed and the other half of the spoonful was still on the spoon, indicating no other food was fed to the resident.
At 1:15 p.m., CNA D was interviewed and asked why she had not fed Resident #19. CNA D stated, She (Resident#19) was very sleepy, so I told the nurse (LPN D) and didn't offer her any more food. LPN (Licensed Practical Nurse) D was interviewed and stated, the speech therapist was changing the resident's diet and the resident would receive another tray, but the resident has thrush so she probably won't eat anyway. The surveyor told LPN D that CNA D stated she was sleepy and that is why she was not eating. LPN D stated she didn't tell me that. Resident #19 was observed for the rest of the shift, and never received another tray. It is notable to mention that the resident's finger stick blood sugar (FSBS) testing that morning indicated 78, which was low for the resident.
On 09/29/2023 at the end of day debriefing, the Administrator and Regional Director of Operations were notified of the findings for Resident #19.
On 10/04/2023 at approximately 2:00 p.m., the Administrator, Corporate Nurse Consultant, and Regional Director of Operations were again notified of the findings, and they stated they had nothing further to provide.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, family interview, staff interview, facility document review, and clinical record review, the facility staf...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, family interview, staff interview, facility document review, and clinical record review, the facility staff failed to complete a 48-hour baseline care plan for one resident (Resident #19) in a survey sample of 48 residents.
For Resident #19, the facility staff failed to develop and operationalize a 48-hour base line care plan after readmission and discontinuance of the resident's former care plan, which was canceled.
The findings included:
For Resident #19, the facility staff did not intervene during the significant weight loss of a resident with known dysphagia following a stroke, insulin dependent Diabetes Mellitus, and 3 wounds.
Resident #19 was admitted to the facility on [DATE], and most recently readmitted after hospitalization on 09/19/2023 with diagnoses including, encephalopathy, urinary tract infection, oral cadidiasis, and COVID-19. The resident had a medical history including, stroke, diabetes, and acute gastrointestinal bleeding with resulting acute post hemorrhagic anemia and weakness from the 12/26/2022 admission.
Resident #19's most recent quarterly Minimum Data Set (MDS) assessment was dated with an assessment reference date of 06/21/023, and coded the resident as moderately cognitively impaired, required extensive assistance with feeding, coded no wounds nor skin problems, at risk for malnutrition, weight 148.0 lbs (pounds), and no swallowing issues. The assessment was in error as Resident #19 had 2 ongoing long standing foot wounds from an original admission known for years.
It is notable to add that no significant change MDS assessment was completed from Resident #19's readmission from the hospital on [DATE] through the time of survey ending on 10/04/2023 (15 days after readmission). Resident #19 had a known significant weight loss before hospitalization, and a new pressure sore on the resident's right buttock was found on the day of readmission at unstageable due to slough in the wound bed. These issues would require further nutritional support for wound healing and significant weight loss. According to the regulations, a significant change assessment should be conducted within 14 days of a known decline in 2 or more areas such as unplanned weight loss and a new unstageable pressure wound.
On 01/02/2023, the Registered Dietician (RD) evaluated Resident #19 and documented Nutrition Assessment (A) Diagnoses .regular diet level 4 pureed texture, regular liquids consistency. Po (oral) intake 25-75% of most meals, supplement none, .pressure wound, medications named .Nutrition Prescription/interventions (1) add multivitamin with minerals to aid in wound healing (2) Add ensure compact 4 ounces by mouth due to variable oral intake, increased needs for wound healing, malnutrition prevention, advanced age Monitor/Evaluation (M/E): Monitor weights, meal intake and provide follow up per protocol.
On 06/20/2023, the last RD evaluation document was completed in the clinical record and stated; Nutrition Assessment (A) quarterly ARD 6-21-23 Diagnoses .regular diet regular texture, thin liquids consistency. Po (oral) intake 50-100% of most meals, supplement med plus 2.0 at 120 milliliters by mouth with (hs) bedtime labs, medications named , continue current interventions Monitor/Evaluation (M/E): Monitor weights, meal intake and provide follow up per protocol. Weight 148.3 lbs (pounds).
On 09/27/2023 and 09/14/2023, dietary notes indicated significant weight loss was identified; however, no new interventions nor orders were added.
The facility inspection/survey began 09/25/2023 and ended 10/04/2023. Resident #19's weight document was reviewed and revealed the following:
1. 07/03/2023 - 145.0 pounds
2. 08/07/2023 - 140.2 pounds (5 pound weight loss in one month begins)
3. 09/06/2023 - 131.6 pounds (now a 14 pound (10 % ) weight loss in 2 months)
4. 09/11/2023 - 129.0 pounds (now a 16 pound weight loss 9 weeks) Resident #19 went out to the hospital on [DATE] and returned on 09/19/2023.
5. 09/19/2023 - 135.0 (a 6 pound weight gain during hospitalization)
6. 09/25/2023 - 126.0 pounds (a 9 pound weight loss begins again)
7. 09/27/2023 - 119.4 pounds (now almost 20% weight loss in less than 4 months) and weight loss continues.
Physician and RD orders were reviewed and revealed that from 01/03/2023, multivitamin was ordered and discontinued on 06/30/2023, the regular diet was discontinued on 06/30/2023, and the Ensure Compact supplement was discontinued on 06/01/2023. The Med Plus 2.0 supplement was started on 06/01/2023 and discontinued on 06/30/2023.
There were no orders for supplements after the 06/30/2023 discontinuance until 09/19/2023 after a significant weight loss had occurred and been ongoing for months. The multivitamin and Med Plus 2.0 were restarted on 09/19/2023; however, the Med Plus 2.0 supplement was discontinued nine days later on 09/28/2023 by a physician's order. Weekly weights were obtained beginning 09/06/2023, indicating knowledge of the significant weight loss (10 days) before hospitalization on 09/16/2023 for Resident #19; however, no interventions were added for the weight loss.
The medication administration record (MAR) documented that the Med plus 2.0 was given daily after 09/28/2023, even after being discontinued, and on 09/28/2023, the diet was changed to mechanically altered which dietary staff indicated meant chopped.
Resident #19 did not receive supplements from 06/30/2023 through 09/19/2023 during a significant weight loss, and the RD did not evaluate nor intervene during a significant weight loss.
Resident #19's nutrition care plan, completed and initiated on 01/02/2023, was canceled on 09/18/2023 by the RD. No new nutrition care plan nor any other care plan had been completed at the time of survey on 09/25/2023 nor through 09/27/2023 (9 days after readmission) when documents were obtained. The new readmission care plan was in development according to staff nurses when asked to review the care plan in the electronic clinical record.
Resident #19 did not have a dehydration care plan even though the resident had experienced dehydration in the facility and received Clysis fluid resuscitation instilled subcutaneously on several occasions. Resident #19 did not receive diuretic medications which remove fluid from the body.
Activities of Daily Living records (ADLs) were reviewed and revealed that Resident #19 needed to be assisted and received extensive assistance. The resident consumed varying amounts of meals from 0% to 75%.
Family interviews to include the resident's daughter and granddaughter, who stated she was an Licensed Practical Nurse (LPN), revealed that the resident had to be fed and will at times accept things in her hands to eat, such as sandwiches; however, she must be cued to eat them. The family was very involved with the resident's care and were there in the facility almost daily. The family stated they had not received a baseline care plan nor had they been invited to a care plan meeting since Resident #19 was readmitted on [DATE], and they were concerned about the resident's weight loss.
Staff interviews revealed that Resident #19 had to be fed, and that she would stop eating if not fed.
Observations conducted on 09/29/2023 at 12:00 p.m., revealed Resident #19 in the communal dining room on the nursing unit. The resident was sitting at a table with 3 other residents with meal trays in front of them, and they were being assisted by one staff member to set up, and feed the residents at the table. Resident #19's tray was observed to have 1/2 inch cubed turkey meat, 1/2 inch chopped cubes of cabbage, mashed potatoes and gravy. Resident #19 was not eating and CNA (Certified Nursing Assistant) D, who was sitting with the residents, stated she would be feeding Resident #19.
Observations were continued and only one teaspoonful of potatoes was placed up to the mouth of Resident #19, of which, the resident took half into her mouth and swallowed. At 1:00 p.m., all trays were loaded onto the cart to return to the kitchen. Resident #19's tray was observed to have 1/2 spoonful of mashed potatoes consumed and the other half of the spoonful was still on the spoon, indicating no other food was fed to Resident #19.
At 1:15 p.m., CNA D was interviewed and asked why she had not fed Resident #19. CNA D stated, She (Resident#19) was very sleepy so I told the nurse (LPN D) and didn't offer her any more food. LPN (Licensed Practical Nurse) D was interviewed and stated, the speech therapist was changing the resident's diet and Resident #19 would receive another tray, but the resident has thrush so she probably won't eat anyway. The surveyor told LPN D that CNA D stated she was sleepy and that is why she was not eating. LPN D stated, she didn't tell me that. The resident was observed for the rest of the shift, and never received another tray. It is notable to mention that Resident #19's finger stick blood sugar (FSBS) testing that morning indicated 78, which was low for the resident.
On 09/29/2023 at the end of day debriefing, the Administrator and Regional Director of Operations were notified of findings for Resident #19.
On 10/04/2023 at approximately 2:00 p.m., the Administrator, Regional RN consultant, and Corporate Director of Operations were made aware of findings, and they stated they had nothing further to provide.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and facility documentation, the facility staff failed to review and rev...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and facility documentation, the facility staff failed to review and revise care plans for 2 residents (Residents #21 and #53), in a survey sample of 48 residents.
The findings included:
1. For Resident #21 the facility staff failed to review and revise the care plan to include interventions after a fall with fractured femur and surgical repair.
On 09/25/2023 at approximately 2:30 p.m., Resident #21 was observed in her wheelchair in her room looking out of the window. She had bare feet. She stated she had a fall a while ago and now is in a wheelchair. She was not sure when the fall occurred or if it was at home or in the facility.
A review of the clinical record revealed that Resident #21 had fallen in the facility on 04/03/2023 and was sent to the hospital on [DATE] with a diagnosis of fractured right hip. Upon return to the facility, the care plan was not updated to include a foley, surgical incision, PT/OT, limitations, nor any new fall interventions since returning from the hospital on [DATE].
The care plan regarding falls read as follows:
FOCUS: The resident has had an actual fall with the potential for further falls IDT expects fluctuations with declines as dementia progresses. Date Initiated: 03/01/2021 Created on: 03/01/2021.
GOAL: The resident will resume usual activities without further incident through the review date. Date Initiated: 03/01/2021 Created on: 03/01/2021 Revision on: 04/24/2023 Target Date: 07/15/2023.
INTERVENTIONS: Assist with repositioning in bed Date Initiated: 05/02/2021 Created on: 05/02/2021.
Education regarding call for assistance Date Initiated: 04/03/2023 Created on: 04/03/2023.
Floor mats Date Initiated: 03/01/2021 Created on: 03/01/2021 Revision on: 04/06/2023.
Provide activities that promote exercise and strength building where possible. Date Initiated: 04/03/2023 Created on: 04/03/2023.
Reeducate resident to wear no skid socks or shoes when ambulating Date Initiated: 04/04/2023 Created on: 04/04/2023.
Re-direct resident and provide diversional activities when noted wandering aimlessly. Date Initiated: 07/28/2021 Created on: 08/16/2021.
On 09/27/2023, an interview was conducted with LPN C who was asked when care plans should be updated, and she stated they should be updated as the care needs of the resident change. When asked who updates the care plans, she stated that usually the MDS coordinator or the DON updates the care plans.
On 10/04/2023 during the end of day meeting, the Administrator was made aware of the concerns and no further information was provided.
2. For Resident #53, the facility staff failed to update the care plan to include Clysis orders for hydration.
On 09/26/2023 during clinical record review, it was noted that Resident #53 was started on Clysis due to AKI (Acute Kidney Injury).
Sodium Chloride Solution 0.9 % Use 100 ml/hr. intravenously X 24 hours for AKI for 2 Days FOR 1.5L, use Clysis 60ml/hr. if iv line not obtained 9/22/2023 6:00 PM.
9/23/2023 12:06 AM Orders - Administration Note Text: Clysis placed to right posterior/lateral thigh d/t residents' size/amount of fatty tissue. Inserted subcutaneously, covered with transparent dressing noted clean, dry, and intact. 0.9% Sodium Chloride infusing via doppler flow at 60ml; resident tolerated well. As of 0011; resident resting peacefully with Clysis intact without any issues noted. Resident to receive a total of 1.5L for AKI. Staff to continue to monitor.
9/23/2023 8:50 PM Health Status Note Text: Resident fine, tolerating Clysis (sodium chloride) well. Ate 90% of dinner with ensure. No complaint of pain and no s/s of distress noted. Will continue to monitor throughout the rest of the shift.
A review of the clinical record revealed the care plan had not been updated since the initial care plan on admission. There was no update to reflect the start of IV fluids or Clysis if the IV line could not be started.
FOCUS: The resident has dehydration or potential fluid deficit r/t Infection Date Initiated: 08/10/2023 Created on: 08/10/2023.
GOAL: The resident will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor.
Date Initiated: 08/10/2023 Created on: 08/10/2023.
INTERVENTIONS: Encourage the resident to drink fluids of choice. See md order for extra fluids Date Initiated: 08/10/2023.
Created on: 08/10/2023.
Ensure that all beverages offered comply with diet/fluid restrictions and consistency requirements. Date Initiated: 08/10/2023.
Lab work as ordered Date Initiated: 08/10/2023 Created on: 08/10/2023.
Monitor/document/report PRN any s/sx of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes. Date Initiated: 08/10/2023 Created on: 08/10/2023.
On 09/27/2023, an interview was conducted with LPN B who stated that the MDS Coordinator or the DON are the ones who update the care plans. When asked if a change in condition or treatment should warrant an update on the care plan, she stated that it should.
On 10/04/2023 during the end of day meeting, the Administrator was made aware of the findings.
No further information was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide care and services in accordance with professional standards for 1 resident, Resident #362, in a survey sample of 48 residents.
The findings included:
For Resident #362, facility staff failed to administer medications as ordered by the physician on 07/17/2023 and 07/18/2023.
On 09/28/2023, Resident #362's clinical record was reviewed and revealed physician orders and medication administration times as follows:
*Aspirin EC-low dose tablet delayed release, 81mg, give 1 tablet by mouth one time a day--ordered on 7/18/23, documented as given on 7/19/23
*Ferrous Sulfate tablet 325 (65 Fe)mg, give 1 tablet by mouth one time a day--ordered on 7/18/23, documented as given on 7/19/23
*Finasteride tablet 5mg, give 1 tablet by mouth one time a day--ordered on 7/18/23, documented as given on 7/19/23
*Gabapentin Oral Capsule 300mg, give 1 capsule by mouth at bedtime--ordered on 7/17/23, documented as given on 7/18/23
*Multiple Vitamin Tablet, give 1 tablet by mouth one time a day--ordered on 7/18/23, documented as given on 7/19/23
*Nifedipine ER Oral Tablet Extended Release 24 Hour 90mg, give 120mg by mouth one time a day--ordered on 7/18/23, documented as given on 7/19/23
*Carvedilol Oral Tablet 6.25mg, give 6.25mg by mouth two times a day--ordered on 7/17/23, documented as given on 7/18/23
*Eliquis Oral Tablet 2.5mg, give 2.5mg by mouth two times a day--ordered on 7/17/23, documented as given on 7/18/23
On 10/02/2023 at approximately 2:00 p.m., an interview was conducted with the Clinical Nurse Consultant (CNC) who confirmed the findings and stated that medications are expected to be given as ordered by the physician. She verified Resident #362 was actually admitted on [DATE] and stated, It appears that most of his [Resident #362's] med orders weren't entered into the system on the day of his admission as they should have been, it is my expectation that upon any resident's arrival to our facility, the admitting nurse will enter all admitting orders which includes all medications, if there is a question about medications then the nurse should contact the doctor for clarification and document it in a note, this nurse failed to follow our admissions process. The admitting nurse was unavailable to interview. The CNC stated the facility's professional nursing standards reference was [NAME]. A facility policy on medication administration was requested and received.
Review of the facility policy entitled, General Guidelines for Medication Administration, revised 08-2020, heading Policy read, Medications are administered as prescribed in accordance with good nursing principles and practices .
According to [NAME] Nursing Procedures, Seventh Edition, 2016, section entitled, Oral Drug Administration, steps in the implementation of medication administration included but were not limited to: Verify the medication is being administered at the proper time .to reduce the risk of medication errors.
On 10/02/2023 at the end of day meeting, the facility Administrator was updated on the findings. No further information was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facili...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide Activities of Daily Living (ADL) assistance to residents residing on 1 of 2 nursing units.
The findings included:
1. For Resident #19, who was dependent upon facility staff for eating, the facility staff failed to provide assistance with the meal to ensure the resident was fed a meal.
Observations conducted on 09/29/2023 at 12:00 p.m., revealed Resident #19 in the communal dining room on the nursing unit. The resident was sitting at a table with 3 other residents with meal trays in front of them, and they were being assisted by one staff member to set up, and feed the residents at the table. Resident #19's tray was observed to have 1/2 inch cubed turkey meat, 1/2 inch chopped cubes of cabbage, mashed potatoes and gravy. The resident was not eating and CNA (Certified Nursing Assistant) D who was sitting with the residents stated she would be feeding Resident #19.
Observations were continued and only one teaspoonful of potatoes was placed up to the mouth of Resident #19, of which, the resident took half into her mouth and swallowed. At 1:00 p.m., all trays were loaded onto the cart to return to the kitchen. Resident #19's tray was observed to have 1/2 spoonful of mashed potatoes consumed and the other half of the spoonful was still on the spoon, indicating no other food was fed to the resident.
At 1:15 p.m., CNA D was interviewed and asked why she had not fed the resident. CNA D stated She (Resident#19) was very sleepy so I told the nurse (LPN D) and didn't offer her any more food. LPN (Licensed Practical Nurse) D was interviewed and stated that the speech therapist was changing the resident's diet and that the resident would receive another tray, but the resident has thrush so she probably won't eat anyway. The surveyor told LPN D that CNA D stated she was sleepy and that is why she was not eating. LPN D stated she didn't tell me that. Resident #19 was observed for the rest of the shift, and never received another tray. It is notable to mention that the resident's finger stick blood sugar (FSBS) testing that morning indicated 78, which was low for the resident.
Activities of Daily Living (ADL) records were reviewed and revealed that Resident #19 needed to be assisted and received extensive assistance. The resident consumed varying amounts of meals from 0% to 75%.
Family interviews to include the resident's daughter, and granddaughter, who stated she was an Licensed Practical Nurse (LPN), revealed that the resident had to be fed and will at times accept things in her hands to eat, such as sandwiches; however, she must be cued to eat them. The family was very involved with the resident's care and were there in the facility almost every day. The family stated they had not received a baseline care plan nor had they been invited to a care plan meeting since the resident was readmitted on [DATE], and they were concerned about the resident's weight loss.
Staff interviews revealed that Resident #19 had to be fed, and that she would stop eating if not fed.
2. Resident Council expressed ongoing concerns over the lack of incontinence care, with no resolution.
On 09/26/2023 at 1:00 p.m., a group meeting was held with 6 residents who were members of the Resident Council. During this meeting with the Surveyor, residents verbalized ongoing concerns over the lack of call bell response time and ADL assistance for residents who are incontinent.
The residents stated, residents who cannot ambulate and have dementia are left in the day room area on the South Hall all day without being changed. Six of the six residents in attendance at the Resident Council meeting stated, that the room is supposed to be used for activities; however, the staff park residents in there and they cannot do activities. They stated the room always smells of urine and feces because they do not change the residents they park in there.
A review of the Resident Council minutes for the past 6 months revealed that residents are complaining about call bell answer times and improper incontinent care repeatedly.
Review of the grievances revealed the same, ongoing concerns about incontinence care and assistance with ADLs.
On 10/03/2023 during an end of day meeting, the facility Administrator was made aware of the above findings.
No further information was provided.
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, clinical record review, and facility documentation review, the facility staff failed to provide respiratory care, consistent with professional standards of pract...
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Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide respiratory care, consistent with professional standards of practice, for 2 residents (Residents #37 and #71) in a survey sample of 46 residents.
The findings included:
1. For Resident #37, the facility staff failed change the nebulizer tubing three times per week as ordered and as per the facility's protocol.
On 09/25/2023 during the initial tour of the building at approximately 12:50 p.m., there was an observation of a nebulizer machine on the bedside table and the tubing and mouthpiece were in a bag that was dated 09/07/2023.
Review of the clinical record was conducted on 09/25/2023 and 09/26/2023.
Review of Resident #37's physician's orders revealed the following:
07/23/2021 - Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3 ML (3 milligrams per 3 milliliters) 3 ml inhale orally every 4 hours as needed for SOB (Shortness of Breath) or wheezing via nebulizer.
11/10/2022 - Nebulizer tubing setup change M-W-F (Night Shift) every night shift every Mon,Wed, Fri for infection prevention.
On 09/25/2023 at approximately 2:00 p.m., an interview was conducted with Licensed Practical Nurse (LPN C) who stated that night shift was supposed to change and date tubing for Nebulizer on Mondays, Wednesdays, and Fridays and change oxygen tubing weekly. She stated the nurse should label and date the tubing when opened and used. When asked about the risks of not changing the tubing as ordered or by the protocol, LPN-C stated there was a risk of infection.
On 09/26/2023 at approximately 2:45 p.m., an interview was conducted with Registered Nurse (RN) B who stated that the nebulizer and oxygen tubing should be dated and stored at the bedside. RN-B stated the nebulizer tubing should be changed every Monday, Wednesday and Friday on the night shift. RN-B stated Resident #37 had an order for nebulizer treatments as needed. When asked if the nebulizer equipment and tubing at the bedside was available for use, RN-B stated Yes, but I hope the nurses would check the date prior to using it. RN-B stated the tubing should be changed as ordered and as per protocol.
During the end of day debriefing on 09/26/2023, the Facility Administrator, Director of Nursing and Corporate Nurse Consultant were informed of the findings.
A copy of the Facility's Policy on Respiratory Care was requested and received on 09/27/2023.
Review of the facility's Respiratory Care Policy and Procedure, effective date 08/04/2015, page 155, number 5 included the excerpt: Nebulizers and bags must be changed every Monday, Wednesday and Friday and dated.
Another copy of the facility Policy on Respiratory Care entitled Respiratory/Oxygen Equipment, Effective date: 3/13/2023 was presented to the surveyor on 09/28/2023. Review of the policy revealed documentation under medicated Nebulizer Treatment number 5 stated: Nebulizers and bags should be changed weekly.
Another copy of the facility Policy on Respiratory Care entitled Respiratory/Oxygen Equipment, Effective date: 3/13/2023 was presented to the surveyor on 09/28/2023. Review of the policy revealed documentation under medicated Nebulizer Treatment number 5 stated: Nebulizers and bags should be changed weekly.
No further information was provided.
2. For Resident #71, the facility staff failed to change the nebulizer tubing three times per week as ordered and as per the facility's protocol.
On 09/25/2023 during the initial tour of the building at approximately 12:50 p.m., there was an observation of a nebulizer machine on the bedside table and the tubing and mouthpiece were in a bag that was dated 09/09/2023.
On 09/26/2023 at 9:30 a.m., another observation was made of the nebulizer with tubing and mouthpiece in a bag dated 09/09/2023.
Review of the clinical record was conducted on 09/25/2023 and 09/26/2023.
Review of Resident #71's physician's orders revealed the following:
07/23/2021- Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3 ML (3 milligrams per 3 milliliters) one tablet inhale orally every 4 hours as needed for SOB (Shortness of Breath).
11/10/2022- Nebulizer tubing setup change M-W-F (Night Shift) every night shift every Mon,Wed, Fri for infection prevention.
On 09/25/2023 at approximately 2:00 p.m., an interview was conducted with Licensed Practical Nurse (LPN C) who stated that night shift was supposed to change and date tubing for Nebulizer on Mondays, Wednesdays and Fridays and change oxygen tubing weekly. She stated the nurse should label and date the tubing when opened and used. When asked about the risks of not changing the tubing as ordered or by the protocol, LPN-C stated there was a risk of infection.
On 09/26/2023 at approximately 2:45 p.m., an interview was conducted with Registered Nurse B who stated that the nebulizer and oxygen tubing should be dated and stored at the bedside. RN-B stated the nebulizer tubing should be changed every Monday, Wednesday and Friday on the night shift.
During the end of day debriefing on 09/26/2023, the facility Administrator, Director of Nursing, and Corporate Nurse Consultant were informed of the findings.
A copy of the facility's Policy on Respiratory Care was requested and received on 09/27/2023.
Review of the facility's Respiratory Care Policy and Procedure, effective date 08/04/2015, page 155, number 5 included the excerpt: Nebulizers and bags must be changed every Monday, Wednesday and Friday and dated.
Another copy of the facility Policy on Respiratory Care entitled, Respiratory/Oxygen Equipment, Effective date: 3/13/2023 was presented to the surveyor on 09/28/2023. Review of the policy revealed documentation under medicated Nebulizer Treatment number 5 stated: Nebulizers and bags should be changed weekly.
No further information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0745
(Tag F0745)
Could have caused harm · This affected 1 resident
Based on interview, clinical record review, and facility documentation, the facility staff failed to provide medically related social services for 1 resident (Resident #22) in a survey sample of 48 re...
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Based on interview, clinical record review, and facility documentation, the facility staff failed to provide medically related social services for 1 resident (Resident #22) in a survey sample of 48 residents.
The findings included:
For Resident #22, the Social Worker failed to assist the resident in obtaining his social security card and state identification card that was lost during his hospital admission prior to admission to the facility.
On 09/25/2023 at approximately 3:00 p.m., Resident #22 was interviewed and stated he has not had his ID or Social Security card since he came to the facility. He stated it was lost during his hospital admission prior to entering the facility. When asked if he had made the staff aware of the need for assistance, he stated I made both of the Social Workers aware a few times but a lot of good that does they both quit on Friday. When asked when he told them, he stated, I have been asking since I got here.
A review of the clinical record revealed there was no documentation at all from social services since arriving at the facility on 05/03/2022.
On 09/26/2023, an interview was conducted with Employee O who was asked if there are no notes in reference to social services in the chart what does that mean? Employee O stated the social services employees are no longer at the facility. They resigned on the previous Friday, so they could not tell whether Resident #22 had any interaction with them regarding his identification.
9/26/2023 4:00 pm -DISCHARGE PLANNING PROGRESS NOTES Text: [Discharge planner name redacted] called [County Social Services name redacted] service and left a voicemail for [Social worker name redacted] (LTC benefits) requesting information (copy of his ID or birth certification), [Resident #22 name redacted] needs to some type of Identification to replace his lost ID. When asked if a resident who has substance abuse issues, mental health concerns, and a diagnosis of PTSD should have seen the Social Worker at least 1 time since arrival at the facility, she stated, he should have at least an admission note.
On 10/04/2023 during the end of day meeting, the Administrator was made aware.
No further information was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on interview, clinical record review, and facility documentation, the facility staff failed to ensure medications were available for 1 resident (Resident #103) in a survey sample of 48 residents...
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Based on interview, clinical record review, and facility documentation, the facility staff failed to ensure medications were available for 1 resident (Resident #103) in a survey sample of 48 residents.
The findings included:
For Resident #103, the facility staff failed to ensure the resident had an adequate supply of Morphine 15mg for her pain control due to a wound.
On 09/25/2023 at approximately 4:30 p.m., an interview was conducted with Resident #103 who stated the facility keeps running out of her pain medicine (Morphine 15 mg). When asked if she knew why this was happening, she stated she did not know but It happened again this morning. She stated the nurse got her an order for Tramadol, but she still has to wait to get that.
A review of the clinical record read:
9/25/2023-4:13 pm Health Status - Note Text: Spoke with Resident this AM due to complaints that medication MS every four prn was not available. Spoke with nurse and pharmacy and medication requiring prior authorization. Physician will be in tomorrow to sign PA, in the meantime new order for Tramadol 50 mg every six hours ordered.
A review of the Medication Administration Record (MAR) revealed that Resident #103 did have a valid order for Morphine 15mg every 4 hours for pain. This medication was unavailable. Resident #103 did not receive morphine from 2:51 p.m. on 09/21/2023 until 09/26/2023 at 7:30 a.m.
9/26/2023 05:35 - Orders - Administration Note-Note Text: Tramadol 50mg every six hours routine every 6 hours related to SUBACUTE OSTEOMYELITIS, LEFT ANKLE AND FOOT Medication in route per pharmacy, unable to pull from omnicel at this time, MD aware that medication required script.
On the afternoon of 09/26/2023, an interview was conducted with the DON who stated the process for reordering medications is that the staff notify the pharmacy for refills and if it requires a hard script, they contact the physician to get it. The DON was asked if they use a back-up pharmacy, she indicated they did have one but if they do not have a physician hard script they cannot get it from the back-up pharmacy either. When asked who is responsible for ensuring a new script is obtained, she stated the nurses are.
On the morning of 09/27/2023, an interview was conducted with LPN B who stated that Resident #103's morphine is not scheduled, it is PRN, so the resident would have to ask for the medication to receive it. When asked if it was available in the cart on 09/25/2023, she stated it was not. When asked if it was in the Omnicell (stat box), she stated it was not. When asked if the Tramadol was available for use, she stated it was in the Omnicell, but needed a script at the time it was ordered because they only had a verbal order.
A review of the Medication Administration Record (MAR) for Sept. 2023 revealed that although nurses notes document the Tramadol was unavailable, yet it is signed off as given on 09/25/2023 at 6:00 p.m., and on 09/26/2023 at 6:00 a.m. It was left blank, but at 12:00 noon it was signed off as being given.
Resident #103 reports not receiving any ordered Tramadol pain medication until 09/26/2023 at 6:00 p.m.
A review of the Resident Council minutes revealed that during the months of March through August, residents complained about medications not being on time and the facility running out of residents' medications.
On the morning of 09/27/2023, an interview was conducted with LPN B who stated Resident #103's morphine is not scheduled, it is PRN. The resident would have to ask for the medication to receive it. When asked if it was available on the cart on 09/25/2023, she stated it was not. When asked if it was in the Omnicell (stat box), she stated it was not.
On 10/04/2023 during the end of day meeting, the Administrator was made aware of the concerns.
No further information was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, resident interview, clinical record review, and facility documentation review, the facility staff failed to measure the success and track performance in their Qu...
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Based on observation, staff interview, resident interview, clinical record review, and facility documentation review, the facility staff failed to measure the success and track performance in their Quality Assurance and Process Improvement (QAPI) program for their abuse protocols resulting in Immediate Jeopardy involving abuse policy implementation for 2 residents (Residents #12 and #13) on 01/20/2023, and again on 09/27/2023 for 3 residents (Residents #53, #85, and #103) 8 months later.
Immediate Jeopardy was found during a standard survey of the facility commencing on 09/25/2023 and conducted through 10/04/2023 when an abatement of the Immediate Jeopardy finding was achieved for the three new residents (Resident #53, #85, and #103), and the facility at large.
The findings included;
On 01/20/2023, Immediate Jeopardy (IJ) was identified at 3:55 p.m., at which time the facility Administrator and Director of Nursing were made aware. Following verification of the removal of immediacy, the facility abated IJ on 01/26/2023 at 4:07 p.m. The scope and severity was lowered to a level 2, pattern.
At that time, the facility failed to implement their abuse policy for 2 residents (Resident #13 and #12) in a survey sample of 9 residents by permitting a known perpetrator of abuse (CNA B) to work in the facility having direct contact with residents on 1 of 2 nursing units.
As part of the facility plan of correction, the QAPI committee was tasked with monitoring, measuring, tracking data, and sustaining compliance performance in their abuse prevention programming.
On 09/27/2023, IJ was again invoked by the state survey agency for failure to implement their abuse program.
The facility staff failed to implement measures to protect residents from abuse as evidenced by their failure to screen employees, failure to take measures to protect residents from alleged perpetrators, failed to report allegations of abuse, failed to conduct investigations of allegations of abuse, and failed to provide education to staff on abuse and mandated reporting.
On 08/10/2023, Resident #53 reported an allegation of sexual abuse by a CNA C, stating that the CNA C, Covered his face with a washcloth, flicked his penis back and forth, and said he was going to shave his pubic hair, causing the resident to yell out for help, which caused CNA C to abruptly stop.
Resident #53 reported the allegations to the Speech Therapist (ST) at 7:50 a.m. The therapist then reported the allegations immediately to nursing administration. CNA C was permitted to continue to provide care to Resident #53 as evidenced by being seen at 9:30 a.m. aggressively feeding Resident #53 the wrong diet including excessive amounts of food being fed quickly. The Speech Therapist had to intervene as she felt it was not safe. The facility staff failed to conduct an investigation into the allegations and protect the resident by removing the alleged perpetrator immediately.
On 08/10/2023 at approximately mid-day, Resident #103 reported an allegation of abuse on behalf of her roommate, Resident #85. Resident #103 stated the same CNA, (CNA C), had shaved Resident #85's pubic area. On 08/10/2023 at 11:57 a.m., a CNA was heard questioning Resident #85 about why she had been shaved down there. The facility staff failed to report and failed to conduct an investigation into the allegation of abuse involving Resident #85.
The facility staff failed to remove the alleged perpetrator, CNA C, until 5 hours after learning of the allegation(s).
Facility staff were unable to verbalize what a mandated reporter is.
On 09/27/2023 during a review of employee record reviews, it was noted that the facility currently has 2 sampled employees that are actively working, and the facility is unaware of their criminal background status because a criminal background check was not obtained.
The facility staff had failed to take measures to implement their abuse policy to identify, protect, report, and investigate allegations of abuse. The facility staff had also failed to screen employees prior to their employment.
The facility staff were required to take immediate action to protect residents from failure by the facility to protect, report, investigate, and screen employees, thus adhering to a federally mandated abuse protocol. Failure to do this would place all residents at risk for further abuse, which could result in physical, sexual, mental, and/or psychosocial harm.
The facility was made aware of all findings and proceeded during the course of survey to abate the immediacy, and IJ on 10/04/2023.
No further information was provided after abatement; however, the facility was tasked at the end of the inspection with producing a plan of correction in the survey report issued by the state survey agency. The plan of correction will require QAPI involvement, and correction, to the QAPI failed practice in regard to their abuse program.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #363, the facility staff failed to provide a chair in her room at her request.
On 09/26/2023 at approximately 9:...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #363, the facility staff failed to provide a chair in her room at her request.
On 09/26/2023 at approximately 9:30 a.m., Resident #363 was observed sitting on her bed in her room. An interview was conducted and Resident #363 stated, I have asked constantly for a chair to be put in my room since I got here a couple of weeks ago because my husband has no where to sit when he comes to visit me. He comes to see me every day and has to sit in my wheelchair; I'm not asking for much, just a chair. He should not have to use my wheelchair to be comfortable while he visits, it makes no sense at all. Resident #363's wheelchair was observed at the foot of her bed, and there was no chair in her room.
On 09/27/2023 at approximately 10:30 a.m., a group interview was conducted with the Facility Administrator and the Clinical Nurse Consultant (CNC), both of whom stated that it was expected for a chair to be placed in a resident's room as part of the regular room set up or at minimum, a chair would be provided upon the resident's request.
No further information was provided.
Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain a safe, clean, comfortable, and homelike environment for residents residing on 2 of 2 units, and for Resident #363.
The findings included:
1. For the facility, residents the staff failed to maintain clean shower rooms on 2 of 2 units and failed to control pests, such as bedbugs and roaches.
On 09/26/2023 at 2:00 p.m. during the Resident Council meeting, the 6 residents (all the residents on that unit) present stated the shower rooms are filthy, who wants to shower in those rooms? Resident #42 stated she would rather sponge bathe daily than use the shower rooms and the other 5 participants agreed.
Observations were made of the shower rooms on 09/26/2023. On 09/27/2023 and 09/29/2023, the shower rooms were not clean, and the shower stalls had orange and black stains. The shower chairs had brown stains and the floor needed repair in the North shower room.
On 09/26/2023 at approximately 3:30 p.m., an interview was conducted with CNA D who was asked if she knew what the black and orange stains were in the shower stalls. CNA D stated that she thought the black stains might be dirt. When asked how often the shower stalls were cleaned, she stated that Housekeeping cleans the shower rooms, but we use the wipes and wipe down the shower chairs between each resident.
From 09/25/2023 through 10/04/2023, fruit flies as well as house flies were sighted throughout the facility in residents' rooms on both units, and in the dining room.
On 09/29/2023 at approximately 1:15 p.m., Surveyor E entered Resident #19's room with CNA D, and when the cabinet door and drawer were opened cockroaches ran out (approximately 5-10 insects) and were all over the sides and top of the bedside cabinet.
A review of the pest control log revealed that on 08/04/2023 room numbers 32, 37, and 54 were treated for bed bugs; however, no follow-up treatment was done to ensure any eggs that have hatched were treated for, which is standard practice for bedbug treatment.
On 09/28/2023, the resident in room [ROOM NUMBER] was complaining of itching, and stated he had bed bugs. The facility did treat that room on 09/29/2023.
On 10/04/2023 during the end of day meeting the Administrator was made aware of the findings.
No further information was provided.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
Based on observation, interview, facility documentation, and clinical record review, the facility staff failed to ensure the resident environment remains free of accident hazards for 1 of 2 units.
The...
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Based on observation, interview, facility documentation, and clinical record review, the facility staff failed to ensure the resident environment remains free of accident hazards for 1 of 2 units.
The findings included:
For the residents using the showers on the South Hall the facility, staff failed to ensure the shower room tiles were in good repair.
On 09/26/2023 at 2:00 p.m. during the Resident Council meeting, it was brought up that the shower rooms were dirty, and Resident #42 added that the shower room has bugs and is dirty. Residents #68 and #18 added that in the shower cubical, the tiles are loose and coming up out of floor. When asked how long this was going on 6 of 6 residents in attendance agreed that it has been a few months (more than 2). When asked were staff aware of the issue, Resident #42 stated and the group agreed The staff have to be aware they are giving showers to residents in that room.
On 09/26/2023 at 4:00 p.m., this surveyor accompanied the Maintenance Director to the shower rooms to observe the condition of the shower room. Upon entering the shower room, the first stall had black and white tiles that were pulled up and several were missing. An interview was conducted with the maintenance director who was asked if that presents a safety issue. The maintenance director stated that it does present a potential safety issue as tiles may be sharp and a resident could possibly cut their feet on the tile. The maintenance director stated he was not aware of the tiles being broken.
On the afternoon of 09/26/2023, an interview was conducted with CNA D who stated she was aware of the broken tiles and had complained about it to the nurse. She stated that they had reported the broken tiles a month or so ago.
On 10/04/2023 during the end of day meeting, the Administrator was made aware of the concern.
No further information was provided.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and facility documentation, the facility staff failed to ensure residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and facility documentation, the facility staff failed to ensure residents maintain acceptable parameters of nutritional status for 3 residents (Residents #22, #53 and #19) in a survey sample of 48 residents.
The findings included.
1. For Resident #22, the facility staff failed to ensure the resident did not sustain a significant weight loss.
On 09/25/2023 at approximately 2:00 p.m., Resident #22 was interviewed and stated, The food is horrible, and they never give what is actually on the ticket. They don't care if I eat or not, I have lost weight being in here.
A review of the clinical record revealed that on admission to the facility on [DATE], Resident #22 weighed 175 lbs. 3 months later on 08/09/2023, Resident # 22 weighed 154 lbs., which is a 12% weight loss (21 lbs.) in 3 months' time.
A review of the care plan revealed the following:
FOCUS:
Resident is at risk for weight fluctuations related to recent hospitalization, BMI, pressure ulcers, Incomplete Lesion of L1 Lumbar Spinal Cord, Paraplegia, Hereditary and Idiopathic Neuropathy, Necrotizing Fasciitis, Colostomy, Psychoactive Substance Abuse, Anemia, malnutrition. date initiated: 5/3/23 Revision on 9/29/23 [Note revision Resident #22 was interviewed]
GOAL:
The resident will have optimal nutrition and hydration status thru review period Date Initiated: 05/03/2023 Revision 9/26/23.
INTERVENTIONS:
Diet as ordered Date Initiated: 09/26/2023 Created on: 09/26/2023.
Encourage to eat Date Initiated: 05/09/2023 Created on: 05/09/2023.
Meds as ordered Date Initiated: 09/26/2023 Created on: 09/26/2023.
RD consult as needed Date Initiated: 05/03/2023 Created on: 05/03/2023.
Record meal % intake Date Initiated: 05/03/2023 Created on: 05/03/2023.
Review dietary preferences with the resident as needed Date Initiated: 06/07/2023 Created on: 06/07/23.
Supplements as ordered Date Initiated: 09/28/2023 Created on: 09/28/2023.
Weights as ordered Date Initiated: 05/09/2023.
A review of the clinical record revealed the following excerpts from the Registered Dietician admission note dated 05/03/2023:
Height: 70 inches, IBW (ideal body weight) =166.0# Weight: 5/3/2023=175.0# (Hosp wt. 175#) BMI: 25.1
Nutrition risk potential for weight fluctuations r/t recent hospitalization, Incomplete Lesion of L1 Lumbar Spinal Cord, Paraplegia, Hereditary and Idiopathic Neuropathy, Sepsis, Necrotizing Fasciitis, Colostomy, Psychoactive Substance Abuse, Anemia in CKD
Nutrition Prescription / Interventions (I): Add MVI with Minerals to aid in wound healing Monitor / Evaluation (M/E): Monitor weights, meal intake and provide follow up per protocol.
The following excerpt is from the Registered Dietician's quarterly note dated 06/06/2023:
Diet: Regular diet, Regular texture, Thin Liquids consistency - Po intake: 76-100% of most meals Supplement: none
Skin: pressure area to Sacrum per 5/30/2023 Skin Observation Tool Labs: none Pertinent Meds: Morphine Sulfate, Famotidine, Ondansetron HCl, Gabapentin, MVI with Minerals, Oxycodone HCl Height: 70 inches, IBW (Ideal Body Weight) =166.0# Weight: 5/3/2023=175.0# (Hosp wt. 175#) BMI: 25.1 Continue current interventions Monitor / Evaluation (M/E): Monitor weights, meal intake and provide follow up per protocol.
The following Registered Dietician note was entered during the survey:
9/29/2023 6:33 AM -Nutrition/Dietary Note: Note Text: Spoke with resident 9/27/2023, requested supplement change from Med Plus to Mighty Shake q day at 2pm. Residents goal weight is ~160.#. Weights now appear stable at goal, resident refused monthly weight. Continues consuming current diet well. Monitor /Evaluation (M/E): Monitor weights, meal intake and provide follow up per protocol.
On 09/29/2023 at approximately 3:00 p.m., an interview was conducted with Resident #22. He was asked if he was trying to lose weight, and he stated he was not and now they are giving him mighty shakes to gain back what he lost.
On 10/4/23 during the end of day meeting, the Administrator was made aware of the concerns.
No further information was provided.
2. For Resident #53, the facility staff failed to ensure the resident did not sustain a significant weight loss.
Resident #53 was admitted to the facility on [DATE] weighing 130 lbs. On 09/25/2023, Resident #53 weighed 119 lbs. this is a weight loss of 8.4% (11lbs) in little over a month.
A review of the care plan read as follows:
FOCUS: Resident is at risk for weight loss or malnutrition related to recent hospitalization, mechanically altered diet, Encephalopathy, HIV, Opioid Dependence, Cerebral Infarction, Dysphagia, Chronic Hepatitis Date Initiated: 08/07/2023 Created on: 08/07/2023.
GOAL: The resident will have optimal nutrition and hydration status thru review period Date Initiated: 08/07/2023 Created on: 08/07/2023.
INTERVENTIONS: Assist with meals as needed and observe for any difficulty eating/swallowing Date Initiated: 08/10/2023 Created on: 08/10/2023.
Diet/fluids as ordered Date Initiated: 08/10/2023 Created on: 08/10/2023.
Encourage to eat Date Initiated: 08/07/2023 Created on: 08/07/2023.
RD consult as needed Date Initiated: 08/07/2023.
Record meal % intake Date Initiated: 08/07/2023 Created on: 08/07/2023.
Review dietary preferences with the resident as needed Date Initiated: 08/10/2023 Created on: 08/10/2023.
Supplements as ordered Date Initiated: 08/07/2023 Created on: 08/07/2023.
Weights as ordered Date Initiated: 08/07/2023 Created on: 08/07/2023.
A review of the clinical record revealed that Resident #53 had only been seen by the Registered Dietician on one occasion, 08/07/2023. Excerpts are as follows:
8/7/2023 09:54 Nutrition/Dietary Note: Note Text: Nutrition Assessment (A) Brief Patient Description: [AGE] year-old male, admitted [DATE] Medical Dx: Encephalopathy, HTN, Asymptomatic HIV, Cardiac Arrhythmia, Rhabdomyolysis, Opioid Dependence, Cerebral Infarction, Dysphagia, Chronic Hepatitis
Diet: Regular diet, Dysphagia Mechanically Altered texture, Nectar Thick Liquid consistency
Po intake: 50-100% of most meals - Supplement: Ensure Nutrition Shake BID.
Height: 67 inches, IBW [Ideal Body Weight] =148.0# Weight: 8/1/2023=130.0# BMI: 20.4 Estimated nutritional needs: 59 kg = 1700-1900 kcal (28-32 kcal/kg), 59-70 gms protein (1.0-1.2 gms/kg), 1700-1900 mL fluid (1 mL/kcal) Nutrition risk potential for weight fluctuations or malnutrition r/t recent hospitalization, mechanically altered diet, Encephalopathy, Asymptomatic HIV, Opioid Dependence, Cerebral Infarction, Dysphagia, Chronic Hepatitis Nutrition Prescription / Interventions (I): Change Ensure Nutrition Shake to Med Plus 2.0 @ 120 mL po BID between meals to allow for increased po intake at meals, mechanically altered diet, malnutrition prevention Monitor / Evaluation (M/E): Monitor weights, meal intake and provide follow up per protocol.
Diet orders for Resident #53 read as follows:
Regular diet, Dysphagia Advanced texture, Thin Liquids consistency Aspiration Precautions; [NAME] Tuck Diet Active 8/23/2023 8:05 am.
On 09/28/2023 at approximately 12:00 p.m., an interview was conducted with Resident #53 who stated he did not like the food at the facility. When asked if anyone had asked him for his preferences or his likes and dislikes he stated, They might have but that is not what I get.
On 10/04/2023 during the end of day meeting, the Administrator was made aware of the findings.
No further information was provided
3. For Resident #19, the facility staff did not intervene during the significant weight loss of a resident with known dysphagia following a stroke, insulin dependent Diabetes Mellitus, and 3 wounds.
Resident #19 was admitted to the facility on [DATE], and most recently readmitted after hospitalization on 09/19/2023 with diagnoses including, encephalopathy, urinary tract infection, oral cadidiasis, and COVID-19. Resident #19 had a medical history including, stroke, diabetes, and acute gastrointestinal bleeding with resulting acute post hemorrhagic anemia and weakness from the 12/26/2022 admission.
The resident's most recent quarterly Minimum Data Set (MDS) assessment was dated with an assessment reference date of 06/21/2023, and coded Resident #19 as moderately cognitively impaired, required extensive assistance with feeding, coded no wounds nor skin problems, at risk for malnutrition, weight 148.0 lbs (pounds), and no swallowing issues. The assessment was in error as Resident #19 had 2 ongoing long standing foot wounds from an original admission known for years.
It is notable to add that no significant change MDS assessment was completed from Resident #19's readmission from the hospital on [DATE] through the time of survey ending 10/04/2023 (15 days after readmission). Resident #19 had a known significant weight loss before hospitalization, and a new pressure sore on the resident's right buttock was found on the day of readmission at unstageable due to slough in the wound bed. These issues would require further nutritional support for wound healing and significant weight loss. According to the regulation, a significant change assessment should be conducted within 14 days of a known decline in 2 or more areas such as unplanned weight loss and a new unstageable pressure wound.
On 01/02/2023, the Registered Dietician (RD) evaluated the resident and documented: Nutrition Assessment (A) .Diagnoses regular diet level 4 pureed texture, regular liquids consistency. Po (oral) intake 25-75% of most meals, supplement none, .pressure wound, medications named , Nutrition Prescription/interventions (1) add multivitamin with minerals to aid in wound healing (2) Add ensure compact 4 ounces by mouth due to variable oral intake, increased needs for wound healing, malnutrition prevention, advanced age Monitor/Evaluation (M/E): Monitor weights, meal intake and provide follow up per protocol.
On 06/20/2023, the last RD evaluation document was completed in the clinical record and stated, Nutrition Assessment (A) quarterly ARD 6-21-23 Diagnoses .regular diet regular texture, thin liquids consistency. Po (oral) intake 50-100% of most meals, supplement med plus 2.0 at 120 milliliters by mouth with (hs) bedtime labs, medications named , continue current interventions Monitor/Evaluation (M/E): Monitor weights, meal intake and provide follow up per protocol. weight 148.3 lbs (pounds).
On 09/07/2023 and 09/14/2023, dietary notes indicated significant weight loss was identified; however, no new interventions nor orders were added.
The facility inspection/survey began on 09/25/2023 and ended on 10/04/2023. Resident #19's weight document was reviewed and revealed the following:
1. 07/03/2023 - 145.0 pounds
2. 08/07/2023 - 140.2 pounds (5 pound weight loss in one month begins)
3. 09/06/2023 - 131.6 pounds (now a 14 pound (10 % ) weight loss in 2 months)
4. 09/11/2023 - 129.0 pounds (now a 16 pound weight loss 9 weeks) Resident #19 went out to the hospital on [DATE] and returned on 09/19/2023.
5. 09/19/2023 - 135.0 (a 6 pound weight gain during hospitalization)
6. 09/25/2023 - 126.0 pounds (a 9 pound weight loss begins again)
7. 09/27/2023 - 119.4 pounds (now almost 20% weight loss in less than 4 months) and weight loss continues.
Physician and RD orders were reviewed and revealed that from 01/03/2023, multivitamin was ordered and discontinued on 06/30/2023, the regular diet was discontinued on 06/30/2023, and the Ensure Compact supplement was discontinued on 06/01/2023. The Med Plus 2.0 supplement was started on 06/01/2023, and discontinued on 06/30/2023.
There were no orders for supplements after the 06/30/2023 discontinuance until 09/19/2023 after a significant weight loss had occurred and been ongoing for months. The multivitamin, and Med Plus 2.0 were restarted on 09/19/2023; however, the Med Plus 2.0 supplement was discontinued nine days later on 09/28/2023 by a physician's order. Weekly weights were obtained beginning 09/06/2023, indicating knowledge of the significant weight loss (10 days) before hospitalization on 09/16/2023 for Resident #19; however, no interventions were added for the weight loss.
The medication administration record (MAR) documented that the Med plus 2.0 was given daily after 09/228/2023, even after being discontinued, and on 09/28/2023, the diet was changed to mechanically altered, which dietary staff indicated meant chopped.
Resident #19 did not receive supplements from 06/30/2023 until 09/19/2023 during a significant weight loss, and the RD did not evaluate nor intervene during a significant weight loss.
Resident #19's nutrition care plan, completed and initiated on 01/02/2023, was canceled on 09/18/2023 by the RD. No new nutrition care plan nor any other care plan had been completed at the time of survey on 09/25/2023, nor through 09/27/2023 (9 days after readmission) when documents were obtained. The new readmission care plan was in development according to staff nurses when asked to review the care plan in the electronic clinical record.
Resident #19 did not have a dehydration care plan even though the resident had experienced dehydration in the facility and received Clysis fluid resuscitation instilled subcutaneously on several occasions. Resident #19 did not receive diuretic medications, which remove fluid from the body.
Activities of Daily Living (ADL) records were reviewed and revealed that the Resident needed to be assisted and received extensive assistance. The Resident consumed varying amounts of meals from 0% to 75%.
Family interviews to include the Resident's daughter, and granddaughter, who stated she was an Licensed Practical Nurse (LPN), revealed that Resident #19 had to be fed and will at times accept things in her hands to eat, such as sandwiches; however, she must be cued to eat them. The family was very involved with the resident's care and were there in the facility almost every day. The family stated they had not received a baseline care plan nor had they been invited to a care plan meeting since the resident was readmitted on [DATE], and they were concerned about the resident's weight loss.
Staff interviews revealed that Resident #19 had to be fed, and that she would stop eating if not fed.
Observations conducted on 09/29/2023 at 12:00 p.m., revealed Resident #19 in the communal dining room on the nursing unit. The resident was sitting at a table with 3 other residents with meal trays in front of them, and they were being assisted by one staff member to set up and feed the residents at the table. Resident #19's tray was observed to have 1/2 inch cubed turkey meat, 1/2 inch chopped cubes of cabbage, mashed potatoes and gravy. The resident was not eating and CNA (Certified Nursing Assistant) D who was sitting with the residents stated she would be feeding Resident #19.
Observations were continued and only one teaspoonful of potatoes was placed up to Resident #19's mouth, of which, the resident took half into her mouth and swallowed. At 1:00 p.m., all trays were loaded onto the cart to return to the kitchen. Resident #19's tray was observed to have 1/2 spoonful of mashed potatoes consumed and the other half of the spoonful was still on the spoon, indicating no other food was fed to the resident.
At 1:15 p.m., CNA D was interviewed and asked why she had not fed Resident #19. CNA D stated She (Resident#19) was very sleepy so I told the nurse (LPN D) and didn't offer her any more food. LPN (Licensed Practical Nurse) D was interviewed and stated, the speech therapist was changing the resident's diet and Resident #19 would receive another tray, but the resident has thrush so she probably won't eat anyway. The surveyor told LPN D that CNA D stated she was sleepy and that is why she was not eating. LPN D stated she didn't tell me that. The resident was observed for the rest of the shift, and never received another tray. It is notable to mention Resident 19's finger stick blood sugar (FSBS) testing that morning indicated 78, which was low for the resident.
On 09/29/2023 at approximately 1:15 p.m., Resident #19's room was entered with CNA D, in the search for Resident #19's dentures which were missing. The resident had 3 plastic denture cups; however, all three were empty. One cup was in the floor behind the headboard of the resident's bed, one was in the large lower door of the bedside cabinet, and the third was in the upper drawer of the bedside cabinet. When the cabinet door and drawer were opened cockroaches ran out (approximately 5-10 insects) and all over the sides and top of the bedside cabinet. CNA D stated she would have maintenance come immediately and spray the area with insecticide. The dentures were not found in the room nor in the medication cart.
On 09/29/2023 at the end of day debriefing, conducted with the Administrator and Regional Director of Operations, they were notified of findings for Resident #19.
On 10/04/2023 at approximately 2:00 p.m., the Administrator, Corporate Nurse Consultant, and Regional Director of Operations were again notified of findings, and they stated they had nothing further to provide.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
Based on interview, clinical record review, and facility documentation, the facility staff failed to provide snacks to residents who wish to eat outside of scheduled meal times.
The findings included:...
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Based on interview, clinical record review, and facility documentation, the facility staff failed to provide snacks to residents who wish to eat outside of scheduled meal times.
The findings included:
For residents who wish to eat outside of regular mealtimes, the facility failed to ensure snacks were available on the units.
On 09/26/2023 at approximately 2:00 p.m.,during the Resident Council meeting, 6 of 6 residents agreed that snacks are not available in the evenings.
A review of the Resident Council minutes revealed that snacks being unavailable has been brought up in 4 of the last 6 meetings.
On 09/28/2023 at 10:00 a.m., an interview was conducted with Employee K who stated that she sends snacks to the floor including cookies, pudding, applesauce, peanut butter crackers, juices, and milk. She stated that she does not know why there is not any left at bedtime.
An interview was conducted with CNA G who stated there is hardly ever any snacks for residents. CNA G stated she has worked evenings and they did not have any when she worked.
An observation was made of the pantry area on each unit on 09/28/2023 at 12:50 p.m., and there were snacks available at that time. Per the Resident Council minutes pantries should be stocked every shift.
On 10/04/2023 during the end of day meeting, the Administrator was made aware of the concerns.
No further information was provided.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Deficiency Text Not Available
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Deficiency Text Not Available
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to obtain consent and provide education prior to the administration of the flu vaccine fo...
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Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to obtain consent and provide education prior to the administration of the flu vaccine for four residents (Residents #43, #47, #20, and #42) in a survey sample of 5 residents reviewed for immunizations.
The findings included:
For Residents #43, #47, #20 and #42, the facility staff failed to provide education regarding the risks and benefits of the immunization to be administered and failed to obtain consent prior to administration of the immunization.
On 09/26/2023, a clinical record review was conducted of the sampled residents reviewed for immunizations. The Surveyor was not able to view all the details regarding the administration of immunizations.
On 09/26/2023 at 4:00 p.m., Surveyor F met with the facility's Infection Preventionist (Employee C). During this meeting, Employee C accessed the clinical record of each of the residents and the following was noted:
1. Resident #43 was administered the influenza immunization on 10/17/2022. Consent for the immunization was not obtained until 10/18/2022, and there was no evidence of any education being provided.
2. Resident #47 was administered the flu vaccine on 10/17/2022. There was no evidence of any education being provided, and consent was not obtained until 10/18/2022.
3. Resident #20 was administered the flu vaccine on 10/18/2022. On 12/08/2022, consent was obtained for the immunization and no education was provided.
4. Resident #42 received the flu vaccine on 12/13/2022 and education was not provided until 07/14/2023.
During this review, the above noted concerns were shared with the Infection Preventionist (IP), who confirmed the findings. The IP stated that education and consent for immunizations are to be obtained/provided prior to the administration of any immunizations.
A review of the facility policy entitled, Influenza Vaccination, effective date 05/01/2023, was conducted. It stated under the subtitle, Procedure: item 1, e, read, Prior to administering the flu vaccine to patients, complete the following: 1. Educate the patient and/or RP [Responsible Party] using the CDC's Vaccination Information Sheet (VIS). Document education in the electronic medical record. 2. Obtain informed consent and document in the electronic medical record.
On 09/26/2023 during an end of day meeting, the Director of Nursing and Corporate staff were made aware of the findings.
No further information was provided.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and facility documentation, the facility staff failed to maintain an ef...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and facility documentation, the facility staff failed to maintain an effective pest control program so that the facility is free of pests involving 2 of 2 units in the facility.
The findings included:
For 2 of 2 units in the facility, roaches and/or bedbugs have been reported.
On 09/29/2023 at approximately 1:15 p.m., Surveyor E entered Resident #19's room with CNA D, in the search for Resident #19's dentures which were missing. When the cabinet door and drawer were opened, cockroaches ran out (approximately 5-10 insects) all over the sides and top of the bedside cabinet.
A review of the pest control log revealed that on 08/04/2023 rooms #32, #37 and #54 were treated for bed bugs; however, no follow-up treatment was done to ensure any eggs that have hatched were treated for, which is standard practice for bedbug treatment.
On 09/28/2023, the resident in room [ROOM NUMBER] was complaining of itching and stated he had bed bugs. The facility did treat that room on 09/29/2023.
On 10/04/2023 during the end of day meeting, the Administrator was made aware of the findings.
No further information was provided.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0949
(Tag F0949)
Could have caused harm · This affected multiple residents
Based on interview, clinical record review, and facility documentation, the facility staff failed to provide behavioral health training for all staff caring for the residents identified as having beha...
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Based on interview, clinical record review, and facility documentation, the facility staff failed to provide behavioral health training for all staff caring for the residents identified as having behavioral healthcare needs for 5 of 5 nursing staff members (Staff #6, Staff #21, Staff #22, Certified Nursing Assistant [CNA]-H and CNA-K) in the sample.
The findings included:
1. For all residents identified as having behavioral healthcare needs, the facility failed to provide training to staff to care for such residents.
A review of the facility assessment and CMS form 672 - Census and Condition Form revealed that there are 46 residents identified with behavioral healthcare needs. A review of the document entitled Facility Assessment, the facility is equipped to care for residents with behavioral healthcare needs, PTSD (Post-traumatic Stress Disorder), and substance abuse issues.
On 09/25/2023 at approximately 1:00 p.m., an interview was conducted with Resident #22 who stated the facility, Does not know how to deal with us. I have PTSD and they don't know how to talk to me. When asked to elaborate, he stated the facility staff are loud and rude and that triggers him to become aggressive. When asked if he has told anyone about this, he stated he has spoken to the DON and the Administrator about it, but nothing is done. He also stated he had a substance abuse problem prior to coming to the facility and that the facility staff use that information against me. When asked what he meant by that, he stated the facility staff downplay his pain because he had a substance abuse issue prior to coming to the facility. He stated the staff have labeled him as drug seeking.
On 09/26/2023 at approximately 3:00 p.m., an interview was conducted with Resident #103 who stated she had a substance abuse problem that she was addressing with the methadone clinic. She stated she also had a diagnosis of PTSD due to past trauma. She indicated the staff at the facility did not understand how to care for her. She stated, They don't know how to talk to me. They don't understand what triggers me and how to handle folks like me. She stated they say she is a drug seeker. She stated she had a PRN morphine order that she sometimes only took 1 time a day. She said, If I was drug seeking, I would be asking for it every 4 hours.
On 09/28/2023 at 11:00 a.m., an interview was conducted with the Staff Development Coordinator who was asked about training for PTSD. She stated, They don't tell me to train on that subject. When asked if she trained on trauma-informed care, she stated she did not. When asked if she trained on behavioral healthcare needs related to substance abuse, she stated she did not. When asked does your staff care for residents in this facility with any or all those issues, and she stated they do.
On 09/28/2023 at approximately 3:00 p.m., an interview was conducted with the Administrator who was asked if the facility accepts residents with PTSD, substance abuse, or other behavioral healthcare issues, and she stated they did. When asked if she expected the staff to be equipped with the training to care for those residents, she stated she did. When asked if she was aware that the Staff Development Coordinator was not conducting training on those areas, she stated that she was not.
On 10/04/2023 during the end of day debriefing, the Administrator was made aware of the concerns.
No further information was provided.
2. The facility failed to provide behavioral health education/training and competencies to include trauma and Post-traumatic Stress Disorder (PTSD) for its staff members.
On 09/25/2023 at 11:50 a.m. during the initial tour of the facility, Resident #22 approached the surveyors and stated he had PTSD and the facility staff, Did not know how to take care of people diagnosed with PTSD. Resident #22 stated he was upset about it. He stated he really was diagnosed with PTSD. They (facility staff) act like they don't know how to handle it (PTSD). Resident #22 also stated the staff treated him as if he was pretending. Resident #22 stated this is serious. The resident stated he did not feel understood by the staff.
On 09/26/2023 at 9:05 a.m., an interview was conducted with Licensed Practical Nurse B (LPN B) who stated there were residents in the facility who had diagnoses of PTSD and other behavioral health conditions. LPN-B stated she had not received specialized training on caring for residents with trauma/PTSD.
On 09/27/2023 at 12:55 p.m., an interview was conducted with Certified Nursing Assistant who stated she had not received any special training on caring for residents with trauma/PTSD.
Review of the Facility Assessment revealed a review date of 08/31/2023. The Facility Assessment, Part 2. Services and Care Offered Based on Resident Needs (on page 1 of 2) Section 2.1 General care and Specific Care or Practices listed the general care area of Mental health and behavior and under Specific Care or Practices was written, Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with trauma/PTSD, other psychiatric diagnoses.
On 09/27/2023 at 2:15 p.m., an interview was conducted with the Staff Development Coordinator who stated she provided in-service education and training to the facility staff members. The Staff Development Coordinator stated staff members also complete computer-based training on required subjects. She stated she was aware the facility accepted residents for admission who were diagnosed with behavioral health issues to include but not limited to mental, psychosocial, or substance use disorder, a history of trauma and/or post-traumatic stress disorder, or other behavioral health condition and dementia according to the facility assessment. The Staff Development Coordinator stated the facility assessment was utilized to ensure residents could receive the care and services necessary for their well-being. The Staff Development Coordinator stated she was not told to include trauma/PTSD in the training topics, but would immediately begin to train on that topic.
Review of the 5 sampled employee training records revealed no documentation of training on trauma/PTSD.
On 09/27/2023 during the end of day debriefing, the facility Administrator, Director of Nursing, and Corporate Nurse Consultant were informed of the findings of no behavioral health training on trauma/PTSD.
On 09/28/2023, the Staff Development Coordinator provided a copy of the training curriculum including topics covered during orientation and training sessions. Review of the curriculum revealed there was no documentation of the topic of trauma/PTSD.
During the end of day debriefing on 10/3/2023, the facility Administrator, Director of Nursing, Corporate Nurse Consultant, and [NAME] President of Operations were informed of the findings.
No further information was provided.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected most or all residents
Based on observation, resident interviews, staff interview, and facility documentation review, the facility staff failed to prepare the meal in accordance with the menu, which affected the residents r...
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Based on observation, resident interviews, staff interview, and facility documentation review, the facility staff failed to prepare the meal in accordance with the menu, which affected the residents residing on 2 of 2 nursing units.
The findings included:
On 09/25/2023 and 09/26/2023 during the initial tour, a significant number of residents, residing on both nursing units, expressed concern regarding the food to all surveyors.
On 09/27/2023 during the morning, Surveyor F made observations of several residents' breakfast trays. The findings were as follows:
For Resident #17, the meal ticket indicated she was to get scrambled eggs, slivered green onions, biscuit, grits, and sausage gravy. There was a notation at the bottom that the resident requested Hb Egg [hardboiled egg]. The meal tray consisted of 2 hardboiled eggs, 2 pieces of toast, and a bowl of oatmeal.
During the above observation of Resident #17's meal tray, the resident said, I don't eat grits, but we never get what is on the ticket.
Additional observations were made, which included but were not limited to Resident #65 and Resident #49. Both residents' meal ticket indicated they were to have scrambled eggs, slivered green onions, biscuit, grits, and sausage gravy. Neither of them had any slivered onions, biscuits, grits, or sausage gravy. Both had scrambled eggs, toast, and oatmeal. Resident #49 said, While you are here and make recommendations, next week it will go back to the same thing, there is no consistency. We never get salt, the toast is burnt on the ends, and we never have sausage gravy.
On 09/27/2023, Surveyor F reviewed the menu, which indicated it was Day 18 and the menu was supposed to be, Scrambled eggs, slivered green onions, biscuit, grits, and sausage gravy.
On 09/27/2023 at 9:20 a.m., Surveyor F conducted an interview with the cook, Employee J. When asked what he had prepared for the meal, Employee J said, eggs, oatmeal, toast, hard boiled eggs, and sausage. When asked what is the purpose of the meal ticket, the cook stated, It tell you what they are eating and their diet. The cook was asked to let the surveyor see the menu for the day. The cook pulled out a binder with the menu which listed the biscuits and sausage gravy and oatmeal. When questioned why these items were not prepared, the cook said, The biscuits didn't come on the truck, we don't do sausage gravy, when you see that on the menu, we do sausage and grits. We changed because they complained they didn't like it anymore.
The dietary manager joined Surveyor F and Employee J during the above interview. The dietary manager was asked to allow Surveyor F to see the menu substitution log. The dietary manager was unable to locate the log and indicated she would have to call the evening cook. At the end of the day, the dietary manager confirmed she had never been able to locate the menu substitution log.
On 09/27/2023 at 10:08 a.m., the dietary manager (DM), Employee K, and the registered dietician (RD),Employee N, were in the conference room with the survey team. The DM and RD were asked about the process with regarding the residents' meals. The DM said they, at the least, discuss it during Resident Council meetings. The survey team shared the abundance of concerns that residents had shared regarding the food. Surveyor F made the RD aware of the observations from breakfast and asked if she had approved such changes to the menu. The RD said she had just been made aware prior to them coming into the conference room and the menu had not formally been changed.
It was also pointed out that their current menu had been in use since January 5, 2022, and that residents have complained about always getting the same thing. The RD and DM both stated they are working to update menus now.
On 09/28/2023 during the breakfast meal observations, it was again noted that the residents were not receiving the meal items that were listed on their meal tickets.
On 09/28/2023 during mid-morning, the Administrator was made aware of the above findings and observations regarding the menus not being followed and residents' concerns with the meals.
On 09/29/2023 during the mid-day/lunch meal, observations were made of residents' meal trays. Again, it was noted that the items listed on the menu were not being served. Squash casserole was supposed to be served according to the menu, the meal tickets had that item crossed out and broccoli hand-written in, but the residents were served cabbage.
On 09/29/2023, the dietary manager presented Surveyor F with a Dietary Menu Substitution Record that indicated for the lunch meal, cabbage was added and squash was omitted. The reason for the change was noted as, Residents choice. There was no indication in any other records reviewed that the residents had requested this change or were previously made aware of the change.
Review of the Resident Council meeting minutes revealed the following:
1. During the August 16, 2023, meeting, Residents expressed, What is on meal tickets are not served .Wrong diets served. The department's response was, Dietary staff will alert pt [patient] when there are menu changes.
2. During the meeting held July 21, 2023, residents expressed, Quality of the food has not improved.
3. In May's meeting, the residents expressed, Alternate meals and sandwiches are not offered. In the resolution section it was noted, Reminder, [contracted dietary company name redacted] is only responsible for posted menu items only per Dietary Manager.
There was no evidence that the Resident Council had expressed any concerns regarding the sausage gravy, grits, or biscuits.
Review of the facility policy titled, Menus was conducted. This policy read, It is the center policy that menus are planned in advance, and to meet the nutritional needs of the residents/patients, will be developed utilizing an established national guideline. 6. Menus are served as written, unless changed in response to preference, unavailability of an items, or a special meal. 7. A menu substitution log will be maintained on file.
On 09/28/2023, at the end of the survey day, the facility Administrator was made aware of the above findings.
No further information was provided.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected most or all residents
Based on observation, resident interview, staff interview, and facility documentation review, the facility staff failed to serve food that was palatable and hot to residents on 2 of 2 nursing units.
...
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Based on observation, resident interview, staff interview, and facility documentation review, the facility staff failed to serve food that was palatable and hot to residents on 2 of 2 nursing units.
Findings include:
For residents residing on both nursing units, the facility staff failed to serve food in a manner to ensure the food was at a preferred temperature when it reached the residents.
On 09/25/2023 - 09/26/2023 during the initial tour process, an abundance of residents on both nursing units expressed concerns about the food not being hot.
On 09/28/2023, observation of breakfast tray distribution was conducted. For residents residing on the North wing, breakfast trays were not served until 10:00 a.m. It was noted that each cart of meal trays held approximately 25-30 meal trays. One entire cart, which served residents in rooms 1-12, were all served in Styrofoam containers, like a restaurant carryout container. Another cart, which served residents in rooms 13-24, approximately half of the trays were on regular dinnerware plates and the other half were in the same Styrofoam containers.
On 09/28/2023 at approximately 10:05 a.m., while breakfast trays were being distributed to residents, interviews were conducted with CNA B and CNA G. When asked about the Styrofoam, their responses were, They must have run out of plates and Sometimes they are all served on Styrofoam.
Resident interviews were conducted, and numerous residents complained that the food was not hot. Resident #65 commented that she did not mind the Styrofoam so much as it did not keep the food warm.
On 09/28/2023 at approximately 10:25 a.m., Surveyor F went to the kitchen to interview the cook. The cook was asked about the timing of meal trays, and he indicated the last cart had just left the kitchen about 10-15 minutes ago. When asked if this was normal or if something impacted the meals being late this morning, the cook said, No, everything went smooth, we had no problems. The cook was asked about residents being served on Styrofoam, and he said that they did not have enough clean plates.
During the above interview, the dietary manager joined the conversation. The dietary manager stated, When late trays don't come back to the kitchen timely at night, we can't wash them, and they aren't available in the morning. The dietary manager also stated the food is hot when it leaves the kitchen, but it sits on the floors/halls and when staff do not pass/distribute them timely, the food gets cold. Additionally, she stated that one of the carts has a broken door and will not latch for the South wing, so it allows the heat to escape and that maintenance is going to work on the cart.
On 09/29/2023, meal trays for lunch were observed on the South wing and multiple residents again complained that the food was not hot.
Review of the Resident Council minutes was conducted. This review revealed a Service Concern Report was submitted in April following the Resident Council meeting for food being cold.
Review of the facility's dietary policies provided to the survey team were reviewed. The policies did not address the palatability and food temperature at the time of meal delivery.
On 09/29/2023, the facility Administrator was made aware of the above findings.
No additional information was provided.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected most or all residents
Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide COVID-19 bivalent vaccines for 5 residents (Residents #43, #47, #1, #20, and #...
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Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide COVID-19 bivalent vaccines for 5 residents (Residents #43, #47, #1, #20, and #42) and 5 staff in a survey sample of 5 residents and 5 employees reviewed for COVID-19 immunizations. They also failed to provide education and obtain informed consent prior to administration of COVID-19 immunizations, for 4 of 5 Residents (Resident #43, #47, #20, and #42).
The findings included:
1. The facility staff failed to offer/provide COVID-19 bivalent immunization, to include education of risks/benefits about COVID-19 immunization, for Residents #43, #47, #1, #20, and #42.
On 09/26/2023, a clinical record review was conducted of the sampled residents reviewed for immunizations. The Surveyor was not able to view all the details regarding the administration of immunizations. There was no indication that any of the sampled residents had been educated on the benefit of or offered the COVID-19 bivalent immunization.
2. The facility staff failed to offer/provide COVID-19 bivalent immunization information to all 5 sampled employees reviewed.
On 09/26/2023, a sample of 5 employees was selected for review of being educated on the benefit of immunization and/or offering of COVID-19 immunizations. For the 5 employees reviewed, the COVID-19 immunization status of 2 employees (LPN E and Employee Q) was not known at the time of survey and there was no evidence they had been provided any education or offer for COVID-19 immunizations. The other 3 employees (RN B, CNA E, and CNA F) had no evidence of having received, offered, or having been educated on the benefit of receiving a COVID-19 bivalent immunization.
On 09/26/2023 at 4:00 p.m., Surveyor F met with the facility's Infection Preventionist (Employee C). During this meeting Employee C accessed the clinical record of each of the residents and Surveyor F questioned the COVID-19 bivalent vaccine being offered.
The facility's Infection Preventionist said, I have my resident COVID listing, and I go from there. When asked specifically about the bivalent vaccine, the IP said, Last year we were going to have one [a clinic] but we had issues and didn't. When asked what kind of issues she was referring to, the IP said, State [surveyors] came in. The IP also stated, A lot of them are jumping at the bit for COVID vaccine, since it is on the rise again. I told them we will get a clinic started as soon as possible. I have to find out how to order the vaccine and set all of this up. When asked if anyone had been offered the COVID bivalent vaccine since it has been out for a year now, the IP said, No, not at this point, that's what we have to work on and will be investigating when [Administrator's name redacted] gets back, how to order, where to order, etc.
On 09/26/2023 at approximately 5:00 p.m., a review of the facility policy entitled, COVID-19 Vaccinations, effective date 05/01/2023, was conducted. It stated under the subtitle, Procedure, item 1, CDC [Centers for Disease Control and Prevention] recommends that everyone stay up to date with COVID-19 vaccination. b. Recommendations: Individuals who have received one or more doses of a monovalent COVID-19 vaccine: A single dose of a bivalent mRNA vaccine, at least 2 months after any monovalent COVID-19 vaccine.
The above policy also stated: 2. Prior to administering any COVID-19 Vaccine (and for each dose) complete the following for patients: a. Provide the Emergency Use Authorization (EUA) Fact Sheet for Recipients and Caregivers to patient and/or RP and educate regarding benefits and potential side effects. 3. Obtain consent from the patient or responsible party and fill out the consent form.
The Centers for Disease Control and Prevention (CDC) document titled, Interim Clinical Considerations for Use of COVID-19 Vaccines in the United States, updated May 12, 2023, page 2, Recommendations for the use of COVID-19 vaccines, read, COVID-19 vaccination is recommended for everyone ages 6 months and older in the United States for the prevention of COVID-19 and CDC recommends that people ages 6 months and older receive at least 1 bivalent mRNA COVID-19 vaccine.
On 09/26/2023 during an end of day meeting, the facility's Director of Nursing and Corporate staff were made aware of the findings.
No further information was provided.
3. The facility staff failed to provide education and obtain informed consent prior to the administering COVID-19 vaccines.
On 09/26/2023, a clinical record review was conducted of the sampled residents reviewed for immunizations. The Surveyor was not able to view all the details regarding the administration of immunizations.
On 09/26/2023 at 4:00 p.m., Surveyor F met with the facility's Infection Preventionist (Employee C). During this meeting, Employee C accessed the clinical record of each of the residents and the following was noted:
1. Resident #43 was administered a Pfizer COVID monovalent booster on 12/17/2021. Consent for the immunization was not obtained until 04/06/2022, and there was no evidence of any education being provided.
2. Resident #47 was administered the Pfizer monovalent COVID booster vaccine dose on 12/17/2021. There was no evidence of any education being provided, and consent was not obtained until 04/06/2022.
3. Resident #20 was administered a Pfizer monovalent booster dose of the COVID vaccine on 12/17/2021. On 04/06/2022, consent was obtained for the immunization and no education was provided.
4. Resident #42 received the Pfizer monovalent COVID booster vaccine on 12/17/2021. Education was not provided, and consent was not obtained until 04/05/2022.
During this review, the above noted concerns were shared with the Infection Preventionist (IP), who confirmed the findings. The IP stated that education and consent for immunizations are to be obtained/provided prior to the administration of any immunizations.
The facility policy entitled, COVID-19 Vaccinations, effective date 05/01/2023, was reviewed. It stated under the subtitle, Procedure, item 1, CDC [Centers for Disease Control and Prevention] recommends that everyone stay up to date with COVID-19 vaccination. b. Recommendations: Individuals who have received one or more doses of a monovalent COVID-19 vaccine: A single dose of a bivalent mRNA vaccine, at least 2 months after any monovalent COVID-19 vaccine.
The above policy also stated, 2. Prior to administering any COVID-19 Vaccine (and for each dose) complete the following for patients: a. Provide the Emergency Use Authorization (EUA) Fact Sheet for Recipients and Caregivers to patient and/or RP and educate regarding benefits and potential side effects. 3. Obtain consent from the patient or responsible party and fill out the consent form.
On 09/26/2023 during an end of day meeting, the facility's Director of Nursing and Corporate staff were made aware of the findings.
No further information was provided.
Jul 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on interview, clinical record review and facility documentation the facility staff failed to review and revise the care plan after assessment for 1 Resident (#1) in a survey sample of 3 Resident...
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Based on interview, clinical record review and facility documentation the facility staff failed to review and revise the care plan after assessment for 1 Resident (#1) in a survey sample of 3 Residents.
The findings included:
For Resident #1, the facility staff failed to review and revise the care plan after falls.
On 7/24/23, a review of the clinical record revealed that Resident #1 had a fall on 6/23/23 and a fall on 7/13/23.
On 7/24/23, a review of the clinical record revealed that Resident #1's care plan had not been updated after she fell.
On 7/25/23, an interview was conducted with the DON who stated that care plans should be updated with any changes in patient conditions, medications and or treatments. When asked if this was done, she stated that it had not been.
On 7/25/23, during the end of day meeting the Administrator was made aware of the concerns and no further information as provided.
Mar 2023
2 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to transfer 1 of 3 sampled residents (Resident #1) properly and as a result Resident #1 s...
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Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to transfer 1 of 3 sampled residents (Resident #1) properly and as a result Resident #1 sustained a fracture. This is Harm, Past Noncompliance.
The findings include:
On 03/15/2023, a review of Resident #1's care plan in effect for 10/31/2022 was reviewed. The review showed that Resident #1 required a two person lift via a Hoyer lift.
Review of Resident #1's clinical record showed a note dated 10/31/2022. The note read that Resident #1 was seen by the Nurse Practitioner (NP) due to complaints of pain to left leg and left shoulder after being put back to bed without hoyer lift. The NP ordered x-rays.
A note dated 11/1/2022 read that Resident #1 had a comminuted mid tibial fracture and subcapital femoral neck [fracture]. The note also read that Resident #1 needed to be sent to the ER.
A review of facility documentation revealed a form titled Employee Corrective Action. The form showed that Certified Nurses Assistant (CNA) B failed to perform transfer according to the resident plan of care and document mode of transfer. The form further showed that this failure resulted in harm to resident.
The facility took corrective actions. The facility re-educated staff concerning transfers and documentation. The facility audited all residents care plans to make sure the care plans had the correct mode of transfer. The facility completed the corrective actions on 11/02/2022. Therefore, this deficient practice will be past non-compliance.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected 1 resident
Based on staff interview and facility documentation review, the facility staff failed to have eight hours of Registered Nurse (RN) coverage for 1 of 30 days reviewed. There was no RN in the facility o...
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Based on staff interview and facility documentation review, the facility staff failed to have eight hours of Registered Nurse (RN) coverage for 1 of 30 days reviewed. There was no RN in the facility on 2/19/2023.
The findings include:
On 03/15/2023, a review of the facility's as worked schedule was conducted. The review showed there was no RN in the facility on Sunday 02/19/2023.
An interview was conducted with the Assistant administrator on 03/15/2023. The Assistant Administrator confirmed there was no RN in the facility on 02/19/2023.
The facility was informed of the findings during a briefing on 03/15/2023.
Jan 2023
17 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Abuse Prevention Policies
(Tag F0607)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility documentation review , the facility staff failed to implement the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility documentation review , the facility staff failed to implement their abuse policy for 2 Residents (Resident #15, and 13) in a survey sample 9 Residents. In addition, the facility staff permitted a known perpetrator of abuse (CNA B) to work in the facility having direct contact with Residents on 1 of 2 nursing units.
Immediate Jeopardy (IJ) was identified on 1/20/23 at 3:55 PM, at which time the facility Administrator and Director of Nursing were made aware. Following verification of the removal of immediacy the facility abated IJ on 1/26/23 at 4:07 PM. The scope and severity was lowered to a level 2, pattern.
The findings included:
1. The facility staff failed to implement their abuse policy with regards to employee screening and protection of Residents, by permitting a known perpetrator of abuse/neglect (CNA B) to work in the facility having direct contact with multiple Residents who resided on 1 of 2 nursing units within the facility. This resulted in Immediate Jeopardy.
A closed clinical record review was conducted 1/18/23-1/20/23. Resident #15 discharged from the facility and therefore was unavailable for interview.
Review of facility documentation to include, but not limited to grievances, revealed Resident #15 and her family had reported numerous concerns of neglect and being left for extended periods of time/hours without any staff assistance for incontinence care. Specifically, it was noted that on 4/16/22, Resident #15's family reported that On 4/15/22, 3-11 PM shift the resident asked her CNA [CNA B's name redacted] to assist her to bed, the CNA told her she would put her to bed at 9 PM. CNA eventually came back at 9:45 PM complaining that the Resident interrupted her break. She deserves a break because she has been on her feet all day, at this time the Resident stated the CNA hit her in the face with the O2 [oxygen] cord unintentionally and stated that she didn't need it so long.
The facility removed CNA B from the schedule and because the CNA was an agency staff member, the agency was contacted and notified of the allegation. Upon conclusion of the facility's investigation the Administrator had a Summary document which was typed and read, .The agency staff, [CNA B's name redacted] was removed from the scheduled immediately until the facility completed their investigation. After completing interviews with residents and staff it was determined that the incidence [sic] was substantiated the facility could substantiate this was a willful intent of abuse [sic].
There was a statement from the facility's Director of Nursing (DON) who indicated CNA B was placed on a DNR [do not return] status with this facility.
On the afternoon of 1/20/23, Surveyor E met with the facility's scheduling coordinator/Employee P. The scheduling coordinator reviewed past records and confirmed that CNA B did not work any shifts following 4/15/22.
However, a review of the facility's submitted as-worked schedules revealed that CNA B was listed as having been scheduled during the survey as recent as 1/19/23 and was scheduled to work on 1/20/23.
On the afternoon of 1/20/23, Surveyor E met with the facility's human resources manager (HRM)/Employee E. The HRM was able to access and confirmed CNA B was hired by the facility on 6/27/22, as a full-time employee and remained so. The HRM also provided CNA B's timecard which revealed CNA B worked as recent as 1/19/23. The employee file for CNA B was requested and received. Upon review it was determined that CNA B disclosed a prior criminal charge of misdemeanor assault on her sworn statement completed 6/19/22.
The facility Administrator and Director of Nursing who were involved in the investigation of and determination that CNA B had abused/neglected Resident #15 in April 2022, were the same individuals in those positions when CNA B was hired on 6/27/22.
On 1/26/23, a review of CNA B's timecard was conducted and revealed the employee had worked a total of 90 days having direct Resident contact. Many of those days CNA B worked double shifts, therefore having access to and interaction with many Residents and potentially having an opportunity to abuse and/or neglect the Residents again.
On the mid-morning of 1/26/23, Surveyor E conducted an interview with the Regional Human Resources Director (RHRD)/Employee K. Employee K stated that the facility's Administrator and Director of Nursing have a role in approving applicants for hire and should not have permitted CNA B to have been hired since they had prior knowledge of the employee's history and findings of abuse/neglect.
The facility policy titled Abuse/Neglect/Misappropriation/Crime: Prevention/Screening/Training read, The Administrator promotes the prevention of abuse . and neglect and misappropriation of property by performing background checks on all employees and by advocating and enforcing patient rights . The policy also stated, 1. Criminal background and reference checks are performed on all employees .
Immediately Jeopardy was identified on 1/20/23 at 3:55 PM, at which time the facility Administrator and Director of Nursing were made aware. Following this notification, CNA B was removed from the facility and clocked out at 4:08 PM.
On 1/24/23 at 1:37 PM, the facility submitted an accepted IJ removal plan and on 1/26/23, submitted a revised plan which read as follows:
1. Certified Nursing Aide (CNA) B was escorted immediately to the Director of Nursing (DON) office, and the Interim Director of Nursing and Regional Director of Clinical Services (RDCS) informed CNA B regarding the incident of the substantiated allegation of abuse and that she is terminated based on history of substantiated abuse/neglect against a resident.
2. CNA B was escorted by the Interim DON to the time clock. She clocked out at 4:08pm, was escorted to her car and she was observed exiting the facility grounds.
3. The surveyors were informed of the above, and a copy given of her clock out time, on the time sheet prior to exit.
4. The Board of Nursing report completed regarding CNA B substantiated abuse/neglect allegation and the employee file reviewed with 2 other corrective actions based on care issues included on report 1/20/2023.
5. On 1/20/2023 a 100% audit of all Facility Reportable Incidents (FRIs) from past year, 2022, to current January 2023 was completed to ensure no employee is currently employed that was involved in any substantiated FRI.
6. On 1/26/2023 a 100% audit of all facility employees' files, to include agency and contracted staff, were reviewed to verify the screening process was completed by Regional Director of HR. For any employee found not in compliance, they will have direct supervision by another employee with an approved background and reference checks.
7. On 1/20/2023 interviews immediately were conducted of the residents assigned to CNA B by Social Service Director and skin checks were completed on the resident's that could not be interviewed.
8. On 1/20/2023 all current residents of the facility that have the ability to be interviewed were conducted by designated management team to identify any concerns with care and/or allegations of abuse/neglect with abuse/neglect process followed.
9. On 1/20/2023 there were 4 additional residents who were identified with allegations of abuse/neglect. The abuse policy was followed, a FRI was submitted, and the resident was protected with the identified employee(s) suspended pending investigation.
10. On 1/20/2023 residents' family members were interviewed for allegations of abuse/neglect or concerns that were associated with allegation of abuse/neglect, or grievance reports.
11. On 1/20/2023 Staff interviews were conducted for all identified/associated staff with any allegation of abuse/neglect.
12. On 1/24/2023 Staff interviews were conducted to identify concerns for abuse/neglect with any findings further investigated by the Interim Administrator, Interim DON or designee with the abuse/neglect policies followed.
13. On 1/24/2023 all other residents of the facility that do not have the ability to be interviewed had skin checks completed.
14. On 1/23/2023 the grievance concern reports, and the resident council minutes were reviewed and any identified as an allegation of abuse/neglect were reported following the abuse/neglect policy.
15. On 1/23/2023 there were 3 additional residents identified with allegation of abuse/neglect from the review of the grievance concern reports. The abuse policy was followed, a FRI submitted, and the patient was protected with the identified employee suspended pending investigation.
16. Education will be provided to the Administrator and department managers to include human resources, staffing coordinator, dietary, nursing, rehab, housekeeping, social service, business office manager, maintenance, activities, and admissions will be by Regional Director of HR regarding the hiring, prevention, and screening process of anyone involved in a substantiated allegation of abuse/neglect to identify if eligible for hiring.
17. All Facility staff, to include agency staff, will be educated on the policies to include abuse/neglect for patient protection, abuse/neglect/misappropriation/crime prevention, screening/training process, reporting and investigating, and resident rights. All staff will be educated prior to working next facility shift.
18. Administrator and department managers educated on 1/23/2023.
19. [Administrator name redacted], Administrator and [DON name redacted], DON were suspended pending investigation on 1/19/2023.
20. On 1/23/2023 [Administrator name redacted], Administrator and [DON name redacted], DON were terminated by the [NAME] President of Operations (VPO) and Regional Director of HR.
21. [VPO name redacted], VPO is the Interim Administrator and [RDCS name redacted] RN/RDCS is the Interim DON.
22. Compliance date for abatement plan 1/26/2023 at 2:51pm.
The survey team verified the IJ removal plan as evidenced by the following:
On 1/20/23, the survey team remained on-site until CNA B was removed from the facility and received evidence that she had clocked out and left the premises.
The survey team reviewed evidence that CNA B had been reported to the Board of Nursing/Department of Health professions.
The survey team reviewed the FRI's for the past year and identified any staff with a substantiated allegation of abuse/neglect and verified that they were not currently employed or working in the facility.
The survey team reviewed the 100% audits conducted by the facility staff with regards to the screening documents required per the facility's abuse policy (i.e. criminal background check and references). The survey team then reviewed the as-worked schedule for the day, 1/27/23, and ensured that any staff who had outstanding screening documents were being directly supervised during Resident interactions by a staff member who had an approved criminal background check and references on file.
The resident interviews conducted of the Residents assigned to CNA B on 1/20/23, were reviewed with no identified concerns noted.
The Resident interviews conducted of all interviewable Residents and skin checks of non-interviewable Residents was reviewed. Concerns that were identified were noted and corresponding FRI's were submitted, which indicated the facility was implementing their abuse policy.
Family interviews conducted by the facility staff were reviewed.
Grievance concerns and Resident council minutes were reviewed, and the survey team confirmed that any identified concerns were being addressed as per the facility abuse policy, (any involved employee removed while an investigation was being conducted, FRI submitted, and investigation initiated)
Staff interviews were conducted across all departments for line staff and management staff which included staff working off shifts (evening and nights) to ensure they had received education and knew the abuse policy.
Survey team observed the Administrator and Director of Nursing being escorted from the premises and reviewed supporting evidence that their employment had been terminated.
Survey team confirmed that an interim Administrator and Director of Nursing were in place and aware of and following the abuse policy as evidenced by their daily presence in the facility during the survey, as well as staff being suspending while investigations were being conducted and FRI's being submitted for identified abuse/neglect allegations
IJ was verified as removed on 1/26/23 at 4:07 PM.
2) For Resident #13, the facility staff failed operationalize their abuse policies to protect, report, and investigate an allegation of abuse on 10-14-2022.
Resident #13's first MDS document (a federal assessment instrument) dated 9-29-22, indicated that the Resident was alert and oriented with no cognitive impairments, no memory nor mood issues, and no aberrant behaviors.
Resident #13's progress notes were reviewed and revealed a fall on 10-4-22, and an incident on 10-15-22.
On 1-19-23 all incident reports for the Resident were reviewed. The review revealed that the only fall prior to the 10-14-22 incident, occurred on 10-4-22. The Resident had a fall in her room getting out of bed. The Resident was in a private room and the incident was unwitnessed. The Resident was assisted off of the floor by the nursing staff and the Resident was assessed to be alert, and oriented, to time person place and situation, with no injuries.
The second incident occurred ten days later on 10-14-22 a Certified Nursing Assistant (CNA) found the Resident sitting on the side of her bed at approximately 8:00 p.m. with a bloody face and golf ball sized raised area in the center of the Resident's forehead, with a moderate amount of blood on the Residents face, sheets, and floor. The document stated the physician was notified and ordered the Resident be sent to the emergency department for evaluation.
The Resident stated that on 10-14-22 she had been hit on the head and knocked to the floor where she was beaten by someone, and she stated that she could not identify who the perpetrator was as she had lost consciousness. She stated she thought it was a man. The Resident indicated she told the facility staff someone had hit her in the head and beat her and asked the facility supervisor nurse on 10-14-22 to call police immediately after the incident and they refused.
The Resident was discharged back to the facility on [DATE].
The Resident stated she was scared to return, however, she wanted to see if she could identify the person responsible and get therapy to strengthen herself before going home. After returning to the facility and having no help to find the perpetrator, she called police herself and made a report on 10-27-22. The Resident stated that three to four days after seeing the police on 10-28-22 and making a report, the Director of Nursing (DON) called the Resident to her office and wanted to know what the Resident had called the police about. The Resident stated she told the DON exactly what she said to the police.
Resident #13's clinical record was reviewed for Social Work notes, and none were found.
On 1-19-2023 an interview was conducted with the Administrator and Director of Nursing (DON) and asked what their policy was on allegations of abuse. They stated all persons alleging abuse must be protected, and an investigation started immediately, and the incident had to be reported per law. They were asked for the investigation and reporting completed for Resident #13, and they stated she alleged a man had attacked her, and there were no men working on the day of the incident according to their investigation. However, on 1-26-23 the time clock punches for all staff were requested for 11-14-22 and received. The documents revealed 7 males working on that day.
On 1-20-23, the facility staff provided a copy of their policy entitled, Abuse/neglect/misappropriation/crime Reporting requirements/investigations #703.
In section 1 .The Administrator will immediately report to the State Agency, but not later than 2 hours after the allegation (of abuse) is made, if the events that caused the allegation involves abuse or results in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury.
In Section 2 The Administrator and/or DON will immediately initiate a thorough internal investigation of the alleged/suspected occurrence.
In policy #704 of the abuse neglect policies, under procedure section 2, injuries of unknown origin should be handled the same as an allegation of mistreatment, neglect or abuse, and must be reported to the state agency.
On 1-24-23 at approximately 3:30 P.M., the Corporate Nurse Consultant and Regional Director of Operations were notified of findings. Both agreed that this incident should have been reported and investigated as an allegation of
abuse. No further information was provided by the facility.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2a. For Resident #15 the facility staff failed to ensure the Resident was free from neglect.
It was noted that on 4/16/22, Resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2a. For Resident #15 the facility staff failed to ensure the Resident was free from neglect.
It was noted that on 4/16/22, Resident #15 and/or family reported to facility staff that On 4/15/22 3-11 PM shift, the resident asked her CNA [CNA B's name redacted] to assist her to bed, the CNA told her she would put her to bed at 9 PM. CNA eventually came back at 9:45 PM complaining that the resident interrupted her break, she deserves a break because she had been on her feet all day, at this time the resident stated the CNA hit her in the face with the O2 [oxygen] cord unintentionally and stated that she didn't need it so long.
The facility provided an investigation summary that indicated they conducted an investigation and substantiated that abuse/neglect occurred and notified CNA B's agency/employer that she was not able to return to the facility.
A review of the facility's abuse policy titled, Abuse/Neglect/Misappropriation/Crime, Patient Protection was conducted. This policy read, Patients of the center have the legal right to be free from verbal, sexual, mental and physical abuse, corporal punishment, involuntary seclusion including abuse facilitated or enabled through the use of technology, and free from chemical and physical restraints except in an emergency and/or as authorized in writing by a physician .
2b. For Resident #15 the facility staff neglected to provide incontinence care resulting in moisture associated skin damage (MASD).
On 1/18/23-1/20/23, a closed record review was conducted of Resident #15's clinical chart. Resident #15's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 11/22/22, was reviewed. This assessment coded Resident #15 in section H as having been incontinence of bowel and bladder frequently. This same assessment coded Resident #15 in section G as having required extensive assistance from one staff member for toileting.
Review of the progress notes revealed a note written 12/7/22, that read, Resident behind [buttocks] had some redness due to sitting up in chair for prolonged period of time on shift prior to nurse working, supervisor aware and resident family aware and on call md [medical doctor] notified. report noted and given to supervisor.
Review of facility grievances revealed that on several occasions Resident #15 and/or her family reported the Resident was neglected. On 12/6/22, the family reported to facility staff, Resident and roommate stated she hadn't been changed. That prior to leaving CNA was told by nurse to put resident into bed and clean up/wash up. Apparently, resident said something, and CNA stated that resident could sit in her pee until 11-7 arrived since she had an attitude. Resident states she wasn't changed entire time- chair was wet. Spoke with daughter during 3rd shift states this is the 3rd time mother has sat in urine for long times and no one answering c/l [call light] .
On 12/13/22, Resident #15 was seen by a skin/wound specialist that provided notes that read as follows:
1. Wound 2 evaluation (12/13/22) location: left upper thigh. length: 9.61 cm, width: 5.66 cm, depth: 0 . Etiology: Moisture associated skin damage (MASD).
2. Wound 3 evaluation (12/13/22) location: Right posterior thigh. length: 14.66 cm, width: 4.68 cm, depth: 0 . Etiology: Moisture associated skin damage (MASD).
Review of the ADL (activities of daily living) documentation from December 2022, revealed multiple shifts where there was no documentation that care was provided. This included but was not limited to, 12/2/22- the evening shift, 12/3/22- the day shift, and on 12/10/22- all shifts.
On 1/24/22 at 11:07 AM, an interview was conducted with CNA D. CNA D was asked how often incontinence care is provided to a Resident. CNA D said, within a regular shift I check my Residents at least twice. There are some that are heavy wetter's so it may be more for them. When asked about documentation, CNA D said, I try to chart after I do something for a Resident, after meals and at the end of my shift. When asked if there is no documentation for a shift, what this means, CNA D said, nothing was done, that's how we were taught.
On 1/24/22 at 11:12 AM, an interview was conducted with CNA E. CNA E was asked to explain the frequency of care to Residents. CNA E said, I try to do every 2 hours but sometimes things happen. When asked about charting and what blanks mean, CNA E said, If it's not charted, it's not done.
On 1/24/22 at 2:32 PM, the facility's Regional Director of Clinical Services/interim Director of Nursing defined neglect as When you do not provide services that any other prudent person would do.
A review of the facility's abuse policy titled, Abuse/Neglect/Misappropriation/Crime, Patient Protection was conducted. This policy read, Patients of the center have the legal right to be free from verbal, sexual, mental and physical abuse, corporal punishment, involuntary seclusion including abuse facilitated or enabled through the use of technology, and free from chemical and physical restraints except in an emergency and/or as authorized in writing by a physician .
On 1/25/22, during an end of day meeting the facility Administrator and Director of Nursing were made aware of the above findings.
No further information was provided.
Based on Resident interview, staff interview, clinical record review, facility documentation review, the facility staff failed to protect 3 Residents (Resident #16, Resident #15, Resident #12) from abuse/neglect in a sample size of 9 Residents.
The findings included:
1. For Resident #16, the Administrator issued a 30-day discharge notice with retaliatory intent for Resident #16.
A review of Resident #16's quarterly Minimum Data Set with an Assessment Reference Date of 10/30/2022 coded the Brief Interview for Mental Status as 15 out of 15 indicative of intact cognition.
On 01/20/2023 at approximately 10:40 A.M., Resident #16 was interviewed by Surveyor C and Surveyor F. When asked about concerns at the facility, Resident #16 explained that at one time, the Administrator yelled at her. When asked about this, Resident #16 stated that they weren't happy I went to the Ombudsman about concerns instead of notifying facility staff. Resident #16 stated that she told the Administrator she did notify facility staff but nothing was done. Resident #16 stated that the Administrator spoke loudly and firmly and told her since she wasn't happy at the facility, they were going to issue a 30-day notice. Resident #16 then stated that the Director of Nursing (DON) and the Discharge Planning Director [DDP](Employee L) issued the 30-day notice. Resident #16 stated that she told them she wouldn't accept it but they laid it on my bed and said I was to leave within 30 days. When asked about how that affected her, Resident #16 stated, I was a wreck! Resident #16 explained that she didn't know what to do; calling her children for help because she needed to find another place to live. Resident #16 stated, I was so upset! I didn't want to leave. Resident #16 stated that the Ombudsman assisted her to file an appeal and we convinced them to rescind it [the 30-day discharge notice]. Resident #16 stated that she was scheduled to be discharged on 08/19/2022. Resident #16 stated that it was the Ombudsman that notified her the 30-day discharge was rescinded. Resident #16 went on to explain that she asked the Administrator for something in writing about it (the rescinded notice) and never received anything. Resident #16 added that the Administrator was just after me because she said I had so much clutter in my room and didn't want the health department seeing all my clutter so she moved me to this room (out of the more visible hall). Resident #16 stated that she doesn't feel welcome at this facility; she feels on guard; she feels that the powers that be don't want me here.
Resident #16's progress notes were reviewed. A discharge planning progress note dated 07/20/2022 at 11:03 A.M. documented, On 7/19/22, DDP issued patient a 30-day notice along with DON present. Patient indicated that her [family member] needed to be notified by which DDP informed her that her [family member] would be contacted after the meeting. DDP returned to office shortly after the meeting and received a call from patient's [family member]. She was told that due to another crisis, DDP hadn't called her yet, but we were able to discuss the 30-day notice and [name] requested a meeting. She will contact DDP when [family member] able to come into the facility and we will schedule the meeting request accordingly.
A psychotherapy note dated 08/09/2022 at 1:00 A.M. documented the following excerpts: She shared recent events and interactions that are contributing to a sense that people don't really care about me. She is particularly worried about finding another place to live if 'they are going to kick me out on the 19th.' She shared [Department of Medical Assistance Services] letter confirming her appeal was being processed. She was interested in the possibility of accessing grants to help support moving to an ALF [assisted living facility] but 'I have friends here' and wasn't sure what about programming and supports exist in an ALF.
Under the Misc tab in Resident #16's electronic health record, there was a letter from the Department of Medical Assistance Services (DMAS) dated 07/27/2022 addressed to the Administrator. An excerpt of the letter documented, [Resident #16] has filed an appeal regarding proposed discharge.
On 01/20/2023 at 11:20 A.M., the [NAME] President of Operations and the Regional Director of Clinical Services were notified of this allegation of abuse by the Administrator. The [NAME] President of Operations stated she knew about this 30-day discharge notice and notified the Administrator that she couldn't do that and so the Administrator rescinded it.
In the facility's document entitled, Resident Handbook under the header Grievances, it was documented, As a resident of our Health and Rehabilitation Center, you have the right to voice grievances/file complaints (orally, in writing, or anonymously) to Center Management, to State Survey and Certification Agencies as well as to any advocacy representative of your choice without fear of discrimination or reprisal.
The facility staff provided a copy of their policy manual section entitled, Abuse/Neglect/Misappropriation/Crime and policy name entitled, Patient Protection. In Section 1, an excerpt documented, Patients of the Center have the legal right to be free from .mental .abuse .
On 01/26/2023 by the end of survey, the [NAME] President of Operations and the Regional Director of Clinical Services stated there was no further information or documentation to submit.
3. For Resident # 12, the facility staff failed to protect from abuse/neglect by staff members.
Resident # 12's most recent Minimum Data Set (MDS) was a Quarterly assessment with an Assessment Reference Date (ARD) of 10/29/2022. The MDS coded Resident # 12 with a BIMS (Brief Interview for Mental Status) Score of 15 out of 15 indicating no cognitive impairment; required extensive to total assistance from one to two staff members for Activities of Daily Living (ADLs). Resident # 12 was alert and oriented and able to make needs known.
Review of the electronic clinical record was conducted during the survey.
On 1/19/2023 at 2:15 p.m., Surveyor B conducted an interview with Resident # 12 who stated some members of the facility staff was verbally abusive and rough. Resident # 12 reported calling the police on 1/17/2023 because of failure of the staff to answer the call bell for over 2 and a half hours while she was in pain.
Surveyor B asked about the frequency of this type of incident. Resident # 12 stated quite honestly every other time, you have the hardest time in here getting help. Resident # 12 then stated I was in pain so bad and nobody came, so I called the police non-emergent police number and asked them to please call over here and get someone up here.
Resident # 12 stated the facility Administrator and Director of Nursing jumped all over me Resident # 12 further stated They said there was no need for me to call the police, I told them I have been in pain for 2 ½ hours and no one has come, what do you expect me to do? Resident # 12 stated She said 'Well you have to wait' . I said for 2 ½ hours give me a break.
Resident # 12 then stated She got mad at me one other time and she made them get me out of bed in the chair and of course that makes it worse
01/19/2023 at 3:40 p.m., the corporate Clinical Nurse Consultant and Corporate Executive Director were informed of the allegations by Resident # 12. They stated We will follow our abuse policy. We will go interview the resident first and get you the policy. The Corporate Consultants stated the two staff persons would be suspended pending the investigation. Then continue the investigation ourselves. They will be suspended, we want to make sure ___ (Resident # 12) is immediately ok .
Review of the facility's Abuse/Neglect Policy effective 1/23/2020 revealed the statement that there was a zero tolerance of mistreatment , abuse, neglect .of any crime against any patient of the Health and Rehabilitation Center
No further information was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on staff interview, clinical record review, facility documentation review and in the course of a complaint investigation, the facility staff failed to report allegations of abuse/neglect involvi...
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Based on staff interview, clinical record review, facility documentation review and in the course of a complaint investigation, the facility staff failed to report allegations of abuse/neglect involving one Resident (Resident #15) in a survey sample of 9 Residents.
The findings included:
The facility staff failed to report allegations of abuse/neglect to Adult Protectives Services (APS) and the Department of Health Professions/Board of Nursing for allegations substantiating abuse.
On 1/18/23-1/20/23, a closed record review of Resident #15's clinical record was conducted. This review revealed no entries with regards to Resident #15's allegations of abuse/neglect.
A review of the facility's investigation files revealed that on 3 occasions reports of abuse or neglect had been reported to the facility staff. The allegations were as follows:
1. On 4/16/22, Resident #15's family reported an allegation of abuse/neglect. The facility staff failed to report this allegation to Adult Protective Services and the Department of Health professions.
Upon review of the investigation documents submitted by the facility there was evidence that during the facility's investigation they determined abuse/neglect had occurred involving Resident #15 and CNA B. The facility failed to have evidence that the allegation or investigation findings were reported to Adult Protective Services or the Department of Health Professions. Additionally, there was no evidence that the result of the investigation was reported to the State Survey Agency.
2. On 10/3/22, the facility staff received notification from Adult Protective Services that they had conducted an investigation into an allegation of abuse. APS's letter to the facility indicated, The agency has determined the report founded for neglect as a review of the facts did show a preponderance of evidence that neglect occurred.
The facility in turn conducted an investigation. During the facilities' investigation a staff member was identified, CNA C. The facility staff failed to have evidence of this allegation being reported to the Department of Health Professions.
3. On 12/6/22, Resident #15 reported an allegation of neglect and verbal abuse to the facility staff. This allegation as not reported to the state survey agency or adult protective services until 12/12/22. This allegation was not reported to the department of health professions.
Upon completion of the facility's investigation, the state survey agency and adult protective services were not notified of the investigation findings until 12/19/22, which is outside of the reporting requirements. Again, the department of health professions was not notified.
Review of the facility policy titled; Reporting Requirements/Investigations was reviewed. It read, .1. b. Notify the Adult Protective Services Agency, the local Ombudsman, and the appropriate local law enforcement authorities (police, sheriff's office, and/or medicals examiner as deemed appropriate) for any incident of patient abuse, mistreatment, neglect, or misappropriation of personal property or other reasonable suspicion of a crime. c. Notify within 24 hours the Department of Health Professions (DHP) for incidences involving nurse aides, RNs, LPNs, Physicians, or others licensed or certified by DHP .
On 1/24/23 at 2:32 PM, a meeting was held with the interim Administrator and interim Director of Nursing. During this meeting, both acknowledged they had identified concerns with reporting to required agencies and the timeliness of reporting. They were made aware of the above specifics of what was missing for the above noted allegations of abuse/neglect.
No further information was provided.
Complaint related deficiency.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to investigate an incident of bruising with a...
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Based on staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to investigate an incident of bruising with an unknown origin involving one Resident (Resident #15) in a survey sample of 9 Residents.
The findings included:
1. For Resident #15 the facility staff failed to have evidence of an investigation being conducted following identification of bruises of unknown origin.
In the course of a complaint investigation the clinical record for Resident #15 was reviewed. A skin observation form conducted 12/7/22, noted the following: Site: Right gluteal fold, Type: Bruising, length: 19 cm, Width: 8 cm, Depth: 0 cm a second line on this same document noted, Site: Left thigh (front), Type: Bruising, length: 12.5 cm, width: 8.4 cm, depth: 0 cm.
There was no further documentation within the clinical record with regards to the bruising. The facility's investigation files were reviewed and there was no evidence of an investigation being conducted following the identification of the bruises.
On 1/24/23, during an end of day meeting, the facility's interim Administrator and interim Director of Nursing (DON) were made aware of the bruising and asked to provide any additional information they may have with regards to this.
A review of the facility policy titled, Abuse/Neglect/Misappropriation/Crime, Reporting Requirements/Investigations was conducted. This policy read, 1. Immediately upon notification of any alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property 2. The Administrator and/or Director of Nursing will immediately initiate a thorough internal investigation of the alleged/suspected occurrence. The investigation protocol will include, but not be limited to, collecting evidence, interviewing alleged victims and witnesses, and involving other appropriate individuals, agents, or authorities to assist in the process and determinations .
On 1/26/23 at 1PM, the interim DON stated the bruising should have been investigated as an injury of unknown origin and stated an investigation had been initiated.
Complaint related deficiency.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Resident interview, Staff interview, Ombudsman interview, Clinical record review, and facility document review, the fac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Resident interview, Staff interview, Ombudsman interview, Clinical record review, and facility document review, the facility staff failed review and revise a nutrition, hydration, and seizure care plan for one Resident (Resident #13) in a sample of 9 residents.
The findings included:
For Resident #13, the facility staff did not review and revise the care plan for weight loss, dehydration, and seizures.
Resident #13 was admitted to the facility with diagnoses including; acute gastrointestinal bleeding with resulting acute post hemorrhagic anemia and weakness. History included diabetes, congestive obstructive pulmonary disease (COPD), seizures.
On 9-26-22 the Registered Dietician (RD) evaluated the Resident and documented nutrition risk related to recent hospitalization, and moderate protein calorie malnutrition as a medical diagnosis. The document describes weight on 9-22-22 was 164 pounds hospital weight upon discharge to the facility. The plan was to Monitor/Evaluation (M/E): Monitor weights, meal intake and provide follow up per protocol.
Resident #13's nutrition care plan, completed on 9-26-22, was reviewed and revealed the only interventions were the following 5 items;
1. administer medications as ordered
2. labs as ordered
3. provide, serve diet as ordered
4. monitor intake and record every meal, offer substitute when intake less than 50%
5. weekly weights
Activities of Daily Living records (ADL's) were reviewed and revealed the following;
September - 9-22-22 through 9-30-22 (8 days), the Resident did not eat, or ate 26-50 percent of meals for 6 of 24 meals (25% of meals).
October - 10-1-22 through 10-15-22 (15 days). the Resident did not eat, or ate 26-50 percent of meals for 23 of 45 meals (50% of meals).
October - 10-24-22 through 11-4-22 (12 days) the Resident did not eat, or ate 26-50 percent of meals for 19 of 36 meals (50% of meals).
It is unknown if substitutions were offered, however, the Resident was documented as consuming the above amounts irregardless of food served, at the end of each meal.
The Resident's weights were not taken for 2 weeks between 9-22-22, and 10-5-22, and then not taken for 9 more days from 10-5-22 to 10-14-22 when the Resident was sent out to the hospital for trauma evaluation. The admission weight in the hospital revealed a 16 pound (approximately 10 %) weight loss since admission to the nursing facility in 23 days. The following are weights which were taken in the facility, and in the hospital as documented in the clinical records.
1. 9-22-22 - 163.0 pounds
2. 10-5-22 - 163.7 pounds
3. 10-14-22 - went out to hospital, admission weight at the hospital was 137.0 pounds.
4. 10-24-22 - returned to the facility, and no weight taken at the facility on readmission.
5. 10-26-22 - 141.2 pounds (4 pound weight gain during hospitalization)
6. 10-28-22 - 139.6 pounds (weight loss begins again)
7. 11-2-22 - 138.4 pounds (weight loss continues for a 3 pound weight loss since readmission in 8 days)
Resident #13 did not have a dehydration care plan, nor seizure disorder care plan upon admit despite receiving diuretic medications which strip fluid from the body, and receiving antiseizure medications. A dehydration care plan, and seizure care plan were also not completed for the Resident upon readmission from the hospital on [DATE], even though dehydration and fluid resuscitation, as well as anti-seizure medication overdose were diagnosed and documented in the hospital discharge records. A dehydration care plan, and a seizure disorder care plan were completed on 11-4-22. The day of the Resident's discharge.
On 1-19-2023 an interview was conducted with the Administrator and Director of Nursing (DON) and asked what their policy was on care plan revisions for weight loss and hydration, both answered that when weight loss or the possibility for dehydration were suspected an immediate care plan revision should be completed to intervene.
On 1-24-23 at approximately 3:30 P.M., the Corporate Nurse Consultant and Regional Director of Operations were notified of findings. No further information was provided by the facility.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and facility documentation review, the facility staff failed to provide care a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and facility documentation review, the facility staff failed to provide care and services in accordance with professional standards of practice for one Resident (Resident #16) in a sample size of 9 Residents.
The findings included:
For Resident #16, the facility staff failed to:
1) administer medications as ordered by the physician
2) notify the physician when medications were not given as ordered
3) obtain/ monitor routine blood pressure measurements when Resident #16 had a known diagnosis of hypertension and received blood pressure medication daily.
On 01/18/2023, Resident #16's medical diagnoses included but was not limited to hypertension. A review of the physician orders revealed that Resident #16 received an oral antihypertensive daily (Lisinopril). There were no physician orders to obtain blood pressures regularly.
The Vital Signs flowsheet was reviewed. There were no blood pressure measurements from 05/31/2022 through 07/07/2022.
On 01/18/2023 at approximately 2:30 P.M., Resident #16's Medication Administration Record for August 2022 was reviewed and revealed the following:
1) There was an 11-day lapse (08/01/2022, 08/12/2022) of the administration of one medication (Trulicity) which was supposed to be administered every 7 days.
2) Mirapex was not administered on 08/27/2023 as ordered by the physician.
The progress notes for August 2022 were reviewed. An administration note associated with the Mirapex administration dated 08/27/2022 at 8:59 P.M. documented, Not on hand.
There was no evidence the physician was notified of the missed dose of Mirapex or the 11-day lapse in the Trulicity administration.
On 01/26/2023 at 9:15 A.M., Licensed Practical Nurse D (LPN D) was interviewed. When asked about the Trulicity 11-day lapse in administration, LPN D referred to the clinical record and stated that there should have been a progress note written as to why the Trulicity was switched from Mondays to Fridays, and that the physician was notified.
The facility staff provided a copy of their policy entitled, Medication Administration. In Section 3, an excerpt documented, If medications are determined to be unavailable for administration, licensed nurse will notify the provider of the unavailability.
According to [NAME] Nursing Procedures, Seventh Edition, 2016, under the section entitled, Blood Pressure Assessment, an excerpt documented, Regular measurement is indicated for patients with a history of hypertension .
On 01/24/2023 at approximately 2:30 P.M., the [NAME] President of Operations and Regional Director of Clinical Services were notified of findings.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
Could have caused harm · This affected 1 resident
Based on Resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to document a discharge summary/recapitulation of stay in the clinical rec...
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Based on Resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to document a discharge summary/recapitulation of stay in the clinical record for one Resident (Resident #13) in a sample of 9 Residents.
The findings included;
The DON was asked for a copy of the Resident's discharge summary/recapitulation of stay from the physician as none was found in the clinical record. The DON supplied a copy of a discharge nursing assessment from a Licensed Practical Nurse (LPN), who had been caring for the Resident, and stated she could not find one from the doctor.
On 1-24-23 at approximately 3:30 P.M., the Corporate Nurse Consultant and Regional Director of Operations were notified of findings. No further information was provided by the facility.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide activities of daily living (ADL) care/assistance to 2 Residents (Resident #15 ...
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Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide activities of daily living (ADL) care/assistance to 2 Residents (Resident #15 and #12) who were dependent upon facility staff for assistance, in a survey sample of 9 Residents.
The findings included:
1. For Resident #15 the facility staff failed to provide assistance with activities of daily living, which included incontinence care.
On 1/18/23-1/20/23, a closed record review was conducted of Resident #15's clinical chart. Resident #15's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 11/22/22, was reviewed. This assessment coded Resident #15 in section H as having been incontinence of bowel and bladder frequently. This same assessment coded Resident #15 in section G as having required extensive assistance from one staff member for toileting.
Review of facility grievances and investigation documents revealed that on several occasions Resident #15 and/or her family reported on 12/6/22, Resident and roommate stated she hadn't been changed. That prior to leaving CNA was told by nurse to put resident into bed and clean up/wash up. Apparently, resident said something, and CNA stated that resident could sit in her pee until 11-7 arrived since she had an attitude. Resident states she wasn't changed entire time- chair was wet. Spoke with daughter during 3rd shift states this is the 3rd time mother has sat in urine for long times and no one answering c/l [call light] .
Review of the ADL (activities of daily living) documentation from December 2022, revealed multiple shifts where there was no documentation that care was provided. This included but was not limited to, 12/2/22- the evening shift, 12/3/22- the day shift, and on 12/10/22- all shifts.
On 1/24/22 at 11:07 AM, an interview was conducted with CNA D. CNA D was asked how often incontinence care is provided to a Resident. CNA D said, within a regular shift I check my Residents at least twice. There are some that are heavy wetter's so it may be more for them. When asked about documentation, CNA D said, I try to chart after I do something for a Resident, after meals and at the end of my shift. When asked if there is no documentation for a shift, what this means, CNA D said, nothing was done, that's how we were taught.
On 1/24/22 at 11:12 AM, an interview was conducted with CNA E. CNA E was asked to explain the frequency of care to Residents. CNA E said, I try to do every 2 hours but sometimes things happen. When asked about charting and what blanks mean, CNA E said, If it's not charted, it's not done.
No additional information was received.
Findings included:
2. For Resident # 12, the facility staff failed to provide incontinence care timely and baths/showers twice a week as scheduled.
Resident # 12's most recent Minimum Data Set (MDS) was a Quarterly assessment with an Assessment Reference Date (ARD) of 10/29/2022. The MDS coded Resident # 12 with a BIMS (Brief Interview for Mental Status) Score of 15 out of 15 indicating no cognitive impairment; required extensive to total assistance from one to two staff members for Activities of Daily Living (ADLs). Resident # 12 was alert and oriented and able to make needs known.
Review of the electronic clinical record was conducted.
An interview was conducted on 01/18/2023 at 03:18 PM via telephone with Resident # 12's family member who stated that Resident # 12 had experienced many problems with some of the facility staff. The family member stated Resident # 12 often complained of being left wet for extended periods of time. The family member reported noticing long periods of time before incontinence was given when visiting Resident #12. The family member stated baths were not given as scheduled. The family member stated it was upsetting and embarrassing to Resident # 12.
On 1/19/2023 at 2:15 p.m.,Surveyor B conducted an interview with Resident # 12 who stated incontinence care was not provided regularly. Resident # 12 stated they do not change us, sometimes we will be laying here wet, you call and tell them you need to be changed and they say you have to wait, I ask wait until what? She [CNA] said until I get a chance. Happened today the [CNA] I usually have didn't have me today and she came in to tell me I would have to wait because she didn't have me today. I started calling them at 9 AM, because I wanted to get changed before breakfast but it (breakfast) didn't come until late and was 11 before I got changed.
Resident # 12 further stated Last weekend (weekend that just passed 1/14/23-1/15/23) we had 2 [CNAs] all weekend on 7-3 shift that gives them 30 patients and the next day we had 1 [CNA] so she had all 60 of us, we got changed once and didn't get bathed, I felt so horrible for them, they don't care about people or their workers it just the money. The nurses didn't even get out and help her. We are supposed to get baths twice a week then they started giving them to us once per week, I think I've been given one bath since I've been over here.
On 1/25/2023 at approximately 4:15 p.m., an interview was conducted with CNA D who stated incontinence care should be provided every two hours or as needed by the resident. CNA D stated baths/showers should be given twice a week. CNA D stated they do the best they can to provide care.
Review of the ADL flow sheets revealed missing documentation of incontinence care being provided. Review of the bathing documentation revealed baths/showers were not given twice a week as scheduled.
During the end of day debriefing, the Administrator and Director of Nursing were informed of the findings.
No further information was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0691
(Tag F0691)
Could have caused harm · This affected 1 resident
Based on resident interview, family interview, staff interview,and clinical record review, the facility staff failed to ensure that one resident (Resident # 12) in the survey sample of 9 residents, re...
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Based on resident interview, family interview, staff interview,and clinical record review, the facility staff failed to ensure that one resident (Resident # 12) in the survey sample of 9 residents, received necessary care for a colostomy.
Findings included:
For Resident # 12, the facility staff failed to provide colostomy care to meet the resident's needs.
Resident # 12's most recent Minimum Data Set (MDS) was a Quarterly assessment with an Assessment Reference Date (ARD) of 10/29/2022. The MDS coded Resident # 102 with a BIMS (Brief Interview for Mental Status) Score of 15 out of 15 indicating no cognitive impairment; required extensive to total assistance from one to two staff members for Activities of Daily Living (ADLs). Resident # 12 was alert and oriented and able to make needs known.
Review of the electronic clinical record was conducted.
On 1/18/2023 at 3:18 p.m., an interview was conducted with the family member of Resident # 12 who stated the facility staff did not provide proper care of Resident # 12's colostomy. The family member stated the bag often overflowed, was not sealed properly and caused Resident # 12 to feel anxious because of fear of it overflowing.
Review of the Activities of Daily Living sheets revealed missing documentation of changes of the colostomy bag.
On 1/19/2023 at 2:15 p.m.,Surveyor B conducted an Interview with Resident # 12 who stated incontinence care was not done timely. Resident # 12 stated the colostomy bag was not changed as needed.
On 1/25/2023 at 459 p.m., an interview was conducted with LPN (Licensed Practical Nurse) C who stated the colostomy bags should be checked frequently every couple of hours to see if they need to be changed. LPN C stated the seal should be checked to prevent leakage. LPN C stated the staff should respond to requests from the residents to have the colostomy bag changed
During the end of day debriefing on 1/25/2023, the Regional [NAME] President and the Regional Director of Clinical Services functioning as the interim facility Administrator and interim Director of Nursing respectively were informed of the findings.
No further information was provided.
.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident # 12, the facility staff failed to ensure medications were available as ordered by the physician,
Review of the ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident # 12, the facility staff failed to ensure medications were available as ordered by the physician,
Review of the electronic clinical record was conducted.
Review of the clinical record revealed documentation of medications being unavailable on at least 3 scheduled times of administration as listed.
1/17/2023 10:26 a.m.
Orders -Administration Note
Note Text: medication n/a [not available] MD [medical doctor] needs to sign new script
1/16/2023 22:50 (10:50 p.m.)
Orders -Administration Note
Note Text: new script needed in order to pull from pyxis [system to access in house medications for first dose] MD aware of new script being needed. resident denies having any pain/discomfort at this time
1/16/2023 22:48 (10:48 p.m.)
Orders -Administration Note
Note Text: new script needed in order to pull from pyxis MD aware of new script being needed. resident denies having any pain/discomfort at this time
1/16/2023 13:57 (1:57 p.m.)
Orders -Administration Note
Note Text: Tramadol HCl Tablet 50 MG [milligrams]
Give 1 tablet by mouth four times a day for pain
Medication on order.
Review of the OMNICELL (onsite first dose) inventory sheet revealed no documentation that the medication, Tramadol was available for administration. There was no documentation of an inventory of items in the Pyxis provided to the survey team.
Interviews conducted with nursing staff revealed the expectation was for the pharmacy to provide medications to enable the facility staff to administer medications as ordered by the physician.
During an interview on 1/20/2023 at 4:59 p.m., LPN (Licensed Practical Nurse) C stated medications were provided by the pharmacy. LPN C stated the staff should check the inventory to determine if the missing medications were available in the facility and notify the physician if medications were unavailable for administration.
During the end of day debriefings on 1/24/2023 and 1/25/2023, the Regional [NAME] President and the Regional Director of Clinical Services functioning as the interim facility Administrator and interim Director of Nursing respectively were informed of the findings of medications being unavailable.
No further information was provided.
Based on staff interview, clinical record review, and facility document review, the facility staff failed to have medications available for administration as per doctors orders for two Residents (Resident #14, Resident #2) in a sample of 9 residents.
The findings included:
1) For Resident #14, the facility staff failed to have available pain medications and a post operative anticoagulants upon admission.
Resident #14 was admitted to the facility on [DATE] with diagnoses including; acute fractured right elbow, and clavicle with surgical repair.
Physician progress notes were reviewed and described the physician's evaluation of the Resident to be oriented to person place time and situation. The physician found no cognitive impairment nor behaviors, and the Resident was able to give her medical history and was appropriate.
Resident #14's physician orders and Medication administration records were reviewed and revealed that on 3-2-22 the Resident was ordered to be given Enoxaparin Sodium 30 milligrams (mg) in 0.3 milliliters (ml) of solution by injection every 12 hours for 30 days post operatively to prevent blood clots after surgery. The Resident was also ordered to be given pain medication for chronic nerve pain Gabapentin 600 mg tablet 2 times per day, and a second medication for acute post operative pain Oxycodone hydrochloride tablets 5 mg every 4 hours as needed for pain. The Resident received a paper copy of the narcotic pain killer from the hospital on 3-1-22 before arriving in the facility on 3-2-22. The Resident supplied the paper prescription to the facility upon admission.
On the following days and time those medications were unavailable for administration.
Enoxaparin Sodium injection - blood thinner - 3-2-22 at 9:00 p.m., and 3-5-22 at 9:00 p.m.
Gabapentin - chronic nerve pain medication - 3-2-22 at 5:00 p.m., 3-3-22 at 9:00 a.m., 3-4-22 at 5:00 p.m., and 3-5-22 at 5:00 p.m.
Oxycodone tablets - pain medication - 3-2-22 none given on day of admission, 3-5-22 none given.
Progress notes for the 5 day stay were reviewed and revealed documented entries of medication unavailable, and waiting on pharmacy to deliver. There were also entries of Resident pain complaints with medication administration documented.
Resident #14's care plan was reviewed and indicated pain as a focus and as an intervention Administer medication as ordered.
On 1-19-2023 an interview was conducted with the Administrator and Director of Nursing (DON) and asked why the medications were omitted/unavailable, and both answered they did not know.
On 1-24-23 at approximately 3:30 P.M., the Corporate Nurse Consultant and Regional Director of Operations were notified of findings. No further information was provided by the facility.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on Resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to prevent unnecessary medication for one Resident (Resident #13) in a sam...
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Based on Resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to prevent unnecessary medication for one Resident (Resident #13) in a sample of 9 residents.
The findings included:
For Resident #13, the facility staff administered unnecessary dosages of Dilantin anti-seizure medication, causing overdose.
Resident #13 had diagnoses including; seizures.
Resident #13's physician orders and Medication administration records were reviewed and revealed that on 9-22-22 the Resident was ordered to be given Dilantin 200 milligrams (mg) four times per day to equal 800 mg per day in the nursing facility.
On 10-14-22 the Resident was sent to the hospital due to an injury. During the 9 day stay there, hospital admission records dated 10-22-22 documented by the physician, that the Dilantin dosage (800mg) was excessive. While in the hospital the Resident was being weaned down to Dilantin 400 mg per day (200 mg twice per day) at the time of discharge. Documents reference the Residents complaints of dizziness were most likely attributed to receiving too much Dilantin.
All laboratory results were reviewed in the clinical record, and revealed no labs were drawn to evaluate Dilantin blood levels with which to base dosage.
On 1-19-2023 an interview was conducted with the Administrator and Director of Nursing (DON) and asked why no care plan had been devised, nor labs had been scheduled for the Resident in regard to her seizure disorder, and both answered they did not know.
On 1-24-23 at approximately 3:30 P.M., the Corporate Nurse Consultant and Regional Director of Operations were notified of findings. No further information was provided by the facility.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, and clinical record review, the facility staff failed to ensure a medication error rate of less than 5% for one Resident (Resident #16) in a sample size of 9 Res...
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Based on observation, staff interview, and clinical record review, the facility staff failed to ensure a medication error rate of less than 5% for one Resident (Resident #16) in a sample size of 9 Residents. For Resident #16, there were 12 opportunities and 5 omissions resulting in a medication error rate of 41% on 01/19/2023.
The findings included:
On 01/19/2023 at approximately 10:10 A.M., this surveyor observed LPN B administer medications to Resident #16. LPN B placed the following oral medications in a medicine cup:
Cyanocobalamin 500 mcg (2 tablets)
Gabapentin 400 mg tablet (1 tablet)
Omeprazole 20 mg capsule (1 capsule)
Tramadol 50 mg tablet (Give 0.5 tablet)
Lisinopril 2.5 mg (1 tablet)
Lipitor 20 mg (1 tablet)
When LPN B handed Resident #16 the medication, Resident #16 counted the 7 pills and stated that there should be 9 pills in the cup. LPN B returned to the medication cart to review Resident #16's Medication Administration Record. LPN B stated that the low dose aspirin (81 mg) and the sertraline (50 mg) were missing and added those medications to the cup. LPN B also stated that Resident #16 should receive 40 mg of Omeprazole and added another 20 mg capsule to the cup. LPN B stated that Resident #16 should have 10 pills in the cup. LPN B then administered the medications to Resident #16 at approximately 10:20 A.M. (an hour and 20 minutes beyond the scheduled time).
On 01/19/2023 at approximately 1:50 P.M., Resident #16's clinical record was reviewed. A review of the Medication Administration Record and Physician's orders for the 9:00 A.M. scheduled medication administration revealed that Resident #16 also had Metformin 500 mg (Give 2 tablets) scheduled for 9:00 A.M. as well.
On 01/19/2023 at approximately 2:00 P.M., LPN B was interviewed. When asked about the 9:00 A.M. dose of Metformin, LPN B stated that the Metformin was administered during the medication administration observation at approximately 10:20 A.M. (which was not the case). LPN B showed where the Metformin had been signed off on the Medication Administration Record as administered.
On 01/24/2023 at 2:30 P.M., the [NAME] President of Operations and Regional Director of Clinical Services were notified of findings.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: [NAME], [NAME]
Based on Resident interview, staff interview, Ombudsman interview, clinical record review, and facilit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: [NAME], [NAME]
Based on Resident interview, staff interview, Ombudsman interview, clinical record review, and facility document review, the facility staff failed to prevent significant medication errors for two Residents (Resident #13, & #14) in a sample of 9 residents.
The findings included:
1. For Resident #13, the facility staff administered unnecessary dosages of Dilantin anti-seizure medication.
1. Resident #13 had diagnoses including; seizures.
Resident #13's physician orders and Medication administration records were reviewed and revealed that on 9-22-22 the Resident was ordered to be given Dilantin 200 milligrams (mg) four times per day to equal 800 mg per day in the nursing facility.
On 10-14-22 the Resident was sent to the hospital due to an injury. During the 9 day stay there, hospital admission records dated 10-22-22 documented by the physician, that the Dilantin dosage (800mg) was excessive. While in the hospital the Resident was being weaned down to Dilantin 400 mg per day (200 mg twice per day) at the time of discharge. Documents reference the Residents complaints of dizziness were most likely attributed receiving excessive Dilantin.
All laboratory results were reviewed in the clinical record, and revealed no labs were drawn to evaluate Dilantin blood levels with which to base dosage.
On 1-24-23 at approximately 3:30 P.M., the Corporate Nurse Consultant and Regional Director of Operations were notified of findings. No further information was provided by the facility.
2. For Resident #14, the facility staff failed to administer pain medications, and post operative anticoagulant upon admission.
Resident #14 was admitted to the facility with diagnoses including; acute fractured right elbow, and clavicle with surgical repair.
Physician progress notes were reviewed and described the physician's evaluation of the Resident to be oriented to person place time and situation. The physician found no cognitive impairment nor behaviors, and the Resident was able to give her medical history and was appropriate.
Resident #14's physician orders and Medication administration records were reviewed and revealed that on 3-2-22 the Resident was ordered to be given Enoxaparin Sodium 30 milligrams (mg) in 0.3 milliliters (ml) of solution by injection every 12 hours for 30 days post operatively to prevent blood clots after surgery. The Resident was also ordered to be given pain medication for chronic nerve pain Gabapentin 600 mg tablet 2 times per day, and a second medication for acute post operative pain Oxycodone hydrochloride tablets 5 mg every 4 hours as needed for pain. The Resident received a paper copy of the narcotic pain killer from the hospital on 3-1-22 before arriving in the facility on 3-2-22. The Resident supplied the paper prescription to the facility upon admission.
On the following days and time those medications were unavailable for administration.
Enoxaparin Sodium injection - blood thinner - 3-2-22 at 9:00 p.m., and 3-5-22 at 9:00 p.m.
Gabapentin - chronic nerve pain medication - 3-2-22 at 5:00 p.m., 3-3-22 at 9:00 a.m., 3-4-22 at 5:00 p.m., and 3-5-22 at 5:00 p.m.
Oxycodone tablets - pain medication - 3-2-22 none given on day of admission, 3-5-22 none given.
Progress notes for the 5 day stay were reviewed and revealed documented entries of medication unavailable, and waiting on pharmacy to deliver. There were also entries of Resident pain complaints with medication administration documented.
Resident #14's care plan was reviewed and indicated pain as a focus and as an intervention Administer medication as ordered.
On 1-19-2023 an interview was conducted with the Administrator and Director of Nursing (DON) and asked why the medications were omitted/unavailable, and both answered they did not know.
On 1-24-23 at approximately 3:30 P.M., the Corporate Nurse Consultant and Regional Director of Operations were notified of findings. No further information was provided by the facility.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
Based on Resident interview, staff interview, and in the course of a complaint investigation, the facility staff failed to provide an ongoing program of activities to support Residents in their choice...
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Based on Resident interview, staff interview, and in the course of a complaint investigation, the facility staff failed to provide an ongoing program of activities to support Residents in their choice of activities on one unit (North Unit) of 2 Units.
The findings included:
1) For the North unit, the Activity Room was consistently locked in the evenings and some weekends resulting in activities being inaccessible to Residents on the North Unit.
On 01/19/2023 at 1:45 P.M., Employee F, the Activities Assistant, was interviewed. The Activities Assistant confirmed her desk/office is located in the North Unit Activity Room. When asked about if it is accessible to Residents in the evenings and weekends, the Activities Assistant stated the room is locked in the evenings and on some weekends (inaccessible to Residents) because her laptop is in there.
On 01/20/2023 at approximately 10:40 A.M., Resident #16 was interviewed. When asked about activities at the facility, Resident #16 indicated she would like to have access to the Activity Room in the evenings to be able to do a puzzle on the puzzle table at times. Resident #16 indicated the Activity Room was closed in the evenings because the Activity Assistant's office was in there.
A review of Resident #16's quarterly Minimum Data Set with an Assessment Reference Date of 10/30/2022 coded the Brief Interview for Mental Status as 15 out of 15 indicative of intact cognition.
On 01/24/2023 at approximately 2:30 P.M., the [NAME] President of Operations and the Regional Director of Clinical Services were notified of findings. At approximately 3:45 P.M., the Regional Director of Clinical Services notified surveyor that the Activity Room on the North Unit would now remain open and accessible to Residents.
On 01/26/2023, the facility staff provided a copy of their Resident Handbook. Under the Section entitled, Resident Rights in subpart 16, an excerpt documented, To meet with and participate in activities of social, religious, and community groups that do not interfere with the rights of others at his/her discretion .
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, the facility staff failed to ensure the environment remained free of accident hazards...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, the facility staff failed to ensure the environment remained free of accident hazards in one of one halls observed.
The findings included:
For the front hall on the south unit, an electrical cord plugged into a red outlet was observed on 01/23/2023 extending across the hall and into a Resident Room on the opposite side of the hall. The cord was not secured to the floor and looped around creating a trip hazard. The cord also prevented Residents in wheelchairs to freely travel the hall.
On 01/23/2023 at 12:44 P.M., the power went out at the facility and the generator was activated. At 12:55 P.M., this surveyor, the Regional Director of Clinical Services, and Registered Nurse B (RN B) observed that a bed and air mattress for the Resident in room [ROOM NUMBER]B was not working. RN B then stated that there were no red plugs (which are plugs that receive power from the generator) in the rooms but they would have to get an extension cord to plug it into the hall outlet. Upon exiting room [ROOM NUMBER]B at approximately 1:00 P.M., an electrical cord was observed plugged into a red outlet in the hall extending across the hall into a different Resident room on the opposite side of the hall.
On 01/24/2023 at 2:00 P.M., RN B was interviewed. When asked about the availability of red plugs, RN B stated there are 2 red plug outlets in the front hall and they are located on the same side of the hall. RN B stated that they plug air mattresses into the red outlets in the hall when the power goes out. RN B also confirmed there are air mattresses in use on both sides of the hall which is why an electrical cord was observed extending across the hall. When asked how Residents in wheelchairs travel the hall when the electrical cord is across the entire hall, RN B stated it is challenging and staff would have to assist the Residents. When asked about safety concerns, RN B indicated that the cord should've been taped down, secured, and signs posted to mitigate a tripping hazard.
On 01/24/2023 at approximately 3:45 P.M., the [NAME] President of Operations and the Regional Director of Clinical Services were notified of findings.
On 01/26/2023 by the end of survey, the [NAME] President of Operations and the Regional Director of Clinical Services confirmed there was no other information or documentation to submit.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, staff interviews, facility documentation review, and in the course of a complaint investigation, the facility staff failed to provide food that is palatable and at an appetizing ...
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Based on observation, staff interviews, facility documentation review, and in the course of a complaint investigation, the facility staff failed to provide food that is palatable and at an appetizing temperature. Specifically, the ice cream in the freezer on 01/18/2023 was observed to be soft and nearly milkshake consistency.
The findings included:
On 01/18/2023 at 3:10 P.M., this surveyor and the Dietary Manager entered the walk-in freezer for an observation. The temperature gauge on the outside of the freezer read (-3) degrees Fahrenheit. The temperature gauge on the inside of the freezer read 40 degrees. When asked about the ice cream, the Dietary picked up a plastic cup labeled chocolate ice cream. When asked if the ice cream was frozen, the Dietary Manager stated Yes. When asked if she could squeeze the cup to test the firmness, the Dietary Manager stated she could squeeze the cup only slightly and that the ice cream was frozen. This surveyor requested to hold the cup. The cup was easily pliable to demonstrate the ice cream was soft and nearly melted. The Dietary Manager went on to say that the ice cream leaves the freezer and gets put on resident food trays, which is then transported to the resident units in the tray warmer so by the time it get to residents, the ice cream is melted. When asked what has been done to fix this problem, the Dietary Manager did not answer.
On 01/18/2023 at 4:30 P.M., the Administrator and Director of Nursing were notified of findings.
On 01/19/2023 at 8:30 A.M., the Administrator stated that she spoke with the Dietary Manager and told staff not to transport ice cream in the tray warmer but keep ice cream stored in the unit refrigerators.
The facility staff provided a copy of their policy entitled, Quality and Palatability. Under the header Policy Statement, it was documented, It is the center policy that food is prepared by methods that conserve nutritive value, flavor, and appearance. Food is palatable, attractive, and served at safe and appetizing temperature. Food and liquids are prepared and served in a manner, form, and texture to meet resident's needs.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, staff interviews, and facility documentation review, the facility staff failed to store food in accordance with professional standards for food service safety. Specifically, the ...
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Based on observation, staff interviews, and facility documentation review, the facility staff failed to store food in accordance with professional standards for food service safety. Specifically, the walk-in freezer was observed on 01/18/2023 to be filled with meat, vegetables, and dairy products and have a temperature range of 40 to 48 degrees Fahrenheit.
The findings included:
On 01/18/2023 at 3:10 P.M., this surveyor and the Dietary Manager entered the walk-in freezer for an observation. The temperature gauge on the outside of the freezer read (-3) degrees Fahrenheit. The temperature gauge on the inside of the freezer read 40 degrees. When asked about this, the Dietary Manager stated that staff have been going in and out of the freezer recently so that's why the freezer temperature is up. The Dietary Manager stated if we wait a few minutes and keep the door closed, the freezer temperature will go back down and get cold again. At 3:15 P.M., Surveyor E and Surveyor F returned and entered the walk-in freezer with the Dietary Manager and the Maintenance Assistant and closed the freezer door. The inside temperature gauge read 48 degrees Fahrenheit. The Maintenance Assistant had a thermometer probe which he stated was new and accurate. After approximately 10 minutes in the freezer, the temperature probe read 35 degrees Fahrenheit.
On 01/18/2023 at 4:30 P.M., the Administrator and Director of Nursing were notified of findings.
On 01/19/2023 at 8:30 A.M., the Administrator stated that the freezer repair technician worked on the freezer last night and it is currently working. The Administrator provided a copy of the work order which documented the following excerpt: Freezer not getting to temp. Unit was frozen across the evap coil. At 8:40 A.M., this surveyor entered the walk-in freezer with the Dietary Manager for an observation. The inside temperature gauge read 10 degrees Fahrenheit and the freezer felt cold. The freezer was empty. The Dietary Manager stated all the food was discarded and expecting a delivery this day.
Sept 2021
11 deficiencies
2 IJ (2 facility-wide)
CRITICAL
(L)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Infection Control
(Tag F0880)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, review of facility policy, and review of Center for Disease Control and Prevention (CDC) gui...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, review of facility policy, and review of Center for Disease Control and Prevention (CDC) guidelines, the facility failed to initiate appropriate Personal Protective Equipment (PPE) to include N95 and eye protection for all staff, failed to initiate quarantine of residents during an outbreak, and failed to ensure all staff, visitors, and vendors were screened for COVID-19 signs and symptoms prior to entrance into the facility. These failures had the likelihood of increasing the risk of transmission of COVID-19 to all residents. Based on interviews, observations, and review of facility policy, the facility failed to ensure staff performed hand hygiene during meal delivery.
On 09/08/21 at 7:39 PM, the Administrator was notified that the failure to ensure all staff were wearing appropriate PPE for outbreak status after the facility was notified on 09/03/21 that a staff member tested positive for COVID-19, failure to initiate quarantine of residents during an outbreak, and failure to screen all staff, visitors, and vendors constituted immediate jeopardy at F880-L: Infection Control.
The facility provided an acceptable plan for removal of the immediate jeopardy for F880-L on 09/10/21 that included staff education regarding the appropriate PPE to wear during outbreak status to include an N95 mask and eye protection in the entire building, the entire North Wing Unit was placed on droplet precautions, and staff education on screening.
The survey team conducted the following to verify implementation of the removal plan for F880-L:
1.The survey team conducted observations of staff on wearing the required PPE for Transmission Based Precautions (TBP) during an outbreak.
2. The survey team conducted interviews with staff on education concerning the required PPE and TBP during an outbreak.
3.The survey team observed signage indicating the facility was in an outbreak status.
4.The survey team observed signage and PPE indicating residents on the North Wing Unit were under quarantine.
5.The survey team reviewed inservice information on screening and PPE usage.
6. The survey team conducted interviews with staff to validate their understanding on screening requirements.
The immediate jeopardy was removed on 09/10/21 at 3:50 PM. The deficient practice remained at an F (potential for more than minimal harm) scope and severity following the removal of the immediate jeopardy.
Findings include:
Review of CDC's Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, dated 02/23/21 states, New Infection in Healthcare Personnel or Resident . Because of the high risk of unrecognized infection among residents, a single new case of SARS-CoV-2 infection in any HCP or a Nursing Home-onset SARS-CoV-2 infection in a resident should be evaluated as a potential outbreak . HCP should care for residents using an N95 or higher-level respirator, eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown . Residents should generally be restricted to their rooms and serial SARS-CoV2 testing performed . Establish a Process to identify and Manage Individuals with Suspected of Confirmed SARS-CoV-2 Infection. Ensure everyone is aware of recommended IPC practices in the facility. Post visual alert (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) with instructions about current IPC recommendations (e.g., when to use source control and perform hand hygiene).
Review of facility policy titled COVID-19, effective date 06/30/21, revealed, Surveillance -Employees. Screen Center employees prior to beginning shift to include Positive travel history to locations with sustained community transmission of COVID-19 withing the past 14 days. Signs or symptoms of COVID-19 (temperature greater than 99.5 degrees F or 37.5 degrees C), chills, sore throat, cough, nasal congestion, congestion, runny nose, fatigue, myalgia, body aches, shortness of breath, difficulty breathing, headache, nausea, vomiting, diarrhea, or new loss of tase or smell).
Review of the facility policy titled, COVID-19 Plan undated revealed: Employee screening: 100% screening of all staff entering the center at the beginning of each shift .
During the entrance conference on 09/07/21 at 09:00 AM, the Administrator indicated that the facility currently had one staff member out of work that tested positive for COVID-19 during a weekly COVID-19 test on 09/03/21.
Upon entry to the facility on [DATE] at 09:00 AM, no signs were observed on the facility entrance indicating that the facility was in outbreak status.
During an interview with the Director of Nursing (DON) and Administrator on 09/08/21 at 9:45 AM, both the DON and Administrator were observed wearing surgical masks and not the required N95 mask and eye protection as required per CDC guidelines during an outbreak status. At this time the DON was unable to indicate what precautions should be put into place after a staff member and/or a resident tests positive for COVID-19.Per the CDC guidance during outbreak status facility is to implement N95 masks and eye protection for all staff, staff is to wear all PPE (N95, eye protection, gowns, and gloves) when caring for residents who have been exposed, residents are to remain in their rooms unless wearing a face mask and practicing social distancing in common areas, and to post signs indicating outbreak status with required PPE.
During an interview on 09/08/21 at 10:00 AM, the Infection Preventionist (IP) indicated that she was in the building working on 09/03/21 and was not notified of a staff member that tested positive for COVID-19, and had she been notified she would have begun CDC recommendations for outbreak status to include, posting signs of the outbreak on the front door, initiating appropriate PPE to include N95 and eye protection, initiating droplet precautions for the unit the staff member was on, and interviewing the NWM as to where she came in, what her symptoms were, and who she came into contact with.
Observations from 09/08/21 at 9:45 AM through 09/09/21 at 10:00 AM revealed staff on the North Wing wearing surgical masks, not N95 face masks, and no eye protection despite the facility being in an outbreak.
It took surveyor intervention on 09/09/21 at approximately 10:00 AM for the facility to implement the CDC guidelines during an outbreak.
During an interview on 09/10/21 at 11:07 AM, Registered Nurse (RN)1 indicated she was in serviced that morning [09/10/21] about what PPE is required during an outbreak this morning.
During an interview on 09/10/21 at 11:39 AM, CNA 3 indicated she was at approximately 10:00 AM as to the appropriate PPE to wear during an outbreak status to include N95 mask, eye protection and using droplet precautions when in residents' rooms.
During a telephone interview on 09/10/21 at 5:00 PM, the North Wing Unit Manger (NWM) stated that at approximately 10:00 AM on 09/03/21 there was an announcement for the weekly COVID-19 testing in the dining room. NWM stated she tested positive during the rapid antigen test and the DON then did a PCR test and immediately sent her home. The NWM further stated that she does not screen herself at the entrance and she thought the screening Kiosk was for visitors. She stated she used it the day of her interview and thought that after she was hired, she was not a visitor anymore. VWM further indicated that no one instructed her to screen before entering the facility. VWM stated she was not instructed on the screening process.
During an interview on 09/09/21 at 4:41 PM, the Administrator indicated that she was unable to find any evidence that NWM screened for signs of COVID-19 prior to working a shift since July 2021. The Administrator was asked to provide to the survey team all screening logs for the facility for the months of July, August, and September 2021. By the end of survey on 09/10/21 at 10:00 PM the Administrator was unable to provide screening logs.
During an interview on 09/09/21 at approximately 5:45 PM, the DON stated that staff are educated upon hire that they are supposed to screen themselves before entering the building, either by using the electronic Kiosk in the front of the building, or the paper form in the back of the building. The DON stated there was no written staff screening policy and procedure, and that it's done verbally, with no paper documentation to indicate staff screening was done.
2. The facility failed to ensure staff performed hand hygiene during meal delivery.
On 09/07/21 at 12:20 PM multiple observations of Certified Nursing Assistant (CNA) 3 were conducted. CNA3 was observed delivering lunch to Resident (R) 74, R24, R50, R67, R44, R62, and R23. CNA3 was observed pushing the food cart, opening the doors of the food cart, handling multiple trays for other residents, and touching his clothes. CNA3 failed to perform hand hygiene of any kind (ABHR, hand washing) between the handling of the residents' food trays.
On 09/07/21 at 12:20 PM multiple observations of CNA5 were conducted. CNA5 was observed delivering lunch to R16, R59, R2, R22. CNA5 was observed pushing the food cart, opening the doors of the food cart, handling multiple trays for other residents, and touching her clothes. CNA5 failed to perform hand hygiene of any kind (ABHR, hand washing) between the handling of the residents' food trays.
On 09/07/21 at 12:20 PM multiple observations of CNA1 were conducted. CNA1 was observed delivering lunch to R3, R71, R6, R52 and R79. CNA1 was observed pushing the food cart, opening the doors of the food cart, handling multiple trays for other residents, and touching her clothes. CNA1 failed to perform hand hygiene of any kind (ABHR, hand washing) between the handling of the residents' food trays.
On 09/07/21 at 12:35 PM an interview with CNA1 was conducted. CNA1 stated, I was not taught to sanitize between trays.
On 09/07/21 at 12:37 PM an interview with CNA5 was conducted. CNA5 stated, I was not taught to sanitize between trays.
On 09/07/21 at 12:45 PM an interview with CNA3 was conducted. CNA3 stated, I'm supposed to wash hands in between trays, but I don't touch anything (doors, tables, etc.) I only handle the trays, so I don't need to wash.
Observation on 09/07/21 at 12:05 PM, revealed Certified Nursing Assistant (CNA) 4 removing a food tray from a food cart stationed in the hallway, entering room [ROOM NUMBER], and delivering a food tray to the resident in bed B. CNA4 failed to perform hand hygiene before entering room [ROOM NUMBER]. CNA4 was further observed leaving room [ROOM NUMBER] and obtaining another food tray from the food tray cart in the hallway. CNA4 delivered the food tray to the resident in bed A room [ROOM NUMBER]. CNA4 failed to perform hand hygiene after delivery the tray to the resident in bed A. CNA4 was observed to exit room [ROOM NUMBER] and obtain a food tray for the resident in room [ROOM NUMBER] bed B. CNA4 failed to perform handwashing before and after the delivery of two food trays to the two residents in the room [ROOM NUMBER].
Continued observation revealed CNA4 leaving room [ROOM NUMBER], proceeding to the food cart, and retrieving a food tray for room [ROOM NUMBER]. No hand hygiene was performed. CNA4 entered room [ROOM NUMBER] and donned (put on) gloves. CNA4 failed to perform hand hygiene before entering resident's room [ROOM NUMBER] and before donning gloves. After donning gloves, CNA4 set up the food tray for the resident in room [ROOM NUMBER] bed A. When set-up was completed, CNA4 doffed (removed) the gloves and left the room without performing any handwashing. CNA4 retrieved a food tray from the food cart, returned to room [ROOM NUMBER], and delivered the food tray to the resident in B bed. No hand hygiene was performed. CNA4 was then observed retrieving the food tray from the resident in the B bed in room [ROOM NUMBER] and returning the tray to the food cart. When asked why, CNA4 stated that the resident in 57B had her own food and had declined the food tray. No handwashing was performed throughout the preceding observations.
CNA4 proceeded to retrieve a food tray for the resident B bed in room [ROOM NUMBER]. CNA4 donned gloves to assist the resident in 58B with the tray. CNA4 discarded gloves, left room [ROOM NUMBER], entered room [ROOM NUMBER], and failed to perform hand hygiene in between assisting the residents in room [ROOM NUMBER] and 59.
Next, CNA4 entered room [ROOM NUMBER] (only one resident in the room) with a food tray, donned gloves, and began to feed the resident in the A bed. No hand hygiene was performed before entering the room, donning gloves, and feeding the resident. CNA4 doffed the gloves and left room [ROOM NUMBER] for the pantry to pick up a can of soda for the resident in bed A in room [ROOM NUMBER]. No hand hygiene was performed. CNA4 reentered room [ROOM NUMBER]A and gave the soda to the resident in room [ROOM NUMBER]. CNA4 donned gloves without performing hand hygiene and continued to feed the resident in bed A room [ROOM NUMBER]. CNA4 doffed gloves and left the room for the nurse's station to get a telephone. Upon returning to the room, CNA4 donned gloves and assisted the resident to make a phone call. With the same gloves still on, CNA4 wet a washcloth and cleaned the resident's face. After cleaning the resident's face, CNA4 discarded the gloves and was observed washing her hands at the sink in room [ROOM NUMBER].
In an interview with CNA4 on 09/07/21 at 12:45 PM, CNA4 stated that she was a TNA (Nursing Assistant in training) and had been a TNA with the facility for about 6 months, training to get her certification as a CNA. CNA4 was told that during observations for the prior 45 minutes that she had been observed going in and out of residents' rooms without performing hand hygiene and only performed hand hygiene one time at 12:45 PM in room [ROOM NUMBER]. CNA4 stated that she only just came on duty and that she had used sanitizer. When CNA4 was told that she had not been observed using hand sanitizer, she gave no further responses.
A review of the facility's policy titled Infection Prevention & Control Policies & Procedures-Handwashing Requirements, Policy Number 401, Effective Date 02/06/20, revealed that:
All staff are trained in proper technique upon hire, annually, and PRN, and are monitored for proper handwashing practices. Employees will wash hands at appropriate times to reduce the risk of transmission and acquisition of infections . Hand hygiene can consist of handwashing with soap and water or use of an alcohol-based hand rub (ABHR).
A. Hand Hygiene
l. The following is a list of some situations that require hand hygiene:
a. When coming on duty.
b. When hands are visibly soiled (handwashing with soap and water); before and after direct patient contact (for which hand hygiene is indicated by acceptable professional practice)
e. Before and after eating or handling food (handwashing with soap and water)
f. Before and after assisting a patient with meals (handwashing with soap and water)
g. Before and after assisting a patient with personal care (e.g., oral care. bathing)
r. After removing gloves or aprons
s. After completing duty
CRITICAL
(L)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0886
(Tag F0886)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of policies and procedures, and review of the Centers for Medicare and Medicaid Servic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of policies and procedures, and review of the Centers for Medicare and Medicaid Services (CMS) QSO 20-38-NH Revised memo, the facility failed to implement outbreak testing of staff and residents to prevent the spread of COVID-19 upon identification that a North Wing Unit Manager (NWM) tested positive for COVID-19 on 09/03/21. This failure increased the likelihood of COVID-19 transmission to the 82 residents living at the facility.
As of 09/08/21 at 7:01 PM, the facility had not begun outbreak testing per CMS guidance.
On 09/08/21 at 7:39 PM, the Administrator was notified that the failure to ensure that all residents and staff were tested for COVID-19, regardless of vaccination status, after the facility was notified on 09/03/21 that the NWM tested positive for COVID-19, constituted immediate jeopardy at F886-L: COVID 19 Testing Residents and Staff.
The facility provided an acceptable removal plan for the immediate jeopardy at F886-L on 09/10/21.
The removal plan for F886-L included: 1. testing of all residents and staff, regardless of vaccination status, completed on 09/09/21; 2. continued testing of all COVID negative staff and residents, regardless of vaccination status every 3-7 days until testing identified no new cases of COVID 10 infections among residents for staff for a period of at least 14 days since the most recent positive case of 09/03/21; 3. staff to be notified of testing dates by a memo at the front entrance and time clock; 4. the Director of Nursing (DON) or designee to document test results of staff and residents on a line list log, the line list will be reviewed by the DON or designee for positive results, and any positive staff or residents will restart the outbreak testing guidelines; and 5.the Infection Preventionist, the DON and the Administrator were educated by the Nurse Consultant on COVID testing requirements and appropriate documentation of the testing results on 09/09/21.
The survey team conducted the following to verify implementation of the removal plan for F886-L:
1.The survey team reviewed the testing logs for all the residents and staff completed on 09/09/21.
2.There were no positive results for the residents and/or staff from the 09/09/21 testing to reset the duration of the outbreak testing at the time of the survey.
3.The survey team observed the posting for staff testing dates.
4.The survey team reviewed the testing/results line list log from 09/09/21.
5. The survey team reviewed the education provided by the Nurse Consultant on COVID testing and documentation.
The immediate jeopardy was removed on 09/10/21 at 3:50 PM. The deficient practice remained at an F scope and severity (potential for more than minimal harm) following the removal of the immediate jeopardy.
Findings include:
Review of facility policy titled, COVID-19 Testing, dated 05/04/21, revealed COVID-19 testing will be performed by trained personnel following CMS recommendations for testing . Outbreak testing for employees and patients: a. An outbreak is defined as a new COVID-19 infection. Upon identification of a single new case of COVID-19 infection in any employee or patient, testing is indicated. b. Outbreak testing of all employees and patients will occur as soon as possible when a new case is identified, regardless of vaccination status. Retesting of negative individuals will occur every 7 days until testing identifies no new cases of COVID-19 infection among employees or patients for a period of at least 14 days since the most recent positive result.
Review of Centers for Medicare & Medicaid Services (CMS), Ref: QSO-20-38-NH, dated 04/27/21, revealed . For outbreak testing, all staff and residents should be tested, regardless of vaccination status, and all staff and residents that tested negative should be retested every 3 days to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result . Documentation of testing: Symptomatic patients and employees- document the date(s) and times(s) of the identification of signs or symptoms, when testing was conducted, when results were obtained, and the actions the Center took based on the results. Identification of a new COVID-19 case in the Center-document the date the case was identified, date that all other patients and employees were tested, and the dates that all negative patients and employees were retested .For routine unvaccinated employee testing, document the centers county positive rate, corresponding testing frequency, and the date each positivity rate was collected, as well as date(s) that testing is performed .
During the entrance conference on 09/08/21 at 09:00 AM, the Administrator indicated that the facility currently had one staff member out of work that tested positive for COVID-19 during a weekly COVID-19 test on 09/03/21. The Administrator further indicated the entire staff and residents were tested on [DATE] and all results were negative. The facility was unable to provide evidence that the residents and staff were tested for COVID-19 on 09/03/21.
During an interview on 09/08/21 at 10:43 AM, the Infection Preventionist (IP) stated that the facility did not perform any COVID testing on 09/03/21. The IP stated that she is required to report the test results to the Department of Health (DOH). Upon asking the DOH for evidence of facility testing, the IP received an email indicating that the DOH was unable to provide any specific information about submitted results.
On 09/08/21 at 11:35 AM an interview with Certified Nursing Assistant (CNA) 2 was conducted. CNA2 stated I have not been tested in the last two weeks.
During an interview on 09/08/21 at 11:39 AM, with two residents (Resident (R) 6 and R52) was conducted. Both stated they were tested last week but neither could remember the exact day. Review of a R6's electronic medical record (EMR) significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/05/21 revealed a Brief Interview for Mental Status (BIMS) of 14 out of 15 indicating intact cognition. Review of R52's EMR quarterly MDS with an ARD of 08/10/21 revealed a BIMS of 14 out of 15 indicating intact cognition.
Interview with North wing Licensed Practical Nurse (LPN)1 on 09/08/21 at 11:42 AM indicated that she was given a facemask and face shield upon entrance to the facility but was not informed that the facility was in outbreak status.
During an interview with the Director of Nursing (DON) and Administrator on 09/08/21 at 10:14 AM, the DON confirmed that the facility could not provide evidence that the residents and staff members were tested for COVID-19 after a staff member tested positive on 09/03/21. The DON indicated that it was the IP who kept the testing logs of both staff and residents. The facility was unable to provide any line listings of staff and/or resident testing prior to the survey team leaving the facility on 09/09/21 at 10:00 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0568
(Tag F0568)
Could have caused harm · This affected 1 resident
Based on interview, record review, and policy review, the facility failed to ensure that each resident or the financial representative received a quarterly accounting of the personal funds for one of ...
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Based on interview, record review, and policy review, the facility failed to ensure that each resident or the financial representative received a quarterly accounting of the personal funds for one of 27 sampled residents (Resident (R) 57).
Findings include:
Review of R57's undated admission Record, located in R57's electronic medical record (EMR) under the Profile tab, revealed a facility re-admission date of 08/06/20 with multiple medical diagnoses.
Review of R57's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/12/21 revealed the facility assessed R57 to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R57 was cognitively intact.
On 09/08/21 at 3:11 PM an interview with R57 was conducted. R57 stated, I have not received any statements about my funds account.
On 09/10/21 at 2:40 PM an interview with the Business Office Manager (BOM) was conducted. The BOM stated R57 has a resident fund account with $16.00 in it. There was a $20.00 deposit made on 06/11/21. Statements were sent out in July, there is no address listed on the statement, I do not know where it was sent.
On 09/10/21 at 2:50 PM an interview with the BOM was conducted. The BOM stated, the corporate office stated the statements for the accounts are sent out by a third party. I'm not sure where it was sent, if it was sent.
Review of the facility policy Patient Trust Funds Accounts, dated 02/01/19, failed to reveal any process related to the processing of resident statements for the trust funds accounts.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0576
(Tag F0576)
Could have caused harm · This affected 1 resident
Based on Resident interview, staff interview and facility documentation review, the facility staff failed uphold Resident Rights with regards to receiving mail unopened for 1 Resident (Resident #805) ...
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Based on Resident interview, staff interview and facility documentation review, the facility staff failed uphold Resident Rights with regards to receiving mail unopened for 1 Resident (Resident #805) in a survey sample of 12 Residents.
The findings included:
On 10/26/21 at 2:00 PM, an interview was conducted with Resident #805. During this interview, Resident #805 stated that her wedding ring had been stolen. When asked if it was replaced, Resident #805 said No ma'am, I never got a penny for it. It was stolen in April when [previous facility Administrator name redacted] was here and I never got a cent.
On 10/27/21 at 10:05 AM, during a follow-up interview with Resident #805, she reported she they lost the ring in April, I reported it to several nurses and said they had it locked in the med cart. The administrator said corporate was going to cut a check and send it, I never received anything. Then these people took over [referring to the change in facility ownership] and [the current Administrator name redacted] said the same thing, they were going to cut a check. That's all they ever tell me.
On 10/27/21, a review of the Facility Reported Incidents (FRI's) was conducted. This review revealed that the facility staff did complete a FRI report on 5/31/21. This report had a statement attached that indicated Resident #805 had removed her wedding rings due to her finger being swollen on 5/21/21. Then on 5/30/21, when the Resident requested the ring it was not able to be located/recovered. The facility conducted an investigation and on 6/4/21, filed a follow-up FRI report which indicated, We concluded that a misappropriation of patient property had occurred.The facility has agreed to reimburse [Resident #805's name redacted] for the missing ring.
On 10/27/21, Surveyor C asked the facility Administrator to provide evidence of Resident #805 being reimbursed for the ring. During investigation of this, it was noted that the reimbursement check got applied to the Resident's account/bill at the facility and was not given to the Resident. The check was made payable to Resident #805. Upon Surveyor B questioning how this happened, it was determined that the facility receptionist opened the Resident mail, then wrote out a receipt for the payment.
On 10/27/21 at 2:28 PM, an interview was conducted with Employee K the receptionist. She was asked about the process when mail is received. Employee K said, I meet him (mail man) in the vestibule and give him going out mail. Resident mail goes into activity mail box and they distribute it. Payments, I open and write in the receipt book and mail them [the sender] a receipt. She was shown a copy of the reimbursement check dated 7/30/21, and asked if she would open mail addressed like this, Employee K said, I would open it and write a receipt for it. She was asked, even though it is in the Resident's name? Employee K said, All payments are opened and written in the receipt book.
Review of the Business Contract/Admissions Agreement for Resident #805 revealed a copy of Resident Rights which noted 15. To have immediate access and visitation rights and to communicate privately with persons of his/her choice, and send and receive his/her personal mail unopened . Resident #805 signed the agreement along with a facility representative/Employee M on 12/12/20. Review of the 6 pages of General Acknowledgements within this same Contract, revealed no authorization for the facility staff to open Resident #805's mail.
On 10/27/21, in the afternoon, a follow-up conversation was held with Resident #805. Resident #805 was unaware that she had ever been mailed a reimbursement check and that the facility staff had opened her mail and applied this reimbursement check to her bill/account at the facility which created a credit on her account. Resident #805 said she had not given authorization for the facility to do this.
On 10/28/21, during an end of day meeting the facility Administrator was made aware that the facility had opened Resident #805's mail without authorization.
No further information was received.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
Based on Resident interview, staff interview and facility documentation review, the facility staff misappropriated a refund check for 1 Resident (Resident #805) in a survey sample of 12 Residents.
Th...
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Based on Resident interview, staff interview and facility documentation review, the facility staff misappropriated a refund check for 1 Resident (Resident #805) in a survey sample of 12 Residents.
The findings included:
On 10/26/21 at 2:00 PM, an interview was conducted with Resident #805. During this interview, Resident #805 stated that her wedding ring had been stolen. When asked if it was replaced, Resident #805 said No ma'am, I never got a penny for it. It was stolen in April when [previous facility Administrator name redacted] was here and I never got a cent.
On 10/27/21 at 10:05 AM, during a follow-up interview with Resident #805, she reported she they lost the ring in April, I reported it to several nurses and said they had it locked in the med cart. The administrator said corporate was going to cut a check and send it, I never received anything. Then these people took over [referring to the change in facility ownership] and the [current Administrator name redacted] said the same thing, they were going to cut a check. That's all they ever tell me.
On 10/27/21, a review of the Facility Reported Incidents (FRI's) was conducted. This review revealed that the facility staff did complete a FRI report on 5/31/21. This report had a statement attached that indicated Resident #805 had removed her wedding rings due to her finger being swollen on 5/21/21. Then on 5/30/21, when the Resident requested the ring it was not able to be located/recovered. The facility conducted an investigation and on 6/4/21, filed a follow-up FRI report which indicated, We concluded that a misappropriation of patient property had occurred.The facility has agreed to reimburse [Resident #805's name redacted] for the missing ring.
On 10/27/21, Surveyor C asked the facility Administrator to provide evidence of Resident #805 being reimbursed for the ring. During Surveyor C's investigation/questioning of this, the facility staff identified that the reimbursement check got applied to the Resident's account/bill at the facility, which created a credit balance. Resident #805 did not receive the reimbursement from the previously misappropriation of her wedding ring. The check was made payable to Resident #805. Upon Surveyor B questioning how this happened, it was determined that the facility receptionist opened the Resident mail, then wrote out a receipt for the payment. The business office manager/Employee O then indicated in writing for the corporate staff to apply the payment towards her patient liability.
Review of the facility policy titled, Manual Section: Abuse/Neglect/Misappropriation/Crime, Policy Name: Administrative Reference Guide, it read, . Misappropriation of Personal Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a patient's belongings or money without the patient's consent.
On 10/27/21, in the afternoon, a follow-up conversation was held with Resident #805. Resident #805 was unaware that she had ever been mailed a reimbursement check and that the facility staff had opened her mail and applied this reimbursement check to her bill/account at the facility which created a credit on her account.
On 10/28/21, during an end of day meeting the facility Administrator was made aware that the facility had misappropriated Resident #805's reimbursement check.
On 10/28/21, the corporate clinical director provided Surveyor C with a copy of a second reimbursement check that the company's corporate office had written and was sending overnight to Resident #805.
No further information was received.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility policy, the facility failed to issue a written transfer notice to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility policy, the facility failed to issue a written transfer notice to a resident and/or legal representative and to the state Ombudsman for one of two residents (Resident (R) 5) reviewed for hospitalizations.
Findings include:
Review of the facility policy titled, Notice of Discharge /Transfer, dated 01/06/20, revealed When the Center initiates a notice of transfer/discharge to a patient and/or responsible party, discharge planning will pursue timely and appropriate transfer/discharge notifications as well as discharge planning initiatives to ensure a safe and orderly discharge from the Center . Provide designated copies of the completed MFA Notice of Transfer/Discharge form to each of those specified on the form, which includes the Ombudsman . Scan a copy of the Notice of Transfer/Discharge into the patient's medical record in PCC [Point Click Care-electronic medical record] under the Misc. [Miscellaneous] tab. Once the document has been scanned into PCC, complete a Discharge Planning Progress note confirming the following: Date Patient and/or RP were given the notice and the method in which they received the notice. Date the notice was sent to the ombudsman and the method by which it was sent (The Ombudsman should be notified as close as possible to the actual time of a facility-initiated transfer or discharge) .
Review of R5's Face Sheet, found in the electronic medical record (EMR) under the Profile tab, revealed that R5 was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD).
Review of R5's EMR Misc. [Miscellaneous] tab revealed a Nursing Note, dated 02/21/21, which indicated that R5 was sent to an acute care hospital and subsequently admitted . Review of R5's EMR lacked evidence to support that a written notice of transfer was given to the resident and/or resident representative and the Ombudsman.
During an interview on 09/03/21 at 11:30 AM, Discharge Planning Director (DPD) verified that there was no evidence that a written transfer notice was provided to the resident and/or resident representative or Ombudsman.
During a telephone interview on 09/10/21 at 8:45 PM, the Director of Nursing (DON) verified that the facility is required to provide a written transfer notice to the resident and/or resident representative and to the Ombudsman.
During an interview on 09/03/21 at approximately 1:05 PM, the Administrator verified that the facility is required to provide a written transfer notice to include appeal rights to the resident and or representative and the Ombudsman.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide the resident and/or the resident representative a written ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide the resident and/or the resident representative a written notice of the bed hold policy in one of two residents (Resident (R) 5) reviewed for hospitalizations.
Findings include:
The facility was unable to provide the requested bed hold policy by the end of the survey on 09/10/21.
Review of R5's Face Sheet, found in the electronic medical record (EMR) under the Profile tab, revealed that R5 was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD).
Review of R5's EMR Misc. [Miscellaneous] tab revealed a Nursing Note, dated 02/21/21, which indicated that R5 was sent to an acute care hospital and subsequently admitted . Review of R5's EMR lacked evidence to support that a written notice of bed hold was given to the resident and/or resident representative.
During an interview on 09/03/21 at 11:30 AM, Discharge Planning Director (DPD) verified that there was no evidence that a written notice of bed hold was provided to the resident and/or resident representative.
During a telephone interview on 09/10/21 at 7:45 PM, the Director of Nursing (DON) verified that the facility is required to provide a written bed hold notice to the resident and/or resident
representative.
During an interview on 09/03/21 at approximately 1:05 PM, the Administrator verified that the facility must provide a written bed hold notice to include cost of care to the resident and or representative.
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 Resident interview, staff interview, facility documentation review and clinical record review the facility staff failed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Resident interview, staff interview, facility documentation review and clinical record review the facility staff failed to administer medications in accordance with physician orders and professional standards of practice for one Resident (Resident #806) in a survey sample of 12 Residents.
The findings included:
On 10/26/21 at 2:04 PM, an interview was conducted with Resident #806. During the interview RN B responded to Resident #806's call light. Resident #806 reported tightness in his chest and said they didn't give me my medicine last night, I think that may be the problem. I didn't get my gabapentin last night. I missed it once before and I got sick.
On 10/26/21 at 2:14 PM, Surveyor C approached RN C at the nursing station. RN C and Surveyor C conducted a narcotic count of Resident #806's gabapentin and the count matched the quantity of pills present. A copy of the narcotic count sheet was obtained.
On 10/26/21, a review of the electronic health record for Resident #806 was conducted. This review revealed physician orders dated 4/6/21, for Gabapentin that read, Gabapentin Capsule 300 MG Give 1 capsule by mouth two times a day for Neuropathy and another order dated 4/6/21, that read, Gabapentin Capsule 300 MG Give 2 capsule by mouth at bedtime for neuropathic pain. Review of the narcotic count sheet revealed that only 1 Gabapentin had been signed off as being provided on 10/25/21.
On 10/27/21 at 12:04 PM, a meeting was held with the DON (Director of Nursing) and facility administrator. The DON said following the surveyor's request for records and asking if any medication errors had been identified she said, I do now have a medication error I've had to complete on his gabapentin. The DON said, It is an order entry error, the NP (nurse practitioner) put two separate orders under one entry, it repeats that one, at 9pm he should have been given 2 tablets and he was only given one. When asked what systems are in place to prevent such errors from occuring, the DON said, Doing those chart checks but that would have required someone to definitely know when you see those orders that say give this tab and that that is typically where 2 orders have been put in under one entry. Also, they now the 6 rights of medication pass, if she had read that order she would have saw where it says 2 tabs at bedtime. The DON stated their professional standards of practice they follow is: [NAME].
According to Lippincott Nursing Procedures, Eighth Edition, Chapter 2, Standards of Care, Ethical and Legal Issues, on page 17 read, Common Departures from the Standards of Nursing Care. Claims most frequently made against professional nurses include failure to . follow physician orders .
Additional Guidance from [NAME]'s Nursing Center.com (www.nursingcenter.com)
Rights of Medication Administration .2. Right medication: Check the medication label. Check the order. 3. Right dose: Check the order. Confirm appropriateness of the dose using a current drug reference. If necessary, calculate the dose and have another nurse calculate the dose as well .5. Right time: check the frequency of the ordered medication. Double-check that you are giving the ordered dose at the correct time. Confirm when the last dose was given.
6. Right documentation: Document administration AFTER giving the ordered medication. Chart the time, route, and any other specific information as necessary. For example, the site of an injection or any laboratory value or vital sign that needed to be checked before giving the drug .
Reference: Nursing2012 Drug Handbook. (2012). [NAME] & [NAME]: Philadelphia, Pennsylvania. Accessed online at: www.nursingcenter.com.
No further information was provided prior to the end of survey.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations, interview, and review of facility policies, the facility failed to store, prepare, and serve food under sanitary conditions. Specifically, air vents, portions of the ceiling, an...
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Based on observations, interview, and review of facility policies, the facility failed to store, prepare, and serve food under sanitary conditions. Specifically, air vents, portions of the ceiling, and electrical cords above food preparation tables and the steam table were found to be covered with dirt and dust. These failures had the potential to affect 78 of 82 residents living at the facility, who received food from the kitchen; there were four residents requiring tube feedings.
Findings include:
On 09/07/21 at 9:30 AM, an initial tour of the kitchen was conducted with the Dietary Manager (DM). Observations of the food preparation area in the kitchen revealed six electrical cords, hanging from the ceiling over the steam table and food preparation area, were noted to be covered with dirt and dust. The air conditioner vent and ceiling located over the reach in refrigerator were noted to be covered in dirt and dust.
On 09/07/21 at 09:40 AM observations conducted in the walk-in refrigerator of the facility kitchen revealed the ceiling and all four walls to be covered in dust.
On 09/07/21 at 9:30 AM an interview with the DM was conducted. The DM confirmed the ceiling, electrical cords and air conditioning vents were covered in dirt and dust. They are all dirty and need to be cleaned.
On 09/07/21 at 9:40 AM an interview with the DM was conducted. The DM confirmed the ceiling, and walls in the walk-in refrigerator were covered in dirt and dust. They are dirty and need to be cleaned, staff will clean them today.
Review of the facility cleaning schedule for the walk-in refrigerator dated for the week of 08/27/21 through 08/31/21 revealed, the floors, walls, food racks, labeling, and utility carts had all been cleaned.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected multiple residents
Based on staff interview and facility documentation review, the facility staff failed to document the COVID-19 vaccination status for 27 out of 85 staff members.
The findings included:
The facility st...
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Based on staff interview and facility documentation review, the facility staff failed to document the COVID-19 vaccination status for 27 out of 85 staff members.
The findings included:
The facility staff failed to obtain and document the COVID-19 vaccination status for 27 out of 85 staff members.
On 10/27/21, a copy of the facility's documentation for the COVID-19 Immunization status staff members was requested and received from the Facility Administrator.
Review of the document revealed that from a list of 85 staff members, the COVID-19 immunization status was unknown for 23 staff members as noted with blank spots in both the 1st vaccine and 2nd vaccine columns and 4 additional staff members that only had a first dose date recorded with a blank spot noted under 2nd vaccine column.
On 10/27/21, an interview was conducted with the facility's Infection Preventionist who verified the list for staff members COVID-19 vaccine status was current and the immunization status was unknown for 23 staff members listed and incomplete for 4 members listed.
The Infection Preventionist further stated, I do not have a vaccination status list for agency staff as well as dietary and housekeeping staff, I am unaware of their [COVID-19 immunization] status there is no written [COVID-19] vaccination policy that I'm aware of.
On 10/28/21 at approximately 10:30 AM, a group interview was conducted with the Infection Preventionist and the facility Staff Development Coordinator, both whom verified there were no additional updates made to the COVID-19 vaccine status list for staff members previously submitted the day before.
On 10/28/21 at approximately 2:00 PM, a group interview was conducted with the Facility Administrator, Director of Nursing, and Corporate Clinical Consultant and updated on the findings. The Corporate Clinical Consultant verified she was aware of the current regulations for COVID-19 Immunizations that were updated by CMS (Centers for Medicare & Medicaid Services) on 5/11/21.
The CMS (Centers for Medicare & Medicaid Services) recommendations found in Ref: QSO-21-19-NH, revised on 5/11/21, page 5, read, The facility must document the vaccination status of each staff member (i.e., immunized or not), including whether fully immunized (i.e., completed the series of multi-dose vaccines).
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0885
(Tag F0885)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, review of facility documents, and review of Centers for Medicare and Medicaid Services (CMS)...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, review of facility documents, and review of Centers for Medicare and Medicaid Services (CMS) memo QSO-20-29-NH, the facility failed to notify in a timely manner residents and resident representatives when a staff member tested positive for COVID-19. This failure had the potential to affect all 85 residents in the facility.
Findings include:
Review of the CMS Ref: QSO-20-29-NH Interim Final Rule Updating Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in Nursing Homes, dated May 6, 2020, revealed The facility must inform residents, their representatives, and families of those residing in facilities by 5:00 PM the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other.
During an entrance conference on 09/07/21 at 9:10 AM, the Administrator indicated that during a routine weekly testing, an asymptomatic staff member tested positive for COVID-19, as indicated by a rapid antigen test. A polymerase chain reaction (PCR) test was immediately done and sent out and the staff member was immediately sent home. Positive PCR results were obtained on 09/03/21.
The Administrator stated that after the positive result all staff and residents were tested on [DATE] with negative results. The Administrator stated that all staff, residents and/or their resident representatives were notified that there was positive COVID-19 in the facility immediately after positive results were obtained.
During an interview with Resident (R) 67 on 09/08/21 at 10:45 AM, R67 indicated he had not been notified of a staff member who tested positive for COVID-19 on 09/03/21.
Review of R67's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/10/21 revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating intact cognition.
During an interview with R5 on 09/08/21 at 10:49 AM, R5 indicated that he had not been notified of a staff member who tested positive for COVID-19 by 09/04/21.
Review of R5's MDS with ARD of 06/09/21 revealed a BIMS of 15 out of 15 indicating intact cognition.
During an interview on 09/08/21 at 9:45 AM with the Director of Nursing (DON) and Administrator, the DON indicated when a resident or staff member test positive for COVID-19 the receptionist is responsible to ensure that all the families are notified of a positive case of COVID-19 in the building. Staff are notified by a notice on the time clock and verbally. The DON was unable to provide evidence that this was done.
During a follow up interview on 09/08/21 at 10:14 AM, the Administrator confirmed residents and/or family representative were not notified of a staff member that tested positive for COVID-19 by 5:00 PM on 09/04/21.
During an interview on 09/08/21 at 10:43 AM, the Infection Preventionist (IP) stated that she was present in the building on 09/04/21 and was not aware that a staff member tested positive for COVID-19. The IP stated that if she had been made aware she would have printed out a resident census and given it to the receptionist to notify family members and would have ensured that staff and residents were notified.
During an interview on 09/08/21 at 11:39 AM, Certified Nursing Assistant (CNA) 5 stated that she was notified by one of her co-workers that there was a positive staff member mid-morning on 09/04/21 after she had already begun her shift. CNA5 verified that she was not notified by the facility management.
During an interview on 09/08/21 at 11:42 AM, Licensed Practical Nurse (LPN)1 indicated that she was given a facemask and face shield upon entrance but was not informed that the facility was in outbreak status.
During an interview on 09/09/21 at approximately 11:06 AM, the Receptionist (RS) indicated that they used to get a facility census during an outbreak, and they would document on the census when they contacted family members to notify them of the outbreak, but she has not seen the book since the old Administration left. The RS could not remember if a census list was provided on 09/03/21 and indicated that it would have been given back to the Administrator.
During an interview on 09/09/21 at 1:21 PM, the Nurse Consultant confirmed that the facility COVID-19 policy did not include, when and how to notify residents and/or resident representatives of a positive case of COVID-19 in the facility.
Oct 2018
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on observations, resident interview, staff interview and review of the facility's policy the facility staff failed to maintain personal privacy for 1 of 41 residents, (Resident #69) in the surve...
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Based on observations, resident interview, staff interview and review of the facility's policy the facility staff failed to maintain personal privacy for 1 of 41 residents, (Resident #69) in the survey sample.
Resident #69's window blinds had blinds missing which resulted in an opening visible to the outside.
The findings included:
Resident # 69 was originally admitted to the facility 09/26/14. The current diagnoses included; chronic ulcer of lower leg, peripheral vascular disease, hypertension, chronic ulcer of unspecified part of unspecified lower leg.
The admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/31/18 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scored a 13 out of a possible 15. That indicated Resident # 69's cognitive abilities for daily decision making was intact.
In section G (Physical functioning) the resident was coded as being independent requiring set up help only with eating; independent with locomotion; limited assistance with dressing, and personal hygiene; set up help bathing; independent with bed mobility and required supervision with transfers, and toileting. In section H Bladder and Bowel, the resident was coded as always continent of bowel and bladder.
On 10/23/18 at approximately 4:22 PM the blinds in Resident # 69's room had an approximate 6 x 6 inch square opening where blinds were missing which made it possible to see outside. The Resident stated that the blinds have been like that for 4 years this past September.
On 10/24/18 at approximately 4:45 PM the blinds in Resident #69's room remained in the same condition.
On 10/25/18 an interview was conducted with License Practical Nurse (LPN #2) in the Resident's room. She stated that she hadn't noticed the opening in the blinds until today or yesterday.
On 10/25/18 The Director of Nursing (DON) and Administrator were approached for the facility's privacy policy. The surveyor was given a Resident Right's hand out by Mosby's Textbook for Long Term Care Nursing Assistants. Chapter 2, page 13, Sixth Edition). It clearly stated the following:
A person has the right to use the bathroom in private. Privacy is maintained for all personal care measures. Bathing and dressing are examples. Protect privacy by: Closing privacy curtains, doors, and window coverings;removing residents from public view.
The current care plan revised on 06/20/2018 had a problem which read (Resident #69) has an ADL (Activities of Daily Living) self-care performance deficit/t disease process. IDT continues to expect cyclic changes r/t DJD/Parkinson's/edema, Asthma and depression. The Care Plan Goal reads; The resident will continue to participate in ADLs through the review date. The interventions included; Report acute changes in need for help to perform ADL tasks to MD. Set up ADL tasks and assist only as needed. Bathing/Showering daily.
Resident # 69 stated she would dress herself independently in her room but she goes inside the restroom to provide ADL care due to opening in the blinds.
On 10/25/18, at approximately 7:30 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. No further information was provided by the facility staff.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #84 was re-admitted to the facility on [DATE]. Diagnosis for Resident #84 included but are not limited to *Cerebrova...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #84 was re-admitted to the facility on [DATE]. Diagnosis for Resident #84 included but are not limited to *Cerebrovascular Accident (CVA) with left *hemiplegia. Resident #84's Minimum Data Set (an assessment protocol) with an Assessment Reference Date (ARD) of 09/27/18 coded Resident #84's Brief Interview for Mental Status (BIMS) scored a 99 indicating short and long-term memory problems and with severe cognitive impairment - never/rarely made decisions. In addition, the MDS coded Resident #84 extensive assistance of one with personal hygiene.
Resident #84's comprehensive care plan revised on 01/23/16 identified Resident #84 with ADL self-care performance deficit r/t (related to) CVA. The goal set for the resident by the staff was that the resident would be groomed and dressed appropriately and personal/oral hygiene will be addressed. One of the intervention/approaches to manage goal include under personal hygiene/oral care requiring the assistance of one staff member.
During the initial tour on 10/23/18 at approximately 11:05 a.m., Resident #84 was observed sitting in a wheel chair outside of his room. The surveyor observed the resident's fingernails were long and thick with a brown substance under the nails.
On 10/25/18 10:40 a.m., Resident #84's fingernails remains unchanged. On the same day at approximately 10:45 a.m., RN #1 assessed Resident #84's fingernails with the surveyor present. The RN stated, Yes, his finger nails need to be trimmed. The surveyor asked, When do the staff trim and cut the resident's nails, she replied, They should be looked at everyday doing resident's care; their fingernails should be cut and trimmed as needed.
On 10/25/18 at approximately 3:10 p.m., Resident #84 was observed with his fingernails cut, trimmed and clean.
Definitions:
-CVA is a medical emergency. Strokes happen when blood flow to your brain stops. Within minutes, brain cells begin to die (https://medlineplus.gov/stroke.html).
-Hemiplegia is the loss of muscle function on one side of the body (https://medlineplus.gov/druginfo/meds/a682514.html).
3. Resident #65 was originally admitted to the facility 8/10/18 and has never been discharged from the facility. The current diagnoses included; stroke with left hemiparesis and depression with crying episodes and poor appetite.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/19/18 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 5 out of a possible 15 (severe cognitive impairment). The resident was also coded for feeling down, depressed and feeling bad about herself. She was also coded as behaviors directed towards self.
In section G (Physical functioning) the resident was coded as requiring total care of 1 with bathing personal hygiene, dressing, locomotion and eating, extensive assistance of 2 people with bed mobility, total care of 2 with transfers and toileting,
Resident #65's person centered care plan dated 8/10/18, had a problem which read; the resident has an ADL self-care performance deficit related to activity intolerance, confusion and contracture. The goal read; the resident will maintain current level of function in all extremities through the next review date 11/27/18. The interventions included; provide a sponge bath when a full bath or shower cannot be tolerated. The resident has contractures of the left arm and leg. Provide skin care daily to keep clean and prevent skin breakdown. The resident requires assistance with meals. The resident is incontinent.
On 10/23/18 at approximately 5:25 p.m., resident #65's was observed seated in a chair outside in the gazebo with her husband. The resident reached her hand out to adjust her blanket. The resident's finger nails were observed to be long (approximately 2 inches beyond the tip of the finger) with broken edges and a brownish substance beneath them.
On 10/24/18 at approximately 10:20 a.m., an interview was conducted with Resident #65. The resident stated I have been in various rehabilitation places since 5/2018 and I know they are not going to ask me if I want my nails cut, cleaned or filed and they don't want me to ask them to do anything. I put my call light on and they don't come for up to an hour or they turn it off and tell me they will back and never return. The resident further stated she would have to ask her daughter to care for her nails.
An interview was conducted with the Director of Nursing (DON) on 10/24/18 at approximately 3:40 p.m. The DON stated a resident's nails are viewed during activities of daily living (ADL) care. If it is determined a resident needs care the licensed nurse directs the Certified Nursing Assistant (CNA) to provide or not provide services based on the resident's diagnosis. The DON stated fingernail care is the responsibility of the CNA and should be provided with baths and when needed. The DON stated she wasn't aware of Resident #65's nail she would follow-up.
No additional information was provided prior the survey team's exit at 8:00 p.m., on 10/25/18.
Based on observations, family interview, staff interviews and facility documentation, the facility staff failed to ensure 3 of 41 residents (Resident #50, #84 and #65) in the survey sample that were unable to carry out Activities of Daily Living (ADL) received services to maintain good grooming and oral hygiene.
1. Resident #50 was observed with adhered food and plaque on her teeth all three days during the survey.
2. The facility staff failed to provide nail care to Resident #84 to include cleaning and trimming.
3. The facility staff failed to provide fingernail care for Resident #65 prior to her finger nail becoming long with broken edges and a brownish substance beneath them.
The findings included:
1. Resident #50 was admitted to the nursing facility on 10/20/17 with diagnoses that included diabetes and dementia.
Resident #50's most recent Minimum Data Set (MDS) assessment was a quarterly and coded the resident with short and long term memory loss and severely impaired in the skills needed for daily decision making. The MDS assessed the the resident as totally dependent on one staff for personal hygiene to include brushing teeth.
The care plan dated 9/13/18 identified that the resident had ADL deficit in self-care performance. The goal set by the staff for the resident was that her ADL needs would be met daily. Some of the approaches the staff would implement to accomplish this goal included provide oral care daily and as needed.
On 10/23/18 at 5:30 p.m., the resident had completed the evening meal. Upon close inspection of the resident, adhered food and plaque was observed on her teeth.
On 10/24/18 at 10:00 a.m., Certified Nursing Assistant (CNA) #10 stated she had completed the resident's bath and all personal care and the resident was ready for the day. The teeth exhibited the same material as previously observed on 10/23/18 at 5:30 p.m.
On 10/24/18 at 10:27 a.m., a family interview was conducted with the Resident's Representative (RR). When asked about bathing and oral care, the RR stated it was something she stressed with the nursing staff consistently to Please brush her teeth because she can't do it herself. The RR stated the resident had her own teeth and she wanted her to keep them as long as possible. The RR stated the resident had seen a dentist and that was not the problem, she just wanted basic brushing by the nursing staff routinely.
On 10/25/18 at 12:00 p.m. and 3:00 p.m., Resident #50's teeth had not been effectively brushed and the teeth were heavily coated with a residual white film and food debris.
On 10/25/18 at 6:30 p.m., the Director of Nursing (DON) and Nurse Consultant presented the policy procedures (undated) they used to provide guidance for mouth care to include brushing teeth. The procedures indicated oral hygiene would be provided during morning care before breakfast and after breakfast, after lunch and at bedtime.
On 10/25/18 at 8:00 p.m., no further information was given prior to survey exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews and review of the facility documentation, the facility failed to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews and review of the facility documentation, the facility failed to ensure the necessary treatment was provided in a manner to prevent infection and promote healing for 1 of 41 Residents (Resident # 52) who entered the facility with pressure ulcers.
The facility staff failed to ensure during wound care, a standard to promote healing and prevent the spread of infection, was implemented.
The findings included:
Resident #52 was admitted to the facility on [DATE]. Diagnosis for Resident #52 included but are not limited to *Diabetes. Resident #52's Minimum Data Set (an assessment protocol) with an Assessment Reference Date (ARD) of 08/31/18 coded Resident #52's Brief Interview for Mental Status (BIMS) scored a 99 indicating short and long-term memory problems and with severe cognitive impairment - never/rarely made decisions.
In section M (Skin Conditions) of MDS 08/31/2018 coded Resident #52 at risk for developing pressure ulcer, but having a Stage 1 or higher *pressure ulcer. Resident #52 was coded as having *unstageable pressure ulcers.
A Braden Risk Assessment Report was completed on 10/17/18; resident scored a ten indicating high risk for the development of pressure ulcers. Mobility is completely immobile; does not make even slight change in body or extremity position without assistance.
Resident #52's revised comprehensive care plan dated 10/18/18 documented Resident #4 with actual skin breakdown with potential for further skin impairment. The goal: the resident will have no evidence of further skin impairment. Some of the intervention/approaches to manage goal included *Alternating Pressure Air Mattress (Atmos 9000) and float heels.
According to the Physician Order Form as of October 2018; Resident #52 treatment read as follow: Apply *Santyl ointment to left and right heel topically every day for wound care starting on 10/09/18.
On 10/25/18 at approximately 12:12 p.m., Resident #52 was lying in bed in a supine position on an alternating low air loss pressure mattress. Licensed Practical Nurse (LPN #4) performed wound care with the assistance of the Unit Manager (UM). Prior to starting wound care to Resident #52, LPN washed her hands x 24 seconds. The LPN placed a barrier pad covering Resident #52's personal over bed table without disinfecting the table. The LPN placed all treatment supplies on the barrier, which consisted of the following: normal saline bullets (2), *Santyl, 4 x 4 gauzes, foam dressing and red bag. The LPN removed the dressing from the right heel; the wound bed was yellow in color with a small amount of serosanquineous drainage noted but without odor. The wound was cleaned with normal saline, gloves were removed, new gloves donned, Santyl ointment applied to wound bed then covered with dressing. The LPN removed her gloves, put in red bag, and without washing or sanitizing her hands, donned another pair of gloves, removed the dressing from the left heel (the wound bed was black in color with no odor noted) dressing was placed in red bag, gloves removed, another pair of gloves donned, Santyl ointment was applied to wound bed then covered with dressing. The LPN removed all wound care supplies from the over bed table then placed the over bed table at resident's bedside without disinfecting.
An interview was conducted with LPN #3 on 10/25/18 at approximately 12:35 p.m. The LPN stated, I should have cleaned the over bed table before and after use. She also said, I should have washed my hands between the left and right heel wounds and after I removed the soiled dressing.
On 10/25/18 at 3:51 p.m., an interview was conducted with UM who stated, The LPN should have washed her hands before starting wound care, after changing of her gloves and after completing wound care. The UM also stated the over bed table should have been wiped down with sanitizer wipes before and after use to help fight the spread of infection.
An interview was conducted with the Director of Nursing on 10/25/18 at approximately 4:15 p.m. The surveyor asked, When should the nurse wash their hands doing wound clear she replied, They should wash their hands before get starting with wound care, after the soiled dressing has been removed, before they start a clean procedure and after the procedure has been completed. The DON also stated, The nurse should have washed her hands between the left and right heel wounds to prevent wound cross contamination. The DON said the over bed table should have been disinfected before and after use.
The facility's policy titled General Wound care/Dressing Changes read in part: (Effective: 02/01/15).
-License nurses will follow recognized standards of practice regarding dressing changes.
Definitions:
1. Diabetes is a complex disorder of carbohydrates, fat, and protein metabolism that is primarily a result off a deficiency or complete lack of insulin secretion (Mosby's Dictionary of Medicine, Nursing & Health Professions 7th Edition).
2. Pressure Injury: 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 (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/).
3. Stage 4 Pressure Injury: Full-thickness skin and tissue loss
Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/).
4. Alternating low air loss pressure mattress is comprised of individual air cells that slowly inflate and deflate under the patient. The alternating or inflation/deflation of cells allow blood flow to reach all areas of the patient's body to heal and prevent bed sores (http://www.alternatingpressuremattress.com/whatisapp.html).
5. Santyl is used to help the healing of burns and ulcers. Collagenase is an enzyme. It works by helping to break up and remove dead skin and tissue. This effect may also help to work better and speed up your body's natural healing process (antibiotics <http://www.webmd.com/cold-and-flu/rm-quiz-antibiotics-myths-facts.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to secure Resident #33 indwelling catheter to prevent potential dislodgement.
The findings include...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to secure Resident #33 indwelling catheter to prevent potential dislodgement.
The findings included:
Resident #33 was originally admitted to the facility 02/25/14 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Carcinoma in situ of bladder, Chronic Kidney disease. Obstructive Uropathy, history of urinary tract infections.
The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 5/03/18 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #33's cognitive abilities for daily decision making were intact.
In section G (Physical functioning) the resident was coded as requiring supervision of 1 person with eating and extensive assistance of 1 person with locomotion, dressing, and personal hygiene and bathing, extensive assistance of 2 people with bed mobility, transfers, and toileting, and total care of 2 people with bathing In section H Bladder and Bowel, the resident was coded as always incontinent of bowel movement and resident has an indwelling catheter.
A Physician's order dated 07/25/2017 read; change foley catheter 18fr/5cc and bag every monthly, every evening shift every 30 days for protocol. Irrigate foley catheter with 60 ml of normal saline every 8 hours as needed related to urinary tract infections.
The current care plan revised on 08/24/2017 had a problem which read (resident #33) has a history of recurrent urinary tract infection (UTI)/Sepsis and a history of obstructive uropathy. The care plan goal read (Resident #33) The resident will receive intervention for complications relating to catheter. The interventions included; Monitor for sign and symptoms of urinary tract infections and keep MD informed. Change indwelling catheter as ordered. Provide indwelling catheter as ordered.
On approximately 10/23/18 3:43 PM while rounding in Resident # 33's room, it was noticed that the indwelling foley catheter tubing was not secured to resident's thigh.
On 10/24/18 at approximately 3:20 PM while Resident # 33 was resting in bed. CNA #2 was at Resident's bedside. She was asked if she could show surveyor the resident's Foley catheter. The foley catheter appeared to be intact but was not secured to resident's leg/thigh. The CNA (Certified Nurses Assistant) stated that usually there's a white thing attached to the leg.
On 10/25/18 at approximately 11:09 AM assisted by CNA # 3, to look at foley catheter, foley catheter was not secure to resident's leg/thigh. CNA #3 stated that foley doesn't drain well.
On 10/25/18 Licensed Practical Nurse (LPN) # 2, Unit Manager, was interviewed and asked to accompany surveyor to resident's room concerning her foley catheter not being secured to her leg/thigh. The LPN # 2 stated that resident #33 should have an anchor but she'll check resident's orders. LPN # 2 later stated that she didn't see any orders written.
The facility's undated policy titled Indwelling Urinary Foley Catheter and Drain Bag Changes read; To protect the closed system of urinary bladder drainage and to prevent ascending urinary tract infection, indwelling urinary foley catheters and drainage bags are changed by the Licensed Practical Nurse with a specific order from the physician defining the frequency change. The Procedure reads; Obtain a physician's order containing the following information: Type of catheter, size of catheter and balloon inflation, frequency of urinary system change, frequency of drainage bag change, Foley catheter care during am care and pm care and after each incontinent stool, diagnosis or justification for use. Maintain the integrity of the closed system at all times. Properly secured catheter tubing.
On 10/25/18, at approximately 7:30 p.m., the above findings were shared with the Administrator, Director of Nursing and corporate consultant during the exit interview. No futher information was provided by the facility staff.
Based on observations, staff interviews, clinical record review, and review of the facility's educational document, the facility staff failed to provide appropriate care and services for two resident (Resident #52 and #33) of 41 residents in the survey sample.
1. The facility staff failed to follow physician orders to change a Foley catheter on a monthly basis for Resident #52.
2. The facility Staff failed to secure the indwelling urinary catheter to prevent potential dislodgement for Resident #33.
The findings included:
1. Resident #52 was admitted to the facility on [DATE]. Diagnosis for Resident #52 included but are not limited to *Urinary Retention. Resident #52's Minimum Data Set (an assessment protocol) with an Assessment Reference Date (ARD) of 08/31/18 coded Resident #52's Brief Interview for Mental Status (BIMS) scored a 99 indicating short and long-term memory problems and with severe cognitive impairment - never/rarely made decisions. In addition, the MDS coded Resident #52 under H (Bladder and Bowel) for the use of indwelling Foley catheter (to include suprapubic).
The comprehensive care plan dated 07/31/18 identified Resident #52 with a *Foley catheter due to urinary retention. The goal set for the resident by the staff was that the resident would show no signs or symptoms of urinary infection. One of the intervention/approaches to manage goal include Foley catheter as ordered/care as ordered.
Resident #52's physician orders for October 2018 contained the following order: change Foley catheter every 30 days and as needed in the evening.
The review of Resident #52's September and October 2018 Treatment Administration Record (TAR), revealed the Foley catheter was scheduled to be changed on 09/09/18 and 10/9/18. The dates for the 09/09/18 and 10/09/18 were without nurse's initials indicating treatment was not completed. The review of Resident #52's clinical record did not show evidence where the treatment was completed, resident had refused or the order was changed.
An interview was conducted with the Director of Nursing (DON) on 10/25/18 approximately 10/25/18 3:50 p.m., who stated, She expect for the nurses to change Resident #52's Foley as ordered by the physician. On the same day at approximately 4:21 p.m., the Nurse Consultant of Clinical Services stated, We were unable to locate in the residents medical record where his Foley was changed as ordered.
Definitions:
*Foley catheter is a tube placed in the body to drain and collect urine from the bladder (https://medlineplus.gov/druginfo/meds/a682514.html).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and facility documentation, the facility staff failed to ensure ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and facility documentation, the facility staff failed to ensure 1 (one) of 41 residents (#85) received the care and services consistent with the standards of practice and comprehensive person-centered care plan.
The facility staff failed to properly assess Resident #85's dialysis shunt.
The findings included:
Resident #85 was re-admitted to the nursing facility on 9/20/18 with a diagnosis that included end stage renal disease (ESRD) on hemodialysis.
The most recent Minimum Data Set (MDS) assessment dated [DATE] was a quarterly and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 3 out of a possible score of 15 which indicated the resident was severely impaired in the skills needed for daily decision making. The resident was coded to receive hemodialysis.
The care plan dated as revised 8/24/18 identified Resident #85 was on dialysis related to ESRD Tuesday, Thursday and Saturday. The goal the staff set for the resident was that she would receive treatments as scheduled with monitoring of disease process through next review. One of the approaches to accomplish this goal included monitor thrill and bruit every shift per order and protocol.
A physician's order dated 5/19/18 indicated the resident was on dialysis and to assess the access site dressing and assess for bruit and thrill to dialysis site on left arm every shift.
On 10/24/18 at 12:05 p.m., Resident #85 was observed in her room sitting at the bedside in her wheelchair. Licensed Practical Nurse (LPN) #8 was asked to demonstrate an assessment of the resident's Arterio-Venous shunt (AV) bruit and thrill as signed off per shift on the Medication Administration Record (MAR). The LPN stated, I am very particular about my dialysis residents and I have assessed the shunt for bruit and thrill and checked the dressing as well. It it a must that it be done. LPN #8 washed his hands for approximately 5 seconds, approached the resident and checked each arm to find the AV shunt. Once located, he took both hands and cuffed them around the upper left arm and stated, The bruit and thrill is good. No stethoscope was used in any part of the aforementioned assessment of the AV shunt's bruit and thrill. Neither did the LPN use gloves when he directly touched the AV site's dressing or wash his hands prior to exiting the resident's room. LPN #8 proceeded down the hallway to the medication cart.
On 10/25/18 at 6:30 p.m., a debriefing was conducted with the Administrator, Director of Nursing (DON) and Nurse Consultant. The Administrator stated he had no evidence that LPN #8, who was an agency nurse, had received training on resident assessment of a dialysis resident, but the agency contractual agreement contract indicated all nurses had completed clinical skills on an annual basis. The contract was reviewed by this surveyor dated 9/21/18 that indicated all agency staff had completed skills check off annually. The specific skill types were not listed in the contract.
On 10/25/18 at 8:00 p.m., the Nurse Consultant stated, I can't believe he did not know how to assess the shunt or that he did not wash his hands after touching the site. There is not excuse for that.
The facility's policy and procedures titled Hemodialysis dated 9/20/18 indicated the licensed nurse will palpate the AV (Arterio-Venous) hemodialysis shunt site that is usually in the arm, to feel the thrill and auscultate the bruit per shift, daily and record on the Treatment Administration Record (TAR).
Definitions:
*ESRD is the last stage of chronic kidney disease. When your kidneys fail, it means they have stopped working well enough for you to survive without dialysis or a kidney transplant (www.kidneyfund.org/kidney-disease/kidney-failure).
*Hemodialysis-cleans blood by removing it from the body and passing it through a dialyzer, or artificial kidney. The process of removing blood from the body, filtering it and returning it takes time. Hemodialysis treatment usually takes three to five hours and is repeated three times a week.
*For dialysis, a catheter is inserted into a large vein in either the neck or chest. A catheter is usually a short-term option; however, in some cases a catheter is used as a permanent access. With most dialysis catheters, a cuff is placed under the skin to help hold the catheter in place. The blood flow rate from the catheter to the dialyzer may not be as fast as for an AV graft or AV fistula; therefore, the blood may not be cleaned as thoroughly as with an arteriovenous access (https://www.davita.com/kidney-disease/dialysis/treatment/arteriovenous-av-fistula-%2597-the-gold-standard-hemodialysis-access/e/1301).
*Bruit is listening for adequate bruit with a *stethoscope. A continuous low-pitched bruit should be present (www.laminatemedical.com/assessment-and-monitoring-of-av-fistulas-for-new-dialysis).
*Thrill - Check the pulse in your access arm. You should feel blood rushing through that feels like a vibration. This vibration is called a thrill.(Source: https://medlineplus.gov/ency/patientinstructions/000705.htm).
*Stethoscope is an instrument used to detect and study sounds produced in the body that are conveyed to the ears of the listener through rubber tubing connected with a usually cup-shaped piece placed upon the area to be examined. (Source: http://c.merriam-webster.com/medlineplus/stethoscope).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and facility documentation, the facility staff failed to ensure ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and facility documentation, the facility staff failed to ensure the licensed nursing staff were competent with the appropriate skills to provide assessments of Arterio-Venous (AV) dialysis shunts for 1 (one) of 41 residents (#85) in the survey sample.
The facility staff failed to ensure licensed nursing staff were competent in the provision of hemodialysis care for Resident #85 to include accurate assessments of *bruit and *thrill.
The findings included:
Resident #85 was re-admitted to the nursing facility on 9/20/18 with a diagnosis that included end stage renal disease (ESRD) on hemodialysis.
The most recent Minimum Data Set (MDS) assessment dated [DATE] was a quarterly and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 3 out of a possible score of 15 which indicated the resident was severely impaired in the skills needed for daily decision making. The resident was coded to receive hemodialysis.
The care plan dated as revised 8/24/18 identified Resident #85 was on dialysis related to ESRD Tuesday, Thursday and Saturday. The goal the staff set for the resident was that she would receive treatments as scheduled with monitoring of disease process through next review. One of the approaches to accomplish this goal included monitor thrill and bruit every shift per order and protocol.
A physician's recent order dated 5/19/17 indicated the resident was on dialysis and to assess the access site dressing and assess for bruit and thrill to dialysis site on left arm every shift.
On 10/24/18 at 12:05 p.m., Resident #85 was observed in her room sitting at the bedside in her wheelchair. Licensed Practical Nurse (LPN) #8 was asked to demonstrate an assessment of the resident's Arterio-Venous shunt (AV) bruit and thrill as signed off per shift on the Medication Administration Record (MAR). The LPN stated, I am very particular about my dialysis residents and I have assessed the shunt for bruit and thrill and checked the dressing as well. It it a must that it be done. LPN #8 washed his hands for approximately 5 seconds, approached the resident and checked each arm to find the AV shunt. Once located, he took both hands and cuffed them around the upper left arm and stated, The bruit and thrill is good. No stethoscope was used in any part of the aforementioned assessment of the AV shunt's bruit and thrill. Neither did the LPN use gloves when he directly touched the AV site's dressing or wash his hands prior to exiting the resident's room. LPN #8 proceeded down the hallway to the medication cart.
On 10/25/18 at 6:30 p.m., a debriefing was conducted with the Administrator, Director of Nursing (DON) and Nurse Consultant. The Administrator stated he had no evidence that LPN #8, who was an agency nurse, had received training on resident assessment of a dialysis resident, but the agency contractual agreement contract indicated all nurses had completed clinical skills on an annual basis. The contract was reviewed by this surveyor dated 9/21/18 that indicated all agency staff had completed skills check off annually. The specific skill types were not listed in the contract.
On 10/25/18 at 8:00 p.m., the Nurse Consultant stated, I can't believe he did not know how to assess the shunt or that he did not wash his hands after touching the site. There is not excuse for that.
The facility's policy and procedures titled Hemodialysis dated 9/20/18 indicated the licensed nurse will palpate the AV (Arterio-Venous) hemodialysis shunt site that is usually in the arm, to feel the thrill and auscultate the bruit per shift, daily and record on the Treatment Administration Record (TAR).
Definitions:
*ESRD is the last stage of chronic kidney disease. When your kidneys fail, it means they have stopped working well enough for you to survive without dialysis or a kidney transplant (www.kidneyfund.org/kidney-disease/kidney-failure).
*Hemodialysis-cleans blood by removing it from the body and passing it through a dialyzer, or artificial kidney. The process of removing blood from the body, filtering it and returning it takes time. Hemodialysis treatment usually takes three to five hours and is repeated three times a week.
*For dialysis, a catheter is inserted into a large vein in either the neck or chest. A catheter is usually a short-term option; however, in some cases a catheter is used as a permanent access. With most dialysis catheters, a cuff is placed under the skin to help hold the catheter in place. The blood flow rate from the catheter to the dialyzer may not be as fast as for an AV graft or AV fistula; therefore, the blood may not be cleaned as thoroughly as with an arteriovenous access (https://www.davita.com/kidney-disease/dialysis/treatment/arteriovenous-av-fistula-%2597-the-gold-standard-hemodialysis-access/e/1301).
*Bruit is listening for adequate bruit with a *stethoscope. A continuous low-pitched bruit should be present (www.laminatemedical.com/assessment-and-monitoring-of-av-fistulas-for-new-dialysis).
*Thrill - Check the pulse in your access arm. You should feel blood rushing through that feels like a vibration. This vibration is called a thrill.(Source: https://medlineplus.gov/ency/patientinstructions/000705.htm).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation during a medication pour and pass, resident interview, staff interview, clinical record review, and review ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation during a medication pour and pass, resident interview, staff interview, clinical record review, and review of the facility's policy the facility staff failed to have ordered pain medication available to administer for 1 of 41 residents (Resident #255), in the survey sample.
The facility staff failed have PRN (as needed) Tramadol 50 mg (milligrams) available to administer to Resident #255 when she experienced pain.
The findings included:
Resident #255 was originally admitted to the facility 10/19/18. The current diagnoses included; end stage kidney disease with dialysis.
The Minimum Data Set (MDS) assessment had not been completed but the nursing admission assessment dated [DATE], indicated the resident was alert, oriented to person, place, situation and her cognition was intact. The assessment further indicated the resident was capable of understandings what was said to her and could make herself understood. The nursing assessment also coded the resident as requiring set-up assistance only with eating, limited assistance with bed mobility. The other activities of daily living were not assessed as well as pain.
The physician order summary revealed an order dated 10/19/18 for Tramadol Hcl 50 mg, one (1) tablet by mouth every 8 hours as needed for pain.
The baseline care plan had a problem created 10/22/18 named Pain. The goal read; the resident will have no/decreased complaints of pain through next review 11/6/18. The interventions included; Medicate as ordered. Notify physician for pain not relieved with medication or with new complaints of pain. Position resident for comfort.
On 10/25/18, at approximately 11:22 a.m., Licensed Practical Nurse (LPN) # 4 entered Resident #255's room to administer a scheduled medication, the resident complained of left arm pain which she said had been present since her return to the facility from the dialysis center earlier that day. Resident #255 rated the pain as 6 out of 10. LPN
#4 reviewed Resident #255's medication orders which indicated the resident could receive Tramadol 50 mg every 8 hours as needed. LPN #4 opened the narcotic control medication box but; didn't see the resident's ordered Tramadol therefore; LPN #4 telephoned the pharmacy to obtain authorization to remove the Tramadol 50 mg from the stat drug box but; the pharmacist stated they couldn't give an authorization for they didn't have a hard prescription from the physician. LPN #4 explained to the pharmacist the hard prescription had been sent to the pharmacy and again the pharmacist told the nurse it wasn't at the pharmacy. LPN #4 telephoned the physician's office, explaining the problem and the need for a hard prescription to be sent to the pharmacist on Resident #255's behalf. LPN #4 also obtained an order for Tylenol 325 mg two (2) tablets by mouth as needed, which was administered at 11:25 a.m.
An interview was conducted with the Director of Nursing on 10/25/18 at approximately 11:55 a.m., she stated she would have to investigate the concern before she could comment. The Director of Nursing offered no information concerning this matter for the duration of the survey.
An interview was conducted with Resident #255 at approximately 3:05 p.m., she stated the medication the nurse had given her didn't help very much.
The facility's policy titled Delivery and Receipt of Routine Deliveries with a revision date pf 1/1/13 read at 2.1.1 Facility staff may access (name of pharmacy) to produce a report of delivered medications Copies of manifests or packing slips may be retained for reference for a period to be determinied by the facility. At 2.5 the policy stated; If an item is ordered and not received, check for a communication slip indicating back orders, ordered too soon notification, drug to drug interaction, formulary changes or other communication explanation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation, staff interviews and facility document review the facility staff failed to store food in accordance with professional standards for food service safety.
The food service staff fa...
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Based on observation, staff interviews and facility document review the facility staff failed to store food in accordance with professional standards for food service safety.
The food service staff failed to ensure foods stored in the freezer were labeled and dated when open.
The findings included:
On 10/23/18 at 10:35 a.m., during the initial inspection of the kitchen with the dietary manager, the following were observed:
Inside the walk in freezer was an open bag of McRibs and 5 hamburger patties in saran wrap; not labeled or dated.
On 10/23/18 at approximately 10:46 a.m., the surveyor asked the dietary manager, Should the open bag of McRibs and hamburger patties be labeled and dated once opened, he replied, Yes. The dietary manager removed the 2 items from the freezer.
During an interview conducted with the Corporate Dietitian on 10/24/18 at approximately 11:30 a.m. it was stated, All items open should be labeled and dated once opened.
The facility's policy titled Refrigerated and Frozen Foods (Effective date: 09/14/18).
-Policy: Foods stored in the refrigerator or freezer will be stored in a manner which maintains the food so that it is safe to eat, and retains optimal nutrient content and aesthetic quality.
-Procedure: All refrigerated and frozen containers will be labeled, indicating the name of the product and use-by-date.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews and review of the facility documentation the facility staff faile...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interviews and review of the facility documentation the facility staff failed to maintain an infection control program to provide a safe, sanitary environment to prevent the potential development and transmission of disease and infection for 3 of 41 residents (Resident #70, #52 and #85) in the survey sample.
1. The facility staff failed to wash hands according to accepted professional practice for handwashing during a dressing change and failed to disinfect the personal over bed table that was used for wound care before and after use for resident # 70.
2. The facility staff failed to perform appropriate hand hygiene during wound care and failed to disinfect the personal over bed table that was used for wound care before and after use for resident # 52.
3. The facility staff failed to wash hands after contact with Resident #85's Arterio-Venous (AV) shunt site and prior to exiting the room to perform other nursing duties.
The findings included:
1. Resident #70 was admitted to the facility on [DATE]. Diagnosis for Resident #70 included but not limited to *Cellulitis of right lower extremity. Resident #70's Minimum Data Set (an assessment protocol) with an Assessment Reference Date (ARD) of 09/21/18 coded Resident #70's Brief Interview for Mental Status (BIMS) scored a 10 out of a possible 15 indicating moderate cognitive impairment.
The care plan created on 09/21/15 with a revision date of 10/25/18 identified Resident #70's care plan with an *abscess to the right lower abdomen/groin. The goal set for the resident by the staff was that the resident will be free from complications related to infection through the next review. Some of the interventions/approaches the staff would use to accomplish this goal included to monitor/document/report signs and symptoms of infections to the physician.
Review of the Resident #70's clinical record evidenced a physician order dated 10/11/18 revealed the following: clean abdominal wound with normal saline, apply wound gel, apply vistopaste and cover with abdominal pads with no tape every daily and evening shift.
Physician visit on 10/24/18 with the following: reason for visit (pelvic abscess). Resident to be started on Keflex and an appointment is scheduled for 10/26/18 at the wound clinic related to pelvic wound abscess.
Review of the Resident #70's clinical note dated 10/24/18 revealed the following: *Keflex (an antibiotic) 500 mg (milligrams) three times daily x 10 days.
On 10/25/18 at approximately 9:20 a.m., a wound care observation was conducted with Licensed Practical Nurse (LPN) #4. Prior to starting wound care to Resident #70, LPN #4 washed her hands x 12 seconds; she used her bare hand to turn off the water faucet; then donned a new pair of gloves. The LPN placed a barrier pad covering Resident #70's personal over bed table without disinfecting the table. The LPN placed all treatment supplies on the barrier, which consisted of the following: Solosite Gel, abdominal pad (absorbent pad), Viscopaste, 4 x 4 gauze (bag) and normal saline. The LPN attached a small red biohazard bag to the bedrail. The LPN removed her gloves, washed her hands x 10 seconds; used her bare hands to turn off the water faucet then donned another pair of gloves. She then removed the dressings from the wound to the right groin. The soiled dressing removed was placed in biohazard bag. There was a moderate amount of drainage noted (gray in color) on the dressing removed and a foul odor noted from the wound. The wound bed was black in color with outer margin of wound noted with gray tissue; gloves removed, hands washed x 9 seconds and faucet turned off with bare hands. The LPN then donned a new pair of gloves. The nurse reached inside the bag of 4 x 4 gauzes, removed several gauzes, cleaned the wound with normal saline then put soiled gauze in red bag. She repeated the same process for the cleaning of the wound three more times. She continued to remove the 4 x 4 gauzes from the bag wearing the same gloves she was cleaning the wound with. The LPN removed her gloves, washed her hands x 10 seconds, then turned off the faucet with her bare hands then donned a new pair of gloves. The nurse applied Solosite gel to the wound using a 4 x 4 gauze, Viscopaste gauze applied over wound then covered with an abdominal pad, gloves removed, placed in red bag, hands washed x 13 seconds, faucet turned off again with her bare hands. The LPN removed all wound care supplies from the over bed table then placed the over bed table at resident's bedside without disinfecting it.
An interview was conducted with LPN #4 on 10/25/18 at approximately 4:00 p.m. The LPN stated, The over bed table should have been disinfected before and after use. She (LPN) said I realized I did not wash my hands x 20 seconds and I should have removed the 4 x 4 gauze from the bag prior to starting wound care and placed them with the other supplies; on the table barrier. The surveyor asked, What is the purpose of handwashing doing wound care she replied, To get rid of germs; germs remains on your hands if your hands are not washed long enough. She (LPN) also said, I should have used a paper towel to turn the water faucet off and not use my bare hands.
On 10/25/18 at approximately 4:15 p.m., an interview was conducted with the Director of Nursing (DON) who stated, I tell my nurses to wash their hands x 30 seconds to make sure they wash they hands long enough. The DON stated, The 4 x 4 gauzes should have been removed the bag and placed on the table for use. The surveyor asked, What is the purpose of good hand washing doing wound care she replied To prevent the spread of infection and prevent potential cross confirmation. The DON said the LPN should have used a paper towel to turn off the water faucet to prevent recontamination and the over bed table should have been disinfected before and after used.
The facility's policy titled Infection Prevention and Control Policies and Procedures Handwashing Requirements was dated 12/26/17. The policy read at procedure
B. Hand washing with antimicrobial soap and water read in part:
-Scrub for at least 15-20 seconds.
-Rinse hands and wrist thoroughly under running water, keeping hands away from the side of the sink.
-Dry hands thoroughly with a disposable towel, turning of the faucet on the hand sink with a disposable paper towel. Discard the towel into the trash can.
2. The facility's Treatment Observation Non-Sterile Treatment Technique (Last revision: 1/18).
Observations to read in part: Clean and sanitize surface before placing waterproof barrier on table.
Definitions:
*Cellulitis is an infection of the skin and deep underlying tissues (https://medlineplus.gov/cellulitis.html).
*Abscess is a tender mass generally surrounded by a colored area from pink to deep red. The vast majority of them are caused by infection. Inside, they are full of pus, bacteria and debris (Webmd.com).
2. Resident #52 was admitted to the facility on [DATE]. Diagnosis for Resident #52 included but are not limited to *Diabetes. Resident #52 was admitted to the facility on [DATE]. Resident #52's Minimum Data Set (an assessment protocol) with an Assessment Reference Date (ARD) of 08/31/18 coded Resident #52's Brief Interview for Mental Status (BIMS) scored a 99 indicating short and long-term memory problems and with severe cognitive impairment-never/rarely made decisions.
In section M (Skin Conditions) of MDS 08/31/2018 coded Resident #52 at risk for developing pressure ulcer, but having a Stage 1 or higher *pressure ulcer. Resident #52 was coded as having *unstageable pressure ulcers.
Resident #52's revised comprehensive care plan dated 10/18/18 documented Resident #4 with actual skin breakdown with potential for further skin impairment. The goal: the resident will have no evidence of further skin impairment. Some of the intervention/approaches to manage goal included *Alternating Pressure Air Mattress (Atmos 9000) and float heels.
According to the Physician Order Form as of October 2018; Resident #52 treatment read as follow: Apply *Santyl ointment to left and right heel topically every day for wound care starting on 10/09/18.
On 10/25/18 at approximately 12:12 p.m., Resident #52 was lying in bed in a supine position on an alternating low air loss pressure mattress. LPN #4 performed wound care with the assistance of the Unit Manager (UM). Prior to starting wound care to Resident #52, LPN washed her hands x 24 seconds. The LPN placed a barrier pad covering Resident #52's personal over bed table without disinfecting the table. The LPN placed all treatment supplies on the barrier, which consisted of the following: normal saline bullets (2), *Santyl, 4 x 4 gauzes, foam dressing and red bag. The LPN removed the dressing from the right heel, wound bed yellow in color with small amount of serosanquineous drainage noted but without odor. The wound was cleaned with normal saline, gloves removed, new gloves donned, Santyl ointment applied to wound bed then covered with covered with dressing. The LPN removed her gloves, put in red bag, donned another pair of gloves, removed the dressing from the left heel, wound bed black in color with no odor noted, dressing removed placed in red bag, gloves removed, another pair of gloves donned, Santyl ointment applied to wound bed then covered with dressing. The LPN removed all wound care supplies from the over bed table then placed the over bed table at resident's bedside without disinfecting.
An interview was conducted with LPN #3 on 10/25/18 at approximately 12:35 p.m. The LPN stated, I should have cleaned the over bed table before and after use. She also said, I should have washed my hands between the left and right heel wounds and after I removed the soiled dressings.
On 10/25/18 at 3:51 p.m., an interview was conducted with UM who stated, The LPN should have washed her hands before starting wound care, after changing of her gloves and after completing wound care. The UM also stated the over bed table should have been wiped down with sanitizer wipes before and after use to help fight the spread of infection.
An interview was conducted with the Director of Nursing on 10/25/18 at approximately 4:15 p.m. The surveyor asked, When should the nurse wash their hands doing wound clear she replied, They should wash their hands before get starting with wound care, after the soiled dressing has been removed, before they start a clean procedure and after the procedure has been completed. The DON also stated, The nurse should have washed her hands between the left and right heel wounds to prevent wound cross contamination. The DON said the over bed table should have been disinfected before and after use.
The facility's policy titled General Wound care/Dressing Changes read in part: (Effective: 02/01/15).
-License nurses will follow recognized standards of practice regarding dressing changes.
Definitions:
1. Diabetes is a complex disorder of carbohydrates, fat, and protein metabolism that is primarily a result off a deficiency or complete lack of insulin secretion (Mosby's Dictionary of Medicine, Nursing & Health Professions 7th Edition).
2. Pressure Injury: 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 (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/).
3. Stage 4 Pressure Injury: Full-thickness skin and tissue loss
Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/).
4. Alternating low air loss pressure mattress is comprised of individual air cells that slowly inflate and deflate under the patient. The alternating or inflation/deflation of cells allow blood flow to reach all areas of the patient's body to heal and prevent bedsores (http://www.alternatingpressuremattress.com/whatisapp.html).
5. Santyl is used to help the healing of burns and ulcers. Collagenase is an enzyme. It works by helping to break up and remove dead skin and tissue. This effect may also help to work better and speed up your body's natural healing process (antibiotics <http://www.webmd.com/cold-and-flu/rm-quiz-antibiotics-myths-facts.
3. The facility staff failed to wash hands after contact with Resident #85's Arterio-Venous (AV) shunt site and prior to exiting the room to perform other nursing duties.
Resident #85 was re-admitted to the nursing facility on 9/20/18 with a diagnosis that included end stage renal disease (ESRD) on hemodialysis.
The most recent Minimum Data Set (MDS) assessment dated [DATE] was a quarterly and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 3 out of a possible score of 15 which indicated the resident was severely impaired in the skills needed for daily decision making. The resident was coded to receive hemodialysis.
The care plan dated as revised 8/24/18 identified Resident #85 was on dialysis related to ESRD Tuesday, Thursday and Saturday. The goal the staff set for the resident was that she would receive treatments as scheduled with monitoring of disease process through next review. One of the approaches to accomplish this goal included monitor *thrill and *bruit every shift per order and protocol.
A physician's recent order dated 5/19/17 indicated the resident was on dialysis and to assess the access site dressing and assess for bruit and thrill to dialysis site on left arm every shift.
On 10/24/18 at 12:05 p.m., Resident #85 was observed in her room sitting at the bedside in her wheelchair. Licensed Practical Nurse (LPN) #8 was asked to demonstrate an assessment of the resident's Arterio-Venous shunt (AV) bruit and thrill as signed off per shift on the Medication Administration Record (MAR). The LPN stated, I am very particular about my dialysis residents and I have assessed the shunt for bruit and thrill and checked the dressing as well. It it a must that it be done. LPN #8 washed his hands for approximately 5 seconds, approached the resident and checked each arm to find the AV shunt. Once located, he took both hands and cuffed them around the upper left arm and stated, The bruit and thrill is good. No stethoscope was used in any part of the aforementioned assessment of the AV shunt's bruit and thrill. Neither did the LPN use gloves when he directly touched the AV site's dressing or wash his hands prior to exiting the resident's room. LPN #8 proceeded down the hallway to the medication cart.
On 10/25/18 at 6:30 p.m., a debriefing was conducted with the Administrator, Director of Nursing (DON) and Nurse Consultant. The Administrator stated he had no evidence that LPN #8, who was an agency nurse, had received training on resident assessment of a dialysis resident, but the agency contractual agreement contract indicated all nurses had completed clinical skills on an annual basis. The contract was reviewed by this surveyor dated 9/21/18 that indicated all agency staff had completed skills check off annually. The specific skill types were not listed in the contract.
On 10/25/18 at 8:00 p.m., the Nurse Consultant stated, I can't believe he did not know how to assess the shunt or that he did not wash his hands after touching the site. There is not excuse for that.
The facility's policy and procedures titled Hand washing Requirements dated 12/26/17 indicated that all employees will wash their hands at appropriate times to reduce the risk of transmission and acquisition of infections. Hand washing will be performed before and after contact with a resident's dressings or handling peripheral vascular catheters and other invasive devices.
*Bruit is listening for adequate bruit with a *stethoscope. A continuous low-pitched bruit should be present (www.laminatemedical.com/assessment-and-monitoring-of-av-fistulas-for-new-dialysis).
*Thrill - Check the pulse in your access arm. You should feel blood rushing through that feels like a vibration. This vibration is called a thrill.(Source: https://medlineplus.gov/ency/patientinstructions/000705.htm).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #61 was re-admitted to the facility on [DATE]. Diagnosis for Resident #61 included but not limited to *Muscle weakne...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #61 was re-admitted to the facility on [DATE]. Diagnosis for Resident #61 included but not limited to *Muscle weakness.
The current Minimum Data Set (MDS), quarterly assessment with an Assessment Reference Date (ARD) of 09/19/18 coded the resident with a 06 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment.
The Discharge MDS assessments was dated for 08/11/18 - discharge return anticipated.
On 08/11/18, according to the facility's documentation, Resident #61 was found on the floor, complaining of pain to her right leg. Once patient was in bed and pants were removed, an obvious dislocation to right knee was noticed. Her knee was splinted with pillows for comfort; 911 called to transport resident to hospital. Resident #61 was re-admitted to the facility on [DATE].
During a discussion with the Administrator on 10/24/18 at 11:00 a.m., he stated they did not have a system of reporting any un-planned discharges to the emergency room, to the local hospital or discharges to the community, and did not capture or audit any missed discharges from the mandated date of 11/28/17. He stated he started a plan from October 9, 2018 going forward.
Definitions:
*Muscles weakness is reduced strength in one or more muscles
(https://medlineplus.gov/ency/article/007365.htm).
5. Resident #57 was originally admitted to the nursing facility on 10/23/14 and re-admitted on [DATE] after an acute hospital stay. The current diagnoses included; hypertension and aphasia.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/13/18 coded the resident as comatose therefore; the Brief Interview for Mental Status (BIMS) was not completed.
Resident #57 was discharged from the facility 6/9/18 to a local hospital for an acute medical problem. The facility staff had no documentation they had notified the local Ombudsman of his discharge.
An interview was conducted with the Administrator on 10/24/18 at 11:00 a.m., The Administrator stated they didn't have a system of reporting discharges to the hospital until the corporate office notified the facility staff of the regulation approximately 10/8/18. The Administrator also stated the facility put a plan in place approximately 10/9/18, to implement the regulation of notifying the local Ombudsman of all hospital discharges, and they did but; they didn't develop a plan to report the hospital discharges which occurred between 11/28/17 through 10/8/18.
An interview was conducted with the Social Worker on 10/24/18 at 12:30 p.m. The Social Worker stated they had not been notifying the Ombudsman of transfers to local hospital until approximately 10/8/18, and any discharges to the hospital prior to that date were not reported for they had no method of obtaining the information.
The facility staff didn't provide any additional information prior to the survey team's exit on 10/25/18 at approximately 8:00 p.m.
6. Resident #41 was originally admitted to the nursing facility on 8/4/16 and re-admitted on [DATE] after an acute hospital stay. The current diagnoses included; stroke, dementia and heart failure.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/24/18 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 10 out of a possible 15. This indicates Resident #41 cognitive abilities for daily decision making are moderately impaired
Resident #41 was discharged from the facility 4/15/18 to a local hospital for an acute medical problem. The facility staff had no documentation they had notified the local Ombudsman of her discharge.
An interview was conducted with the Administrator on 10/24/18 at 11:00 a.m., The Administrator stated they didn't have a system of reporting discharges to the hospital until the corporate office notified the facility staff of the regulation approximately 10/8/18. The Administrator also stated the facility put a plan in place approximately 10/9/18, to implement the regulation of notifying the local Ombudsman of all hospital discharges, and they did but; they didn't develop a plan to report the hospital discharges which occurred between 11/28/17 through 10/8/18.
An interview was conducted with the Social Worker on 10/24/18 at 12:30 p.m. The Social Worker stated they had not been notifying the Ombudsman of transfers to local hospital until approximately 10/8/18, and any discharges to the hospital prior to that date were not reported for they had no method of obtaining the information.
The facility staff didn't provide any additional information prior to the survey team's exit on 10/25/18 at approximately 8:00 p.m.
The facility's policy titled Notice of Transfer/discharge date d 4/25/18, read notice of transfer/discharge are to be sent to designated persons including the local Ombudsman.
Based on clinical record review, staff interviews, and facility document review the facility staff failed to notify the office of the State Long-Term Care Ombudsman in writing of applicable discharges for 6 of 41 residents in the survey sample (Residents #79, #21, #, 95, #61, #57 and #35).
1. The facility staff failed to notify the office of the State Long-Term Care Ombudsman of Resident #79's discharges to the hospital on 1/12/18 and 8/15/18.
2. The facility staff failed to notify the office of the State Long-Term Care Ombudsman of Resident #21's discharge to the hospital on 4/18/18.
3. The facility staff failed to notify the office of the State Long-Term Care Ombudsman of Resident #95's discharges to the hospital on 6/26/18 and 8/30/18.
4. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #61's transfer and admission to the hospital on [DATE].
5. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #57's transfer and admission to the hospital on 6/9/18.
6. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #41's transfer and admission to the hospital on 4/15/18.
The findings included:
1. The facility staff failed to notify the office of the State Long-Term Care Ombudsman of Resident #79's discharges to the hospital on 1/12/18 and 8/15/18.
Resident #79 was originally admitted to the nursing facility on 6/1/16 and re-admitted on [DATE] and diagnoses that included dementia and diabetes mellitus.
The most recent Minimum Data Set (MDS) assessment was an admission dated 10/15/18 and coded the resident with short and long term memory loss and moderately impaired in the skills needed for daily decision making.
During a discussion with the Administrator on 10/24/18 at 11:00 a.m., he stated they did not have a system of reporting any un-planned discharges to the emergency room, to the local hospital or discharges to the community, and did not capture or audit any missed discharges from the mandated date of 11/28/17 to September 8, 2018. He stated he started a plan from October 9, 2018 going forward.
On 10/24/18 at 12:30 p.m., during an interview with the Social Worker, she stated, they had not been notifying the Ombudsman of transfers to local hospital or discharges from the nursing facility until recently which did not include Resident
#79's discharges to the local hospital on 1/12/18 and 8/15/18.
The facility's policy dated 4/25/18 titled Notice of Transfer/Discharge indicated notice of transfer/discharge to be sent to designated persons including the local Ombudsman.
No further information was shared prior to survey exit on 10/25/18 at 8:00 p.m.
2. The facility staff failed to notify the office of the State Long-Term Care Ombudsman of Resident #21's discharge to the hospital on 4/18/18.
Resident #21 was admitted to the nursing facility on 5/5/05 and readmitted on [DATE] with a diagnoses that included age related osteoporosis and left tibial/fibula fracture.
The most recent Minimum Data Set (MDS) assessment was a quarterly dated 7/27/18 and coded the resident with short and long term memory loss and severely impaired in the skills needed for daily decision making.
During a discussion with the Administrator on 10/24/18 at 11:00 a.m., he stated they did not have a system of reporting any un-planned discharges to the emergency room, to the local hospital or discharges to the community, and did not capture or audit any missed discharges from the mandated date of 11/28/17 to September 8, 2018. He stated he started a plan from October 9, 2018 going forward.
On 10/24/18 at 12:30 p.m., during an interview with the Social Worker, she stated, they had not been notifying the Ombudsman of transfers to local hospital or discharges from the nursing facility until recently which did not include Resident
#21's discharge to the local hospital on 4/18/18.
No further information was shared prior to survey exit on 10/25/18 at 8:00 p.m.
3. The facility staff failed to notify the office of the State Long-Term Care Ombudsman of Resident #95's discharges to the hospital on 6/26/18 and 8/30/18.
Resident #95 was originally admitted to the nursing facility on 6/22/18 and re-admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease, (COPD) and diabetes mellitus.
The most recent Minimum Data Set (MDS) assessment was an admission dated 10/5/18 and coded the resident with a score of 13 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident was intact with the necessary skills for decision making.
During a discussion with the Administrator on 10/24/18 at 11:00 a.m., he stated they did not have a system of reporting any un-planned discharges to the emergency room, to the local hospital or discharges to the community, and did not capture or audit any missed discharges from the mandated date of 11/28/17 to September 8, 2018. He stated he started a plan from October 9, 2018 going forward.
On 10/24/18 at 12:30 p.m., during an interview with the Social Worker, she stated, they had not been notifying the Ombudsman of transfers to local hospital or discharges from the nursing facility until recently which did not include Resident
#95's discharges to the local hospital on 6/26/18 and 8/30/18.
No further information was shared prior to survey exit on 10/25/18 at 8:00 p.m.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 5 life-threatening violation(s), Special Focus Facility, 7 harm violation(s), $334,071 in fines. Review inspection reports carefully.
- • 94 deficiencies on record, including 5 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $334,071 in fines. Extremely high, among the most fined facilities in Virginia. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Henrico Health & Rehabilitation Center's CMS Rating?
HENRICO HEALTH & REHABILITATION CENTER does not currently have a CMS star rating on record.
How is Henrico Health & Rehabilitation Center Staffed?
Staff turnover is 54%, compared to the Virginia average of 46%. RN turnover specifically is 56%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Henrico Health & Rehabilitation Center?
State health inspectors documented 94 deficiencies at HENRICO HEALTH & REHABILITATION CENTER during 2018 to 2025. These included: 5 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 7 that caused actual resident harm, and 82 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Henrico Health & Rehabilitation Center?
HENRICO HEALTH & REHABILITATION CENTER is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility is operated by LIFEWORKS REHAB, a chain that manages multiple nursing homes. With 120 certified beds and approximately 108 residents (about 90% occupancy), it is a mid-sized facility located in HIGHLAND SPRINGS, Virginia.
How Does Henrico Health & Rehabilitation Center Compare to Other Virginia Nursing Homes?
Compared to the 100 nursing homes in Virginia, HENRICO HEALTH & REHABILITATION CENTER's staff turnover (54%) is near the state average of 46%.
What Should Families Ask When Visiting Henrico Health & Rehabilitation Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the substantiated abuse finding on record.
Is Henrico Health & Rehabilitation Center Safe?
Based on CMS inspection data, HENRICO HEALTH & REHABILITATION CENTER has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 5 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 0-star overall rating and ranks #100 of 100 nursing homes in Virginia. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Henrico Health & Rehabilitation Center Stick Around?
HENRICO HEALTH & REHABILITATION CENTER has a staff turnover rate of 54%, which is 8 percentage points above the Virginia average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Henrico Health & Rehabilitation Center Ever Fined?
HENRICO HEALTH & REHABILITATION CENTER has been fined $334,071 across 5 penalty actions. This is 9.2x the Virginia average of $36,420. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Henrico Health & Rehabilitation Center on Any Federal Watch List?
HENRICO HEALTH & REHABILITATION CENTER is currently on the Special Focus Facility (SFF) watch list. This federal program identifies the roughly 1% of nursing homes nationally with the most serious and persistent quality problems. SFF facilities receive inspections roughly twice as often as typical nursing homes. Factors in this facility's record include 5 Immediate Jeopardy findings, a substantiated abuse finding, and $334,071 in federal fines. Facilities that fail to improve face escalating consequences, potentially including termination from Medicare and Medicaid. Families considering this facility should ask for documentation of recent improvements and what specific changes have been made since the designation.