WAYLAND NURSING AND REHABILITATION CENTER
For profit - Corporation
90 Beds
PRINCIPLE LONG TERM CARE
Data: November 2025
Trust Grade
68/100
#114 of 285 in VA
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Wayland Nursing and Rehabilitation Center has a Trust Grade of C+, which means it is considered decent and slightly above average compared to other facilities. It ranks #114 out of 285 in Virginia, placing it in the top half, and is the only option in Charlotte County. However, the facility is showing a worsening trend, with issues increasing from 12 in 2022 to 13 in 2025. Staffing is a strength at this facility, with a 4 out of 5 rating and a turnover rate of 27%, well below the state average of 48%, indicating that staff are likely to remain long-term and provide consistent care. The facility has no fines on record, which is a positive sign, and it also boasts more RN coverage than 89% of Virginia facilities, ensuring that trained nurses are available to catch potential problems. On the downside, there have been serious incidents, including a case of resident-to-resident abuse where one resident caused a significant injury to another that required emergency treatment. Additionally, recent inspections revealed concerns about food safety, as staff failed to maintain proper sanitation in the kitchen, which could pose health risks. There were also issues regarding the documentation of quality assurance meetings, indicating a lack of oversight in maintaining standards. Families should weigh these strengths and weaknesses when considering this facility for their loved ones.
- Trust Score
- C+
- In Virginia
- #114/285
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ✓ Good
- 27% annual turnover. Excellent stability, 21 points below Virginia's 48% average. Staff who stay learn residents' needs.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Virginia facilities.
- Skilled Nurses ✓ Good
- Each resident gets 48 minutes of Registered Nurse (RN) attention daily — more than average for Virginia. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 38 deficiencies on record. Higher than average. Multiple issues found across inspections.
68/100
Top 40%
Needs review
12 → 13 violations
★★★★☆
4.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★★
5.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2022: 12 issues
2025: 13 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Low Staff Turnover (27%) · Staff stability means consistent care
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover is low (27%)
21 points below Virginia average of 48%
Facility shows strength in staffing levels, quality measures, staff retention, fire safety.
The Bad
Chain: PRINCIPLE LONG TERM CARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 38 deficiencies on record
1 actual harm
Apr 2025
13 deficiencies
CONCERN
(D)
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, facility document review, and clinical record review, the facility staff failed to provide education a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, the facility staff failed to provide education and the opportunity to refuse the implementation of psychoactive medications for one of 19 residents in the survey sample, Resident #41.
The findings include:
For Resident #41 (R41) the facility staff failed to provide education for and the opportunity to refuse the implementation of the use of Risperidone (1) and Sertraline (2).
A review of R41's clinical record revealed an order for Risperidone 0.5 mg (milligrams) daily and Sertraline 50 mg daily. A review of R41's MARs (medication administration records) for March and April 2025 revealed these medications were administered as ordered.
Further review of the record failed to reveal any evidence that the facility provided the resident (and/or resident representative) education about the risks versus benefits of these medications or offered the opportunity to refuse the administration of these medications.
On 4/15/25 at 3:36 p.m., ASM (administrative staff member) #2, the director of nursing, was interviewed. She stated: We are supposed to get consent and provide education. She stated psychoactive medications carry a specialized risk for side effects which can be pretty bad.
On 4/15/25 at 4:00 p.m., ASM #1, the administrator, ASM #2, ASM #3, the facility nurse consultant, and ASM #4, an administrator colleague, were informed of these concerns.
A review of the facility policy, Psychotropic Drug Therapy, revealed, in part, The resident has the right to accept or decline the initiation or increase of a psychotropic medication. To demonstrate compliance, the resident's medical record must include documentation that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options, and was able to choose the option he or she preferred.
No additional information was provided prior to exit.
References
(1) Risperidone (generic for Risperdal) is used to treat the symptoms of schizophrenia (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) in adults and teenagers [AGE] years of age and older. It is also used to treat episodes of mania (frenzied, abnormally excited, or irritated mood) or mixed episodes (symptoms of mania and depression that happen together) in adults and in teenagers and children [AGE] years of age and older with bipolar disorder (manic depressive disorder; a disease that causes episodes of depression, episodes of mania, and other abnormal moods). Risperidone is also used to treat behavior problems such as aggression, self-injury, and sudden mood changes in teenagers and children 5 to [AGE] years of age who have autism (a condition that causes repetitive behavior, difficulty interacting with others, and problems with communication). Risperidone is in a class of medications called atypical antipsychotics. It works by changing the activity of certain natural substances in the brain. This information is taken from the website https://medlineplus.gov/druginfo/meds/a694015.html.
(2) Sertraline is used to treat depression, obsessive-compulsive disorder (bothersome thoughts that won't go away and the need to perform certain actions over and over), panic attacks (sudden, unexpected attacks of extreme fear and worry about these attacks), posttraumatic stress disorder (disturbing psychological symptoms that develop after a frightening experience), and social anxiety disorder (extreme fear of interacting with others or performing in front of others that interferes with normal life). This information is taken from the website https://medlineplus.gov/druginfo/meds/a697048.html#:~:text=Sertraline%20is%20in%20a%20class,that%20helps%20maintain%20mental%20balance.
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 document review, it was determined that the facility staff failed to notify the physician of a change in condition in a timely manner for ...
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Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to notify the physician of a change in condition in a timely manner for 1 of 19 residents, Resident #197.
The findings include:
For Resident #197 (R197), the facility staff failed to notify the physician of swelling and redness to the residents left knee observed on 3/6/24 in a timely manner.
R197 no longer resided at the facility and could not be observed or interviewed. The record was reviewed as a closed record.
A facility synopsis of events for R197 dated 3/8/24 documented in part, .Swelling & redness noted to LT (left) knee. MD in to see. X-ray of knee ordered- found acute appearing distal femur fx (fracture) proximal to LT knee replacement. Resident sent to ER. See attached summary . The attached summary documented in part, Resident was noted with redness and swelling to LT knee on 3/6/24. Primary nurse was made aware. Primary nurse assessed resident and found redness and swelling to LT knee and decision was made to notify MD. Resident had no complaints of pain when asked. MD saw resident on 3/7/24 and order given for x-ray. [Name of x-ray service] in on 3/8/25 and performed x-ray. Radiology reading of x-ray states resident had an acute-appearing fracture of the distal femur proximal to her knee replacement. Resident sent to the ER for evaluation. The hospital attributed the fracture to her fall on 2/25/24. Orthopedic surgeon felt that surgical intervention could cause more harm to resident than nonsurgical intervention. States knee was already starting to heal. Knee immobilizer placed in hospital to help with keeping fracture in alignment during healing. Resident has a diagnosis of osteopenia, osteoarthritis, Vitamin B and D deficiencies.
The progress notes for R197 documented in part,
- 02/25/2024 09:15 (9:15 a.m.) Incident Note. Note Text: CNA (certified nursing assistant) had resident turned on her side to change her sheets and she was scooting to the edge of the bed and was going to fall. CNA stated she was able to catch her but had to ease her to the floor. No injury noted. VS (vital signs) 122/74 (blood pressure)-70 (pulse)-18 (respirations)-98.4 (temperature)-97% (oxygen saturation).
- 02/27/2024 13:30 (1:30 p.m.) Note Text: No injury noted from fall on 2/25/24. Voices no complaints of pain or discomfort.
- 03/07/2024 13:38 (1:38 p.m.) Note Text: Order for x-ray of residents left knee ordered by [Name of physician]. Call placed to [Name of x-ray service] to alert them of the order. Copy of x-ray order and residents face sheet placed in the front nurses station.
- 03/08/2024 11:36 (11:36 a.m.) Note Text: X-ray tech in facility at this time to obtain X-ray.
- 03/08/2024 13:45 (1:45 p.m.) Note Text: Received results of Xray. MD notified and gave order to send resident to ER.
The physician progress note for R197 dated 3/7/24 documented in part, .Chief complaint/reason for this visit: Left knee pain. HPI (history of present illness) relating to this visit: [age and sex of R197] with history of CAD (coronary artery disease), Dementia, Chronic A. (atrial) fibrillation, CVA (cerebrovascular accident) and OA (osteoarthritis) is seen today for evaluation of pain in her left knee with swelling that she complained about this morning. This knee has had joint replacement in 2011. There were no reports of any trauma. She does complain of pain with moving the knee .Musculoskeletal: Joint Swelling/Inflammation, Mobility, Painful Movement, Left knee tender . Assessment and Plan: 1. left knee pain has had surgery 2021. 1: Obtain x-ray. Tylenol prn (as needed) pain. 2. Dementia: Continue safety precautions. Reorient as necessary .
The clinical record failed to evidence documentation regarding the swelling and redness of the left knee first observed on 3/6/24 or notification of the physician.
On 4/15/25 at 10:27 a.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing who stated that R197 had been assisted to the floor during care by a former CNA on 2/25/24 and had only complained of some back pain the day after the fall which was addressed by the physician. She stated that the physician assessed R197 on 2/26/24 and started Tylenol for back pain. She stated that when she had investigated the incident, she had found that R197 had only complained of generalized pain when turning and had not knee pain or swelling until 3/6/24 when the CNA observed it and reported it to the LPN (licensed practical nurse). ASM #2 stated that the LPN had assessed R197's knee and notified the physician by placing it in the physician communication book. She stated that the physician saw R197 on 3/7/24 and ordered the x-ray which was obtained on 3/8/24 and the resident was sent out when the results came in. She stated that in hindsight the nurse should have called the physician and documented the assessment and findings in the medical record.
On 4/15/25 at 12:42 p.m., an interview was conducted with LPN #1 who stated that the former CNA had called her on 2/25/24 when R197 was on the floor. She stated that the CNA told her that she was changing the resident and R197 had grabbed the rail and rolled over too far, and the CNA was not able to catch her in time to keep her in the bed and had lowered her to the floor. She stated that R197 was a one person assist at that time and would use the rail to hold herself over when they were providing care but had a habit of going over too far. She stated that she had assessed R197 who had no complaints of pain or injuries observed. She stated that she had notified the physician and resident representative at that time. LPN #1 stated that the physician book was used to communicate anything non-urgent that they needed to address when they came in the next day. She stated that the physician came in twice a week and the nurse practitioner came in three days a week and someone was on call on the weekends. LPN #1 stated that observed swelling and redness in the knee should have been documented in the medical record to cover them and show what was going on and should have been called to the physician rather than placed in the book.
On 4/15/25 at 1:01 p.m., ASM #3, the facility nurse consultant provided a binder which documented a five-point performance improvement plan for regarding pain management. Review of the plan with an initiation date of 3/9/24, documented the following actions taken:
Like Patient or System:
- On 3/9/24, the DON initiated a Pain Assessment of all residents not able to report for signs and symptoms of pain. The purpose of the assessments is to identify any resident with new onset of pain or pain not relieved with current interventions and to ensure all residents with s/s pain have been assessed with interventions initiated, MD/RR notified with documentation in the clinical record, and the resident is care planned for pain/pain interventions. All areas of concern will be immediately addressed during the audit. The audit will be completed by 3-10-24.
- On 3/15/24 the social worker initiated resident questionnaires with all alert and oriented residents regarding pain. The purpose of the questionnaires is to identify any resident with new onset of pain, worsening pain or pain not relieved with current interventions and to ensure all residents with s/s of pain have been assessed with interventions initiated, MD/RR notified with documentation in the clinical record, and the resident is care planned for pain/pain interventions. All areas of concern will be immediately addressed during the audit. The questionnaires will be completed by 3-15-24.
- On 3/9/24, the facility nurse consultant will review the MAR (medication administration record) for all residents receiving pain medication for the past 30 days. The audit ensures the resident's pain medication regimen is effective, including PRN pain medications. The physician will be contacted for any identified areas of concern during the audit. The audit will be completed by 3/10/24.
- On 3/21/24 the DON initiated staff questionnaires to ensure there were no residents with unrelieved pain. This was to ensure staff had reported any changes in pain to a nurse and follow-up had occurred.
Plan:
- On 3/9/24, the DON initiated and in-service with all nursing assistants regarding reporting changes in resident condition including but not limited to pain.
- On 3/9/24 the DON initiated an in-service with all nurses regarding assessment of acute changes in condition to include but not limited to pain, notification to the physician and resident representative, initiation of an intervention to address the pain, updates to the resident care plan, and documentation in the clinical record.
- The inservices will be completed on 3/15/24. After 3/15/24 all nurses that have not worked and received the inservice will complete upon their next scheduled shift.
Monitoring:
- The DON/SDC will review residents' progress notes 5x per week x 4 weeks, then monthly x 1 month to identify residents with pain. The purpose of the audit is ensuring the pain was assessed by nursing staff with documentation in the electronic record, new onset of pain, worsening pain, or pain not relieved by current interventions are referred immediately to the physician for further interventions, the RR (Resident Representative) is notified of the pain, and the plan of care reflects pain. The resident will be assessed and/or notification to the provider with documentation in the clinical records, and the nurse will be retrained for all identified areas of concern.
- The audit will be discussed during the cardinal IDT (interdisciplinary team) meeting 5x per week x 4 weeks then monthly x 1 month and documented on the pain audit tool.
- The administrator or DON will present the findings of the Audit Tools to the QAA committee monthly for 2 months. The QAA committee will meet monthly for 2 months and review the Audit Tools to determine trends and/or issues that may need further interventions and the need for additional monitoring.
The performance improvement plan documented a compliance date of 3/21/24.
Review of the evidence binder documented completed resident pain assessments, resident and staff questionnaires, pain medication audits, progress note audits and education sign-in sheets documenting training on assessing for change in condition, pain, notification of the physician and resident representative, updating the care plan, pain interventions and documentation in the clinical record.
The staff sign-in sheets for the inservice training were reviewed and verified by multiple staff interviews. The other points of the plan of correction as described in this writing were verified with resident interviews and observations. No current concerns were identified.
On 4/16/25 at 3:38 p.m., ASM #1, (administrator), ASM #2, (director of nursing), ASM #3, (facility nurse consultant) and ASM #4, (administrator colleague from another facility) were made aware of the concern at past non-compliance.
No further information was provided prior to exit.
PAST NONCOMPLIANCE
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to maintain a homelike environment for 1 of 19 residents in th...
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Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to maintain a homelike environment for 1 of 19 residents in the survey sample, Resident #9.
The findings include:
For Resident #9 (R9), the facility staff failed to maintain the resident's wheelchair cushion in good repair.
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/6/25, the resident scored 12 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately impaired for making daily decisions.
On 4/14/25 at 1:24 p.m., an observation was made of R9 in their room eating lunch. R9 was observed sitting in a manual wheelchair. The black cushion underneath R9 was observed to be torn on both corners exposing the yellow foam underneath.
On 4/14/25 at 1:34 p.m., an interview was conducted with R9 who stated that he had the wheelchair cushion for a long time and the holes in the cushion had started very small but had gotten larger over time. He stated that the cushion had lost its padding from age, and he needed a new one, but no one had ever offered one.
Additional observation of R9's wheelchair cushion with the tears on both sides exposing the yellow foam underneath was made on 4/15/25 at 8:10 a.m.
On 4/15/25 at 12:42 p.m., an interview was conducted with LPN (licensed practical nurse) #1 who stated that if they saw that a residents wheelchair cushion was torn or damaged, they contacted therapy to replace it. She stated that normally it was a conversation with them to replace the cushion. On 4/15/25 at 12:58 p.m., LPN #1 observed R9's wheelchair cushion with the torn areas on both sides exposing the yellow foam underneath and stated that the cushion should be replaced She stated that she would let R9's nurse know so that therapy could order him a replacement.
The facility policy titled, Environment and Property dated 8/2019, documented in part, .The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely .
On 4/15/25 at 3:59 p.m., ASM #1, (administrator), ASM #2, (director of nursing), ASM #3, (facility nurse consultant) and ASM #4, (administrator colleague from another facility) were made aware of the findings.
No further information was presented prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For R1, the facility staff failed to evidence required documentation was provided to the receiving facility for a transfer to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For R1, the facility staff failed to evidence required documentation was provided to the receiving facility for a transfer to the hospital on [DATE] and 04/06/2025.
On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 03/26/2025, R1 scored an 8 (eight) out of 15 on the BIMS (brief interview for mental status), indicating R1 was moderately impaired of cognition for making daily decisions.
The facility's nursing progress noted for R1 dated 02/25/2025 documented, Note Text: Resident complaining that she can't breathe. O2 (oxygen) concentrator, tubing, and all working properly. Nasal spray administered and neb (nebulizer) tx (treatment) given without relief. Md (medical doctor) notified and received order to send to ER (emergency room) for workup.
The facility's nursing progress noted for R1 dated 04/06/2025 at 8:00 p.m. documented, Note Text: Writer call to resident room observed resident yelling out, I can`t breathe, Writer observed resident O2 at 4L/M (four liters per minute) intact via (by) nasal canula. Resident observed having difficulty breathing using abdominal muscle. Writer placed POSAT (pulse oximeter) (1) on resident finger an notice her SATS (saturation) was 85 (85 percent). Writer immediately started resident on breathing treatment and notice SATS increase to 90 then went back down to 85. Writer notified (Name of Director of Nursing), DON (director of nursing) as ordered to do so, suggested to writer to contact MD (medical doctor) and see what he advises.
The facility's nursing progress noted for R1 dated 04/06/2025 at 8:15 p.m. documented, Note Text: Writer notified (Name of Doctor) and received order to send resident to [NAME] (emergency room department). Writer notified 911 rescue gave report to dispatcher who told me that he has recue in route. Writer notifies (Name of Hospital) [NAME] gave report to (Name of Nurse), RN Registered Nurse).
Review of the EHR (electronic health record) failed to evidence documentation of required information provided to the hospital on [DATE] and 04/06/2025 for R1.
On 04/15/2025 at approximately 2:55 p.m., an interview was conducted with ASM (administrative staff member) #1, administrator regarding evidence that the required documentation sent to the receiving facility for a resident's transfer. He stated that the nurse's notes document what information is provided to the receiving facility. When asked about the evidence of the documentation that was sent to the hospital on [DATE] and 04/06/2025 for R1's transfer, ASM #1 stated that that there was no evidence of any documentation was sent for the transfers on 02/25/2025 and 04/06/2025 for R1.
On 04/15/2025 at approximately 4:05 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, facility nurse consultant and ASM #4, administrator colleague, were made aware of the above findings.
No further information was provided prior to exit.
Based on clinical record review, facility document review, and staff interview, it was determined the facility staff failed to evidence required documents were sent to the receiving facility at the time of a facility-initiated transfer for two of 19 residents in the survey sample, Residents #38 and #1.
The findings include:
1. For Resident #38 (R38), the facility staff failed to evidence that clinical documentation pertaining to the continuity of care was sent to the receiving hospital on 2/2/25 for a facility-initiated transfer.
The progress notes for R38 documented in part,
- 02/02/2025 14:02 (2:02 p.m.) Note Text: Resident reassessed for temp, increased to 103.7 after Tylenol administered. VS (vital signs) obtained and relayed to MD. Per MD send out to ER for further eval and tx. RR (resident representative), [Name of RR] called and made aware. She agreed to send to ER.
- 02/02/2025 14:04 (2:04 p.m.) Note Text: Emergency transport in at this time to transport to [Name of hospital].
- 02/02/2025 18:28 (6:28 p.m.) Note Text: Called ER to check on resident's status. Resident is being admitted with Influenza, UTI (urinary tract infection) and Sepsis.
Further review of the clinical record failed to evidence that the resident's representative and physician contact information, advance directive information, instructions for ongoing care, medication list, or care plan goals were sent to the receiving facility.
On 4/15/25 at 11:45 a.m., a request was made to ASM (administrative staff member) #1 for evidence of the clinical documentation sent to the receiving hospital on 2/2/25 for R38.
On 4/15/25 at 12:42 p.m., an interview was conducted with LPN (licensed practical nurse) #1 who stated that when they transferred a resident to the hospital, they sent a copy of the face sheet, the DNR (do not resuscitate) form if applicable, medication list, transfer form and bed hold policy. She stated that they had sent the care plan in the past, but they had stopped because some were over 50 pages, so she did not think they did that anymore.
On 4/16/25 at 10:17 a.m., ASM #1 stated that they did not have any evidence to provide of the clinical documentation sent to the receiving hospital on 2/2/25 for R38.
A review of the facility policy, Discharge and Transfer dated 8/2012, documented in part, .When a resident is transferred or discharged to a hospital or to a nursing home, a copy of an approved transfer and referral record and a copy of any additional medical information, as required by the facility receiving the resident, will accompany him/her .
On 4/16/25 at 3:38 p.m., ASM #1, (administrator), ASM #2, (director of nursing), ASM #3, (facility nurse consultant) and ASM #4, (administrator colleague from another facility) were made aware of the findings.
No further information was provided prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to develop and/or implement the comprehensive care plan for tw...
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Based on observation, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to develop and/or implement the comprehensive care plan for two of 19 residents in the survey sample, Resident #1 (R1) and R3
The findings include:
1. For R1, the facility staff failed to follow the comprehensive care plan for the administration of oxygen.
R1 was admitted to the facility with diagnoses that included but were not limited to COPD (chronic obstructive pulmonary disease) (1) and respiratory failure (2).
On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 03/26/2025, R1 scored an 8 (eight) out of 15 on the BIMS (brief interview for mental status), indicating R1 was moderately impaired of cognition for making daily decisions. Section O Special Treatments, Procedures and Programs coded R1 as receiving oxygen therapy while a resident.
On 04/14/25 at approximately 1:15 p.m., an observation revealed R1 in bed receiving oxygen by nasal cannula. Observation of the flow meter on the oxygen concentrator revealed an oxygen flow rate between two and three liters per minute.
On 04/15/25 at approximately 8:56 a.m., an observation revealed R1 in bed receiving oxygen by nasal cannula. Observation of the flow meter on the oxygen concentrator revealed an oxygen flow rate between two and three liters per minute.
On 04/15/25 at approximately 1:50 p.m., an observation revealed R1 in bed receiving oxygen by nasal cannula. Observation of the flow meter on the oxygen concentrator revealed an oxygen flow rate between two and three liters per minute.
The physician's order for R1 dated 04/10/2025 documented in part, Oxygen flow is 2 (two) L/min (liters per minute): Type of administration used nasal cannula.
The comprehensive care plan dated 12/28/2023 for R1 documented in part, Focus: Potential for or Actual Ineffective Breathing Pattern R/T (related to): COPD and Respiratory failure. Date Initiated: 12/28/2023. Created on: 12/28/2023. Under Interventions it documented in part, Oxygen therapy (specify rate) via (specify device) as ordered. Date Initiated: 02/27/2025.
On 04/15/2025 at approximately 2:20 p.m., an interview was conducted with LPN (licensed practical nurse) #1. When asked about the purpose of a resident's care plan she stated that it provides direction for providing care to the resident. When asked if the care plan was followed if the if the oxygen was not set according to the physician's orders, she stated no.
The facility's policy Guidelines For Documentation By Interdisciplinary Care Team documented in part, The care team should develop appropriate interventions for the prevention of negative outcomes. Potential negative outcomes may include but not limited to incontinence, skin breakdown, decreased range of motion, decrease ability to ambulate, loss of bone and muscle strength, increase risk of injury, loss of appetite, increased risk of infection, agitation, symptoms of withdrawal, depersonalization, dependency, feelings of entrapment, depression or reduced social contact. The care plan team should design interventions that minimize or eliminate the medical symptom .
On 04/15/2025 at approximately 4:05 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, facility nurse consultant and ASM #4, administrator colleague, were made aware of the above findings.
No further information was provided prior to exit.
References:
(1) Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html.
(2) When not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html.
2. For Resident #3 (R3), the facility staff failed to develop a care plan for the resident's contractures.
On the following dates and times, R3 was observed lying supine in bed, with her head elevated. At each observation, both R3's hands and feet were contracted: 4/14/25 at 12:35 p.m. and 3:36 p.m.; 4/15/25 at 7:49 a.m. and 9:52 a.m. At no time was any contracture related device observed.
A review of R3's comprehensive care plan failed to reveal information related to prevention of worsening of R3's contractures.
On 4/15/25 at 10:21 a.m., RN (registered nurse) #1, the wound nurse, and ASM (administrative staff member) #2, the director of nursing, were interviewed as they completed R3's wound care. RN #1 and ASM #2 identified R3's bilateral feet and hands as being contracted.
On 4/15/25 at 2:16 p.m., CNA (certified nursing assistant) #1 was interviewed. She stated there was nothing required for R3's contractures as far as she knew.
On 4/15/25 at 3:09 p.m., RN #2, the MDS (minimum data set) coordinator, was interviewed. She stated R3's most recent comprehensive MDS did not include consideration of R3's contractures as a concern needing interventions or a care plan. She stated ordinarily, a new therapy screening or intervention, or a physician's order for interventions, would trigger an entry on the resident's care plan. She said contractures should definitely be captured in a resident's care plan.
On 4/15/25 at 4:00 p.m., ASM #1, the administrator, ASM #2, ASM #3, the facility nurse consultant, and ASM #4, an administrator colleague, were informed of these concerns.
No additional information was provided prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for 1 of 19 r...
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Based on observation, resident interview, staff interview, facility document review and clinical record review, the facility staff failed to provide ADL (activities of daily living) care for 1 of 19 residents in the survey sample, Resident #9.
The findings include:
For Resident #9 (R9), the facility staff failed to provide routine fingernail care.
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 3/6/25, the resident scored 12 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately impaired for making daily decisions. The assessment documented R9 being independent for personal hygiene and bathing.
On 4/14/25 at 1:34 p.m., an observation was made of R9's fingernails. The fingernails on both hands were observed to be approximately 1/4 inch long. At that time an interview was conducted with R9 who stated that the staff came around at times and would ask them if they needed their nails trimmed but had not been in recently. R9 stated that they had needed their nails trimmed for a while and was not able to do it himself.
Additional observation of R9's fingernails was made on 4/15/25 at 8:10 a.m. and 11:57 a.m.
The diagnosis information for R9 did not document a diagnosis of diabetes.
The comprehensive care plan for R9 documented in part, Activities of Daily Living/ Personal Care
related to dementia, OA (osteoarthritis), edema. Date Initiated: 01/10/2020. The goal of the care plan documented, Activities of Daily Living/Personal Care will be completed with staff support as
appropriate to maintain or achieve highest practical level of functioning through the next review.
Date Initiated: 01/10/2020. Created on: 01/10/2020. Revision on: 05/15/2024. Target Date: 06/03/2025.
On 4/15/25 at 12:42 p.m., an interview was conducted with LPN (licensed practical nurse) #1 who stated that usually the CNA (certified nursing assistant) staff trimmed the residents' fingernails unless the resident was diabetic and then the nurse did it. She stated that the nails were checked every so often and if they noticed that they were long they trimmed them. On 4/15/25 at 12:58 p.m., LPN #1 observed R9's fingernails and stated that they were long and needed to be trimmed.
On 4/15/25 at 2:14 p.m., an interview was conducted with CNA #1 who stated that the CNA staff trimmed residents' fingernails unless the resident was diabetic. She stated that the fingernails were assessed every day and especially on shower days when it was the time to give the most attention to the resident for things like shaving and nail care.
The facility policy titled, Grooming dated 8/2012, documented in part, Grooming will be performed daily and PRN (as needed) as needed. This includes shampooing, shaving, nail care, and mouth care.
On 4/15/25 at 3:59 p.m., ASM #1, (administrator), ASM #2, (director of nursing), ASM #3, (facility nurse consultant) and ASM #4, (administrator colleague from another facility) were made aware of the findings.
No further information was presented prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to implement interventions for contractures for one of 19 residents in the survey...
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Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to implement interventions for contractures for one of 19 residents in the survey sample, Resident #3.
The findings include:
For Resident #3 (R3), the facility staff failed to implement interventions to prevent worsening of contractures.
On the following dates and times, R3 was observed lying supine in bed, with her head elevated. At each observation, both R3's hands and feet were contracted: 4/14/25 at 12:35 p.m. and 3:36 p.m.; 4/15/25 at 7:49 a.m. and 9:52 a.m. At no time was any contracture related device observed.
On 4/15/25 at 10:21 a.m., RN (registered nurse) #1, the wound nurse, and ASM (administrative staff member) #2, the director of nursing, were interviewed as they completed R3's wound care. RN #1 and ASM #2 identified R3's bilateral feet and hands as being contracted. RN #1 stated, We float her heels, and it brings her feet back. She stated the staff also puts something in both hands, as the resident tolerates. ASM #2 stated if the staff attempted to implement an intervention to prevent contractures and the resident did not tolerate the intervention, there should be a progress note.
A review of R3's clinical record, including therapy notes and screenings, failed to reveal evidence that the resident's contractures had been assessed or that interventions to prevent worsening of the contractures had been implemented.
On 4/15/25 at 2:16 p.m., CNA (certified nursing assistant) #1 was interviewed. She stated there was nothing required for R3's contractures as far as she knew.
On 4/15/25 at 2:27 p.m., OSM (other staff member) #3, a certified occupational therapy assistant, was interviewed. She stated R3 has bilateral contractures in both hands and both feet, but she could not find any evidence of assessment or treatment for R3's contractures in the therapy records. She stated the facility had undergone several changes of therapy providers, and all previous therapy notes are not available to the current staff. She stated therapy screenings occur approximately every three months, and that the therapy staff should be screening for contractures. She stated the therapy staff will be assessing R3's contractures and making a treatment plan this week.
On 4/15/25 at 4:00 p.m., ASM #1, the administrator, ASM #2, ASM #3, the facility nurse consultant, and ASM #4, an administrator colleague, were informed of these concerns.
A review of the facility policy, Range of Motion, revealed, in part: Range of motion is performed daily with bath. Because of this daily care, range of motion exercises will not be documented.
No additional information was provided prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to provide respiratory care and services for one of 19 residen...
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Based on observation, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to provide respiratory care and services for one of 19 residents in the survey sample, Resident #1 (R1).
For R1, the facility staff failed to maintain the oxygen (O2) flow rate at two liters per minute according to the physician's orders.
The findings include:
R1 was admitted to the facility with diagnoses that included but were not limited to COPD (chronic obstructive pulmonary disease) (1) and respiratory failure (2).
On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 03/26/2025, R1 scored an 8 (eight) out of 15 on the BIMS (brief interview for mental status), indicating R1 was moderately impaired of cognition for making daily decisions. Section O Special Treatments, Procedures and Programs coded R1 as receiving oxygen therapy while a resident.
On 04/14/25 at approximately 1:15 p.m., an observation revealed R1 in bed receiving oxygen by nasal cannula. Observation of the flow meter on the oxygen concentrator revealed an oxygen flow rate between two and three liters per minute.
On 04/15/25 at approximately 8:56 a.m., an observation revealed R1 in bed receiving oxygen by nasal cannula. Observation of the flow meter on the oxygen concentrator revealed an oxygen flow rate between two and three liters per minute.
On 04/15/25 at approximately 1:50 p.m., an observation revealed R1 in bed receiving oxygen by nasal cannula. Observation of the flow meter on the oxygen concentrator revealed an oxygen flow rate between two and three liters per minute.
The physician's order for R1 dated 04/10/2025 documented in part, Oxygen flow is 2 (two) L/min (liters per minute): Type of administration used nasal cannula.
The comprehensive care plan dated 12/28/2023 for R1 documented in part, Focus: Potential for or Actual Ineffective Breathing Pattern R/T (related to): COPD and Respiratory failure. Date Initiated: 12/28/2023. Created on: 12/28/2023. Under Interventions it documented in part, Oxygen therapy (specify rate) via (specify device) as ordered. Date Initiated: 02/27/2025.
On 04/15/2025 at approximately 2:20 p.m., an interview was conducted with LPN (licensed practical nurse) #1. When asked to describe how to read the flow meter on the oxygen concentrator she stated the bottom of the float ball inside the flow meter should be on the liter line.
The (Name of Manufacturer's) Oxygen Concentrator Instruction Guide documented in part, Check the flow meter to make sure the flow meter ball is centered on the line next to the prescribed number of your flow rate.
The facility's policy Oxygen Therapy documented in part, 5. Adjust flow meter to prescribe rate.
On 04/15/2025 at approximately 4:05 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, facility nurse consultant and ASM #4, administrator colleague, were made aware of the above findings.
No further information was provided prior to exit.
References:
(1) Disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html.
(2) When not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, the facility staff failed to monitor residents f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, the facility staff failed to monitor residents for the administration of unnecessary psychoactive medications for two of 19 residents in the survey sample, Residents #41 and #17.
The findings include:
1. For Resident #41 (R41) the facility staff failed to monitor for side effects for the use of Risperidone (1) and Sertraline (2).
A review of R41's clinical record revealed an order for Risperidone 0.5 mg (milligrams) daily and Sertraline 50 mg daily. A review of R41's MARs (medication administration records) for March and April 2025 revealed these medications were administered as ordered.
Further review of the record failed to reveal any evidence that the facility was monitoring for the side effects of the medications.
On 4/15/25 at 3:36 p.m., ASM (administrative staff member) #2, the director of nursing, was interviewed. She stated the facility is responsible for monitoring for side effects of all psychoactive meds. She stated psychoactive medications have the potential for pretty bad side effects for residents, including tardive dyskinesia. She stated the facility's software sometimes automatically triggers for staff to monitor for side effects, but in R41's case, the software had not triggered.
On 4/15/25 at 4:00 p.m., ASM #1, the administrator, ASM #2, ASM #3, the facility nurse consultant, and ASM #4, an administrator colleague, were informed of these concerns.
A review of the facility policy, Psychotropic Drug Therapy, failed to reveal specific steps to be taken for monitoring for side effects of psychoactive medications.
No additional information was provided prior to exit.
References
(1) Risperidone (generic for Risperdal) is used to treat the symptoms of schizophrenia (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) in adults and teenagers [AGE] years of age and older. It is also used to treat episodes of mania (frenzied, abnormally excited, or irritated mood) or mixed episodes (symptoms of mania and depression that happen together) in adults and in teenagers and children [AGE] years of age and older with bipolar disorder (manic depressive disorder; a disease that causes episodes of depression, episodes of mania, and other abnormal moods). Risperidone is also used to treat behavior problems such as aggression, self-injury, and sudden mood changes in teenagers and children 5 to [AGE] years of age who have autism (a condition that causes repetitive behavior, difficulty interacting with others, and problems with communication). Risperidone is in a class of medications called atypical antipsychotics. It works by changing the activity of certain natural substances in the brain. This information is taken from the website https://medlineplus.gov/druginfo/meds/a694015.html.
(2) Sertraline is used to treat depression, obsessive-compulsive disorder (bothersome thoughts that won't go away and the need to perform certain actions over and over), panic attacks (sudden, unexpected attacks of extreme fear and worry about these attacks), posttraumatic stress disorder (disturbing psychological symptoms that develop after a frightening experience), and social anxiety disorder (extreme fear of interacting with others or performing in front of others that interferes with normal life). This information is taken from the website https://medlineplus.gov/druginfo/meds/a697048.html#:~:text=Sertraline%20is%20in%20a%20class,that%20helps%20maintain%20mental%20balance.
2. For Resident #17 (R17), the facility staff failed to for side effects for the use of Seroquel (1)
A review of R17's clinical record revealed an order for Seroquel 50 mg (milligrams) nightly. A review of R17's MARs (medication administration records) for March and April 2025 revealed this medication was administered as ordered.
Further review of the record failed to reveal any evidence that the facility was monitoring for the side effects of the medications.
On 4/15/25 at 3:36 p.m., ASM (administrative staff member) #2, the director of nursing, was interviewed. She stated the facility is responsible for monitoring for side effects of all psychoactive meds. She stated psychoactive medications have the potential for pretty bad side effects for residents, including tardive dyskinesia. She stated the facility's software sometimes automatically triggers for staff to monitor for side effects, but in R17's case, the software had not triggered.
On 4/15/25 at 4:00 p.m., ASM #1, the administrator, ASM #2, ASM #3, the facility nurse consultant, and ASM #4, an administrator colleague, were informed of these concerns.
No additional information was provided prior to exit.
Reference
(1) Quetiapine tablets and extended-release (long-acting) tablets are used to treat the symptoms of schizophrenia (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). Quetiapine tablets and extended-release tablets are also used alone or with other medications to treat episodes of mania (frenzied, abnormally excited or irritated mood) or depression in patients with bipolar disorder (manic depressive disorder; a disease that causes episodes of depression, episodes of mania, and other abnormal moods). In addition, quetiapine tablets and extended-release tablets are used with other medications to prevent episodes of mania or depression in patients with bipolar disorder. Quetiapine extended-release tablets are also used along with other medications to treat depression. Quetiapine tablets may be used as part of a treatment program to treat bipolar disorder and schizophrenia in children and teenagers. Quetiapine is in a class of medications called atypical antipsychotics. It works by changing the activity of certain natural substances in the brain. This information is taken from the website https://medlineplus.gov/druginfo/meds/a698019.html.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for two o...
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Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to maintain a complete and accurate clinical record for two of 19 residents in the survey sample, Residents #35 and #197.
The findings include:
1. For Resident #35 (R35), the facility staff failed to document care they provided for the resident's indwelling urinary catheter each shift.
On the following dates and times, R35 was observed utilizing an indwelling urinary catheter: 4/14/25 at 12:44 p.m. and 1:14 p.m.; 4/15/25 at 7:51 a.m. and 11:17 a.m. On 4/15/25 at 11:17 a.m., R35 was interviewed about routine care for his indwelling urinary catheter. He stated the staff (especially CNAs [certified nursing assistants]) do a wonderful job of caring for his catheter. He stated they clean the catheter at least every shift.
A review of R35's clinical record revealed no orders for catheter care, and no evidence that routine catheter care was being provided to R35.
On 4/15/25 at 2:16 p.m., CNA (certified nursing assistant) #1 was interviewed. She stated she regularly cares for R35, and that she always provides catheter care each morning when she gives the resident a bath. She stated it is important to keep the catheter as clean as possible to prevent a possible urinary tract infection. She stated she is not aware of any place to document the care she gives in the clinical record.
On 4/15/25 at 4:00 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, ASM #3, the facility nurse consultant, and ASM #4, an administrator colleague, were informed of these concerns.
A review of the facility policy, Rules for Medical Records Documentation, revealed, in part: The resident's medical record is used to plan continuous care; coordinate clinical care contributions; communicate ad keep apprised of the resident medical condition; and provide clinical data for continuing education and research. A resident's medical record is legal proof of the quality of care provided .Document any action taken in response to a resident's problem.
No additional information was provided prior to exit.
2. For Resident #197 (R197), the facility staff failed to maintain a complete medical record documenting observed swelling and redness to the residents left knee on 3/6/24.
R197 no longer resided at the facility and could not be observed or interviewed. The record was reviewed as a closed record.
A facility synopsis of events for R197 dated 3/8/24 documented in part, .Swelling & redness noted to LT (left) knee. MD in to see. X-ray of knee ordered- found acute appearing distal femur fx (fracture) proximal to LT knee replacement. Resident sent to ER. See attached summary . The attached summary documented in part, Resident was noted with redness and swelling to LT knee on 3/6/24. Primary nurse was made aware. Primary nurse assessed resident and found redness and swelling to LT knee and decision was made to notify MD. Resident had no complaints of pain when asked. MD saw resident on 3/7/24 and order given for x-ray. [Name of x-ray service] in on 3/8/25 and performed x-ray. Radiology reading of x-ray states resident had an acute-appearing fracture of the distal femur proximal to her knee replacement. Resident sent to the ER for evaluation. The hospital attributed the fracture to her fall on 2/25/24. Orthopedic surgeon felt that surgical intervention could cause more harm to resident than nonsurgical intervention. States knee was already starting to heal. Knee immobilizer placed in hospital to help with keeping fracture in alignment during healing. Resident has a diagnosis of osteopenia, osteoarthritis, Vitamin B and D deficiencies.
The physician progress note for R197 dated 3/7/24 documented in part, .Chief complaint/reason for this visit: Left knee pain. HPI (history of present illness) relating to this visit: [age and sex of R197] with history of CAD (coronary artery disease), Dementia, Chronic A. (atrial) fibrillation, CVA (cerebrovascular accident) and OA (osteoarthritis) is seen today for evaluation of pain in her left knee with swelling that she complained about this morning. This knee has had joint replacement in 2011. There were no reports of any trauma. She does complain of pain with moving the knee .Musculoskeletal: Joint Swelling/Inflammation, Mobility, Painful Movement, Left knee tender . Assessment and Plan: 1. left knee pain has had surgery 2021. 1: Obtain x-ray. Tylenol prn (as needed) pain. 2. Dementia: Continue safety precautions. Reorient as necessary .
The clinical record failed to evidence documentation regarding the swelling and redness of the left knee first observed on 3/6/24.
On 4/15/25 at 10:27 a.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing who stated that R197 had been assisted to the floor during care by a former CNA on 2/25/24 and had only complained of some back pain the day after the fall which was addressed by the physician. She stated that the physician assessed R197 on 2/26/24 and started Tylenol for back pain. She stated that when she had investigated the incident, she had found that R197 had only complained of generalized pain when turning and had not knee pain or swelling until 3/6/24 when the CNA observed it and reported it to the LPN (licensed practical nurse). ASM #2 stated that the LPN had assessed R197's knee and notified the physician by placing it in the physician communication book. She stated that the physician saw R197 on 3/7/24 and ordered the x-ray which was obtained on 3/8/24 and the resident was sent out when the results came in. She stated that in hindsight the nurse should have documented the assessment and findings in the medical record.
On 4/15/25 at 12:42 p.m., an interview was conducted with LPN #1 who stated that the physician book was used to communicate anything non-urgent that they needed to address when they came in the next day. She stated that the physician came in twice a week and the nurse practitioner came in three days a week and someone was on call on the weekends. LPN #1 stated that the observed swelling and redness in the knee should have been documented in the medical record of R197 to cover them and show what was going on.
On 4/16/25 at 3:38 p.m., ASM #1, (administrator), ASM #2, (director of nursing), ASM #3, (facility nurse consultant) and ASM #4, (administrator colleague from another facility) were made aware of the findings.
No further information was provided prior to exit.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, staff interview, and facility document review, facility staff failed to prepare store and serve food in a sanitary manner in one of one facility kitchens.
The findings include:
O...
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Based on observation, staff interview, and facility document review, facility staff failed to prepare store and serve food in a sanitary manner in one of one facility kitchens.
The findings include:
On 04/14/2025 at approximately 11:30 a.m., an observation of the facility's kitchen revealed the following:
On 04/14/2025 at approximately 11:25 a.m., an observation of the facility's kitchen revealed a 26-inch fan sitting on a cart blowing into the kitchen and onto a metal shelving unit with four shelves. Observations of the shelves revealed, the top shelf contained 25 clean meal tray covers, the second from the top shelf contained 12 clean tray bottoms, the third from the top shelf contained 30 clean eight-ounce bowls and the bottom shelf contained three racks of clean cups and glasses. Observation of the fan revealed the fan blades, and the front and back fan guards were coated in dust.
Observation of the inside of the facility's walk-in refrigerator revealed a ladder rack containing two sheet pans with a combined total of 40, eight-ounce bowls containing mixed fruit. Further observation revealed that the fruit bowls were uncovered.
Observation of the top, right hand shelf inside the facility's walk-in refrigerator revealed a Ziploc bag containing three one-half pound stacks of sliced Swiss cheese. Observation of one of the stacks of cheese revealed it was open to the environment. Observation of the Ziploc bag revealed it was open to the environment.
Observation of a shelf, second from the top, on the right-hand side inside the facility's walk-in refrigerator revealed a sandwich wrapped in a paper wrap. Further observation failed to evidence a name or date on the sandwich.
Observation of the food processor located in the facility's kitchen on a food preparation table was conducted with OSM #1. When asked if the food processor was cleaned and ready for use OSM #1stated, Yes. Observation of the inside of the food processor lid revealed it was wet, standing water inside the bowl and a wet blade. After observing the food processor bowl OSM #1 verbally agreed that the inside of the lid, bowl and blade were wet.
On 04/14/2025 at approximately 2:20 p.m., an interview was conducted with OSM (other staff member) #1. When asked about the fruit on the ladder rack in the walk-in refrigerator being uncovered, she stated the bowls should have been covered to keep any debris from falling on them. OSM #1 stated the Swiss cheese in the Ziploc bag should have been closed, the sandwich found on the shelf in the walk-in refrigerator should have been labeled with a resident's name and dated. Regarding the food processor, she stated it should have been air dried to prevent the development of bacteria or mold. After being informed of the observation of the fan blowing on the clean items on metal shelving, OSM #1 observed the fan and verbally agreed the fan blades, and front and rear fan guards were coated in dust. She further stated the fan should not have been blowing into the kitchen and it was blowing dust onto the clean items on the metal shelving.
The facility's policy Cleaning Procedures. Warewashing documented in part, Dishes and other reusable components of metal service, pots and pan, will be washed using the proper temperature, correct chemicals, and then air-dried.
On 04/15/2025 at approximately 4:05 p.m., ASM (administrative staff member) #1, administrator, ASM #2, director of nursing, ASM #3, facility nurse consultant and ASM #4, administrator colleague, were made aware of the above findings.
No further information was provided prior to exit.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0865
(Tag F0865)
Could have caused harm · This affected multiple residents
Based on staff interview and facility document review it was determined that the facility staff failed to evidence a continuous Quality Assurance and Performance Improvement (QAPI) program that monito...
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Based on staff interview and facility document review it was determined that the facility staff failed to evidence a continuous Quality Assurance and Performance Improvement (QAPI) program that monitored its performance and ensured that improvements were sustained, which had the ability to affect all residents within the facility for nine of ten quarters reviewed.
The findings included:
The facility staff failed to evidence QAPI sign-in sheets for meetings held between Q4 of 2022 and Q4 of 2024.
On 4/14/25 at 11:28 a.m., during entrance conference a request was made to ASM (administrative staff member) #1, the administrator for QAPI meeting attendance records from 7/28/22 to the present.
On 4/16/25 at 12:38 p.m., ASM #1 provided QAPI meeting attendance records and stated that he was not able to find all the sign-in sheets going back to the last survey and what was provided was all that he had. ASM #1 stated that he was not able to identify the dates that the meetings took place, and they did not have dates on the sign-in sheets or any documentation identifying when the meetings took place.
Review of the provided QAPI meeting attendance records documented a meeting completed in Q1 of 2025. A QAPI meeting attendance record dated 10/24/24 documented the medical director, administrator and director of nursing attending with no additional staff members. Three undated QAPI meeting attendance records documented three meetings with the required attendees, one meeting with the infection preventionist not attending and one meeting with the director of nursing not attending.
On 4/16/25 at 3:49 p.m., an interview was conducted with ASM #1 who stated that since he had been at the facility the QAPI team met monthly with a minimal of a quarterly meeting to discuss subjects that they identified through audits, tracking, morning meetings, the clinical team and resident suggestions. He stated that they worked as a team to determine performance improvement projects, tracked progress of ongoing projects and perform root cause analysis of identified problems.
The facility policy, Quality Assurance and Performance Improvement (QAPI) Plan revised 10/15/2022, documented in part, . The QAPI Committee will meet on a regular basis, and at least quarterly .
On 04/16/25 at 3:38 p.m., ASM #1, (administrator), ASM #2, (director of nursing), ASM #3, (facility nurse consultant) and ASM #4 (administrator colleague from another facility) were made aware of the concern.
No further information was provided prior to exit.
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on observation, staff interview and facility document review, it was determined that the facility staff failed to post daily nurse staffing information prior to the start of the shift on one of ...
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Based on observation, staff interview and facility document review, it was determined that the facility staff failed to post daily nurse staffing information prior to the start of the shift on one of three dates observed and post daily nurse staffing information in a prominent place readily accessible to residents and visitors on three of three dates observed.
The findings include:
The facility staff failed to post daily nurse staffing information prior to the start of the shift on 4/14/25 and post daily nurse staffing information in a prominent place readily accessible to residents and visitors on 4/14/25, 4/15/25 and 4/16/25.
On 4/14/25 at 11:28 a.m., an observation was made of the facility. There was no daily nurse staffing information posted. Observation at 12:50 p.m. revealed a daily nurse staffing posted on the wall inside a plastic page protector. The posting was observed to be hanging on the wall inside the nurses' station on the interior wall not readily accessible to residents or visitors.
On 4/15/25 at 8:02 a.m., an observation was made of daily staff posting hanging inside the nurses' station located on the interior wall inside a plastic page protector not readily accessible to residents or visitors.
On 4/16/25 at 8:18 a.m., an observation was made of daily staff posting hanging inside the nurses' station located on the interior wall inside a plastic page protector not readily accessible to residents or visitors.
On 4/14/25 at 11:44 a.m., an interview was conducted LPN (licensed practical nurse) #2 who stated that the night nurse posted the daily staffing and that it normally hung beside them at the nurses' station. LPN #2 pointed to an empty plastic page protector hanging on the wall on the inside of the nurses' station and stated that she could print one out.
On 4/16/25 at 9:53 a.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing, who stated that the night nurse posted the daily staffing. She stated that they had not posted it on 4/14/25 so she had posted it later that day. ASM #2 stated that residents and visitors did not go in the nurses' station for privacy reasons. She stated that the posting probably could not be seen from a wheelchair or if someone had bad eyesight from where it was hanging on the wall inside the nurses' station.
On 4/16/25 at 3:38 p.m., ASM #1, (administrator), ASM #2, (director of nursing), ASM #3, (facility nurse consultant) and ASM #4, (administrator colleague from another facility) were made aware of the findings.
No further information was provided prior to exit.
On 4/16/25 at 5:02 p.m., ASM #1 stated via email that the facility did not have a policy regarding daily staff posting and that they followed the federal regulations.
Jul 2022
12 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
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, it was determined the facility staff failed to pr...
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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, it was determined the facility staff failed to provide evidence that all required clinical information was provided to the hospital staff for 2 out of 29 residents in the survey sample that were transferred to the hospital; Residents #29 and Resident #12.
The findings include:
1. The facility staff failed to evidence provision of required resident clinical information to a receiving facility at the time of discharge for Resident #29. Resident #29 was transferred to the hospital on 6/21/22.
Resident #29 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: end stage renal disease, heart failure and discitis.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 6/8/22, coded the resident as scoring a 07 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the Section G-functional status coded the resident as requiring extensive assistance for transfer, dressing and hygiene; totally dependent for bed mobility, locomotion and bathing; supervision for eating. Section O-special procedures/treatments coded the resident as dialysis yes.
A review of the comprehensive care plan dated 2/26/22, which revealed, FOCUS: End Stage Renal Disease: The resident is at risk for complications due to hemodialysis. INTERVENTIONS: Dialysis (Tuesday, Thursday, Saturday). Diet as ordered; 1000ml daily Fluid Restriction.
A review of the nursing progress note dated 6/21/22 at 11:55 AM, revealed, Time Resident Returned from Dialysis: 11:55. Condition of Shunt Site (dressing intact, bleeding, drainage, etc.): intact. Bruit & Thrill: =/- Site: +. Condition & Mental Status upon return (alert, oriented, confusion, lethargy, other symptoms, etc.): lethargic. Instructions &/or Communication from Dialysis Center (pre/post weights, order changes, lab results, etc.): patient complained of upset stomach. Complained of not feeling well. Blood pressure within normal limits. Heart rate tachycardia/irregular. Patient coughed and heart rate dropped within normal limits. 20 min later heart rate up to 129. Vital signs 112/82-118-18-98.1. Additional Comments (time dressing removed, MD notification & orders changes/verified, etc.). 12:30 resident complained of chest pain and left arm pain with nausea. Physician in room. Vital signs 159/83-90-16-95.9. O2 saturations at 85%. O2 applied via nasal cannula at 2 liters per minute. Order to send to emergency room. 12:43 911 called. 13:10 county rescue squad arrived. Resident left facility via stretcher and 2 attendants at 13:15. 13:20 report called to emergency room.
There is no evidence of transfer documentation in the medical record. A request for clinical documents for the transfer of Resident #29 on 6/21/22 was made on 7/26/22 at 4:40 PM.
On 7/27/22 at 7:35 AM, ASM (administrative staff member) #2, the director of nursing stated, there is no evidence of the clinical documentation for this resident for this transfer.
An interview was conducted on 7/27/22 at 8:30 AM with LPN (licensed practical nurse) #1. When asked what information is provided to the hospital upon transfer of a resident, LPN #1 stated, there is some paperwork that we send. When asked if there is a checklist, LPN #1 stated, We do not have a checklist.
On 7/27/22 at approximately 4:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, assistant director of nursing, were made aware of the findings.
A review of the facility's Discharge and Transfer policy dated 8/12, reveals, Discharge and/or transfer to other medical facilities will be effected only when medically appropriate as indicated by the attending physician. When a resident is transferred or discharged to a hospital or to a nursing home, a copy of an approved transfer and referral record and a copy of any additional medical information, as required by the facility receiving the resident, will accompany him/her.
No further information was provided prior to exit.2. The facility staff failed to provide Resident #12's (R12) comprehensive care plan goals to the hospital staff when R12 was transferred to the hospital on 6/20/22.
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/9/22, the resident's cognitive skills for daily decision making were coded as severely impaired.
A review of R12's clinical record revealed the resident was transferred to the hospital on 6/20/22 for abdominal distention and hypoactive bowel sounds. Further review of R12's clinical record failed to reveal evidence of the clinical documentation provided to hospital staff.
On 7/27/22 at 9:14 a.m., an interview was conducted with RN (registered nurse) #1 (the nurse who sent R12 to the hospital). RN #1 stated she provides hospital staff with a copy of residents' face sheets, a copy of monthly orders, a copy of telephone orders that are received after the monthly orders are signed, a copy of the physician's order to send the residents to the hospital, a copy of the bed hold and a do not resuscitate form if applicable. RN #1 stated sometimes she provides a piece of residents' care plans that is related to the problem but she did not provide any portion of the care plan or the comprehensive care plan goals when R12 was transferred to the hospital on 6/20/22.
On 7/27/22 at 4:35 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.
No further information was presented prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to develop a complete baseline care plan for one of 29 residents in the survey sam...
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Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to develop a complete baseline care plan for one of 29 residents in the survey sample, Resident #149.
The facility staff failed to include Resident #149's (R149) indwelling urinary catheter on the resident's baseline care plan.
The findings include:
On 7/27/22 at 8:14 a.m., R149 was observed lying in bed with an indwelling urinary catheter.
A review of R149's clinical record revealed a physician's order dated 7/19/22 for a urinary catheter. R149's baseline care plan initiated on 7/20/22 failed to document information regarding an indwelling urinary catheter.
On 7/27/22 at 12:45 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated the purpose of a care plan is to drive the resident's plan of care. RN #1 stated she initiates a resident's baseline care plan if she is the admitting nurse and an indwelling urinary catheter should be included on the baseline care plan because a resident receives specialized care related to the catheter.
On 7/27/22 at 4:35 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.
The facility policy titled, RESIDENT CARE PLAN documented, The initiation of a baseline care plan will begin upon admission by the designated RN. Baseline care plans will include the instructions needed to provide effective and patient-centered care for residents that meet professional standards of quality care.
No further information was presented prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility failed to revise the comprehensive care plan to include correct fluid restriction for Resident #29.
Resident #29...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility failed to revise the comprehensive care plan to include correct fluid restriction for Resident #29.
Resident #29 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: end stage renal disease and heart failure.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 6/8/22, coded the resident as scoring a 07 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the Section G-functional status coded the resident as requiring extensive assistance for transfer, dressing and hygiene; totally dependent for bed mobility, locomotion and bathing; supervision for eating. Section O-special procedures/treatments coded the resident as dialysis yes.
A review of the comprehensive care plan dated 2/26/22, which revealed, FOCUS: End Stage Renal Disease: The resident is at risk for complications due to hemodialysis. INTERVENTIONS: Dialysis (Tuesday, Thursday, Saturday). Diet as ordered; 1000ml daily Fluid Restriction.
A review of the physician's order dated 7/15/22, revealed, Fluid restriction 1200 milliliters daily.
On 7/27/22 at 12:00 PM, a request was made for evidence of 1200 milliliters daily fluid restriction monitoring for July 2022.
A review of the nursing progress note dated 7/27/22 at 7:00 PM, revealed, Physician called to clarify fluid restriction order for the resident.
On 7/28/22 at 9:00 AM, ASM (administrative staff member) #2 stated, We do not have any evidence of monitoring the fluid restriction at 1200 milliliters. Normally the order is more specific with dietary and nursing having specific set amounts. When asked if the care plan should have been revised to reflect the new order, ASM #2 stated, It should have been revised. The care plan currently has the 1000 milliliters fluid restriction.
On 7/28/22 at 9:30 AM, an interview was conducted with LPN (licensed practical nurse) #1. When asked the purpose of the care plan, LPN #1 stated the care plan is the plan of care specific for that resident. When asked if fluid restrictions should be on the care plan, LPN stated yes, it should. When asked if the care plan should be revised if the fluid restriction amount is changed, LPN #1 stated, if there is an amount on the care plan, it should be revised.
On 7/27/22 at approximately 4:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, assistant director of nursing, were made aware of the findings.
A review of the facility's Resident Care Plan policy revised 11/17, reveals, Review and/or modification of the plan will occur after each assessment, including the comprehensive and quarterly review assessments. Any new problem or need of the resident, which is identified between his/her scheduled care plan review, will be addressed on the care plan by the appropriate disciplines and brought to the next scheduled care plan meeting to inform the ICP (interdisciplinary care plan) team of its addition.
No further information was provided prior to exit.
Based on clinical record review, staff interview and facility document review, it was determined that facility staff failed to review or revise the comprehensive care plan for 2 of 29 residents in the survey sample, Residents #22 (R22) and (R29).
The findings include:
1. The facility staff failed to update (R22) comprehensive care plan following (R22's) fall on 07/07/2022.
(R22) was admitted to the facility with diagnosis that included but was not limited to: a history of falls.
(R22's) most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 06/02/2022, coded (R22) as scoring a 13 on the brief interview for mental status (BIMS) which indicated the resident was cognitively intact for making daily decisions.
The facility's progress note dated 07/07/2022 documented in part, Called to resident's bathroom @ (at) 1305 (1:35 p.m.). Resident noted to be sitting on bottom on bathroom floor with back against wall. Assessed for injury, none noted. When asked what happened, she stated that she got dizzy and lost her balance. Assisted back into room into bed x2 assist. VS obtained .
The facility's fall investigation for (R22) dated 07/707/2022 documented in part, Incident Description. Nursing Description: Called to resident's bathroom @ (at) 1305 (1:35 p.m.). Resident noted to be sitting on bottom on bathroom floor with back against wall. Resident Description: stated that she got dizzy and lost her balance. Type of Injury: No injuries observed at time of incident.
The comprehensive care plan for (R22) dated 02/10/2022 documented, Focus: Problematic manner in which resident acts characterized by ineffective coping: Wandering and/or at risk for unsupervised exits from facility related to: cognitive impairment, restlessness Date Initiated: 02/10/2022. Under interventions it documented, At Risk Wandering Protocol Date Initiated: 02/10/2022, Document episodes of wandering per facility protocol Date Initiated: 02/10/2022, Wander guard alarm bracelet Date Initiated: 02/10/2022. Further review of the care plan failed to evidence documentation that that it was reviewed or revised regarding (R22's) fall on 07/07/2022.
On 07/28/22 at approximately 8:00 a.m., an interview was conducted with ASM (administrative staff member) #2, director of nursing, regarding the revision or review of (R22's) care plan following the fall on 07/07/2022. ASM #2 stated that the care plan was revised yesterday, 07/27/2022. They further stated that (R22's) medications were reviewed at the time of the fall by the physician but they failed to update the care plan at that time. When asked to describe the procedure for revising/ reviewing a resident's care plan ASM #2 stated that the care is reviewed/revised at the time of the new intervention. When asked to describe the purpose of a resident's care plan ASM #2 stated that the care plan makes a continuous continuity of care for the resident.
The facility's policy Resident Care Plan documented in part, The resident care plan will be an ongoing process and will include current problems and/or needs identified from a complete assessment including the Minimum Data Set (MDS) and Care Assessments (CAAs) relevant to the resident's response to aging, illness, and his/her general health status. Any new problem or need of the resident, which is identified between his/her scheduled care plan review, will be addressed on the care plan by the appropriate disciplines and bought to the next scheduled care plan meeting to inform the ICP team of its addition.
On 07/28/2022 at approximately 11:35 a.m., ASM #1, administrator and ASM #2, were made aware of the findings.
No further information was provided prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to provide care and services for an indwelling catheter for on...
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Based on observation, staff interview, clinical record review, and facility document review, it was determined that facility staff failed to provide care and services for an indwelling catheter for one of 29 residents in the survey sample, Residents #11 (R11).
The facility staff failed to keep (R11's) catheter collection bag off the floor.
The findings include:
(R11) was admitted to the facility with diagnoses that included but were not limited to: neuromuscular dysfunction of the bladder (1).
(R11's) most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 07/18/2022, coded (R11) as scoring a 3 (three) on the brief interview for mental status (BIMS) which indicated severely impaired cognition for making daily decisions. Section H Bladder and Bowel coded (R11) as having an indwelling catheter.
On 07/26/22 at approximately 12:32 p.m., an observation of (R11) revealed they were sitting in their wheelchair with the catheter collection bag attached to the underside of the wheelchair. Observation of the catheter collection bag revealed that it was dragging on the floor under the wheelchair.
On 07/26/22 at approximately 1:58 p.m., an observation of (R11) revealed they were sitting in their wheelchair with the catheter collection bag attached to the underside of the wheelchair. Observation of the catheter collection bag revealed that it was dragging on the floor under the wheelchair.
On 07/26/22 at approximately 3:50 p.m., an observation of (R11) revealed they were sitting in their wheelchair with the catheter collection bag attached to the underside of the wheelchair. Observation of the catheter collection bag revealed that it was dragging on the floor under the wheelchair.
The physician's order dated 05/22/2022 for (R11) documented in part, .indwelling urinary catheter to gravity drainage .
The comprehensive care plan for (R11) dated 03/22/2022 documented in part, Focus: Altered Pattern of Urinary Elimination with Indwelling Catheter . - At Risk for Infection due to urinary retention Date Initiated: 03/22/2022.
On 07/27/2022 at approximately 12:53 p.m. an interview was conducted with RN (registered nurse) #1. When asked how the catheter collection bag should be positioned when a resident is in a wheelchair RN #1 stated that the collection bag is hooked up underneath wheelchair and off the floor. When asked why it was important to keep the collection bag off the floor RN #1 stated that is was to prevent the spread of infection and discomfort for the resident.
On 07/27/2022 at approximately 4:35 p.m., ASM #1, administrator and ASM #2, were made aware of the findings.
No further information was provided prior to exit.
References:
(1) A problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition. This information was obtained from the website: https://medlineplus.gov/ency/article/000754.htm.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, facility document review and clinical record review, it was determined the facilit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to provide monitoring for fluid restriction for one of 29 residents, Resident #29.
The findings include:
The facility failed to provide monitoring for fluid restriction for Resident #29.
Resident #29 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: end stage renal disease and heart failure.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 6/8/22, coded the resident as scoring a 07 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was severely cognitively impaired. A review of the Section G-functional status coded the resident as requiring extensive assistance for transfer, dressing and hygiene; totally dependent for bed mobility, locomotion and bathing; supervision for eating. Section O-special procedures/treatments coded the resident as dialysis yes.
A review of the comprehensive care plan dated 2/26/22, which revealed, FOCUS: End Stage Renal Disease: The resident is at risk for complications due to hemodialysis. INTERVENTIONS: Dialysis (Tuesday, Thursday, Saturday). Diet as ordered; 1000ml daily Fluid Restriction.
A review of the physician's order dated 7/15/22, revealed, Fluid restriction 1200 milliliters daily.
On 7/27/22 at 12:00 PM, a request was made for evidence of 1200 milliliters daily fluid restriction monitoring for July 2022.
A review of the nursing progress note dated 7/27/22 at 7:00 PM, revealed, Physician called to clarify fluid restriction order for the resident.
On 7/28/22 at 9:00 AM, ASM (administrative staff member) #2 stated, we do not have any evidence of monitoring the fluid restriction at 1200 milliliters. Normally the order is more specific with dietary and nursing having specific set amounts.
On 7/28/22 at 9:30 AM, an interview was conducted with LPN (licensed practical nurse) #1. When asked the purpose of fluid restriction, LPN #1 stated, the fluid restriction is for residents who are at risk for fluid overload such as those with heart failure or renal failure. When asked how fluid restriction is monitored, LPN #1 stated, the restriction is split between dietary and nursing, the order usually specifies that division.
On 7/28/22 at approximately 4:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, assistant director of nursing, were made aware of the findings.
A review of the facility's Intake and/or Output Monitoring revised 11/12, reveals, Residents may be placed on intake and/or output as the resident's condition warrants, at the discretion of the licensed nurse or as ordered by the physician. Consideration for monitoring the intake and/or output may include but is not limited to: fluid restrictions. Restricted Fluids: tray cards may contain fluid restrictions. MARs (medication administration record) may contain the fluid allowed with medication administration. Resident Care Guides may contain fluid restrictions.
No further information was provided prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on staff interview, facility document review and clinical record review, the facility staff failed to act upon pharmacy recommendations for one of 29 residents in the survey sample, Resident #25...
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Based on staff interview, facility document review and clinical record review, the facility staff failed to act upon pharmacy recommendations for one of 29 residents in the survey sample, Resident #25.
The facility staff failed to follow up on pharmacy recommendations dated 3/30/22 and 4/29/22 for the reduction of Resident #25's (R25) antipsychotic medication, Seroquel (1).
The findings include:
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/1/22, the resident's cognitive skills for daily decision making was coded as severely impaired.
A review of R25's clinical record revealed a physician's order dated 3/3/22 for Seroquel 25 mg (milligrams) twice a day. Further review of R25's clinical record revealed pharmacist consultant progress notes dated 3/30/22 and 4/29/22 that documented, Medication regimen review completed. Recommendation to PCP (primary care physician). A pharmacist consultant progress note dated 5/9/22 documented, MD (Medical Doctor) reviewed Pharmacy recommendation. Resident is being cared for by Hospice, PCP will refer recommendations to Hospice MD to evaluate. Recommendations faxed to (name) Hospice.
A pharmacy recommendation with a medication regimen review date of 3/30/22 documented, Please add the indication for use to the directions for Seroquel. Please consider tapering off. Change to Seroquel 25 mg (milligrams) qhs (every hour of sleep) x 14 days, then d/c (discontinue). There was no physician/prescriber response except for the medical director's note that R25 was not under her care.
A pharmacy recommendation with a medication regimen review date of 4/29/22 documented, Please add the indication for use to the directions for Seroquel. Please consider tapering off. Change to Seroquel 25 mg (milligrams) qhs (every hour of sleep) x 14 days, then d/c (discontinue). There was no physician/prescriber response except that R25 was on hospice.
On 7/28/22 at 11:35 a.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 stated the pharmacist completes monthly reviews then sends recommendations to her. ASM #2 stated she gives the recommendations to the physician who evaluates what she is going to do. ASM #2 stated the physician writes her orders then gives the recommendations with a follow up response back to ASM #2. ASM #2 stated she gives the recommendations with response to the medical records employee who scans the recommendations into the computer. ASM #2 stated R25's recommendations were provided to the medical director but R25 is not under her care so the recommendations were faxed to hospice. ASM #2 stated she could not provide evidence that the hospice physician responded to the recommendations.
On 7/28/22 at 12:04 p.m., ASM #1 (the administrator) and ASM #2 were made aware of the above concern.
The facility policy titled CONSULTANT PHARMACIST'S RESPONSIBILITIES documented, A report shall be prepared monthly and sent to the Administrator reporting the Medication Regimen Review and any significant irregularities. The Director of Nursing will review this report monthly and document action taken on the recommendations of the Consultant Pharmacist.
No further information was presented prior to exit.
Reference:
(1) Quetiapine (Seroquel) tablets and extended-release (long-acting) tablets are used to treat the symptoms of schizophrenia (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). Quetiapine tablets and extended-release tablets are also used alone or with other medications to treat episodes of mania (frenzied, abnormally excited or irritated mood) or depression in patients with bipolar disorder (manic depressive disorder; a disease that causes episodes of depression, episodes of mania, and other abnormal moods). In addition, quetiapine tablets and extended-release tablets are used with other medications to prevent episodes of mania or depression in patients with bipolar disorder .Important warning for older adults with dementia: Studies have shown that older adults with dementia (a brain disorder that affects the ability to remember, think clearly, communicate, and perform daily activities and that may cause changes in mood and personality) who take antipsychotics (medications for mental illness) such as quetiapine have an increased risk of death during treatment. Quetiapine is not approved by the Food and Drug Administration (FDA) for the treatment of behavioral problems in older adults with dementia. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a698019.html
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to ensure ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to ensure a resident was free of unnecessary medication for one of 29 residents in the survey sample, Resident #25.
The facility staff failed to ensure there was an adequate clinical indication for Resident #25's (R25) continued use of the medication Seroquel (1) and failed to attempt a gradual dose reduction or document a clinical rational for the contraindication of a gradual dose reduction.
The findings include:
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/1/22, the resident's cognitive skills for daily decision making was coded as severely impaired.
A hospital Discharge summary dated [DATE] documented, While Seroquel was started for her and Scopolamine (2), these could be weaned off and see how she does apart from these. Defer to hospice and facility providers. Scopolamine helped with patient handling her secretions and Seroquel was utilized because of anxiety and possibly paranoia.
A review of R25's clinical record revealed a physician's order dated 3/3/22 for Seroquel 25 mg (milligrams) twice a day (no diagnosis for the medication was documented). Further review of R25's clinical record revealed pharmacist consultant progress notes dated 3/30/22 and 4/29/22 that documented, Medication regimen review completed. Recommendation to PCP (primary care physician). A pharmacist consultant progress note dated 5/9/22 documented, MD (Medical Doctor) reviewed Pharmacy recommendation. Resident is being cared for by Hospice, PCP will refer recommendations to Hospice MD to evaluate. Recommendations faxed to (name) Hospice.
A pharmacy recommendation with a medication regimen review date of 3/30/22 documented, Please add the indication for use to the directions for Seroquel. Please consider tapering off. Change to Seroquel 25 mg (milligrams) qhs (every hour of sleep) x 14 days, then d/c (discontinue). There was no physician/prescriber response except for the medical director's note that R25 was not under her care.
A pharmacy recommendation with a medication regimen review date of 4/29/22 documented, Please add the indication for use to the directions for Seroquel. Please consider tapering off. Change to Seroquel 25 mg (milligrams) qhs (every hour of sleep) x 14 days, then d/c (discontinue). There was no physician/prescriber response except that R25 was on hospice.
Another physician's order dated 7/14/22 documented an order for Seroquel 25 mg twice a day for vascular dementia without behavior disturbance.
A review of R25's MARs (medication administration records) revealed R25 received Seroquel 25 mg twice a day March 2022 through July 2022.
On 7/26/22 at 12:41 p.m., 7/26/22 at 3:58 p.m. and 7/27/22 at 8:11 a.m., R25 was observed quietly lying in bed.
R25's hospice physician was not available for interview during the survey.
On 7/28/22 at 11:35 a.m., an interview was conducted with ASM (administrative staff member) #2. ASM #2 stated R25's pharmacy recommendations were provided to the medical director but R25 is not under her care so the recommendations were faxed to hospice. ASM #2 stated she could not provide evidence that the hospice physician responded to the recommendations.
On 7/28/22 at 10:43 a.m., an interview was conducted with ASM #6 (the medical director). ASM #6 stated the indications for Seroquel use include: hallucinations, depression, and aggressive behaviors with worsening dementia. ASM #6 stated paranoia is an adequate indication for use and Seroquel can be used for anxiety but there are medications with less toxic effects that can be used for the elderly. ASM #6 stated she doesn't typically like to use Seroquel but a lot of residents are admitted on the medication so she tries to taper off the medication per the pharmacy recommendations. In regards to R25's Seroquel use, ASM #6 stated hospice manages R25's care but she has interacted with the resident. ASM #6 stated R25 does not present with any behaviors except for calling out when CNAs (certified nursing assistants) give care. ASM #6 stated R25 used to not do this.
On 7/28/22 at 11:08 a.m., another interview was conducted with ASM #2. ASM #2 stated R25 presents with agitation as evidenced by scooting and moving in bed. ASM #2 stated R25 does not present with hallucinations, delusions, paranoia, verbal behaviors or physical behaviors.
On 7/28/22 at 12:04 p.m., ASM #1 (the administrator) and ASM #2 were made aware of the above concern.
The facility policy titled, ANTIPSYCHOTIC DRUG MONITORING POLICY documented, It will be the policy of the facility to discourage the use of antipsychotic drugs in residents for whom such therapy is NOT supported by: 1. An acceptable clinical diagnosis or indication for use.
No further information was presented prior to exit.
Reference:
(1) Quetiapine (Seroquel) tablets and extended-release (long-acting) tablets are used to treat the symptoms of schizophrenia (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). Quetiapine tablets and extended-release tablets are also used alone or with other medications to treat episodes of mania (frenzied, abnormally excited or irritated mood) or depression in patients with bipolar disorder (manic depressive disorder; a disease that causes episodes of depression, episodes of mania, and other abnormal moods). In addition, quetiapine tablets and extended-release tablets are used with other medications to prevent episodes of mania or depression in patients with bipolar disorder .Important warning for older adults with dementia: Studies have shown that older adults with dementia (a brain disorder that affects the ability to remember, think clearly, communicate, and perform daily activities and that may cause changes in mood and personality) who take antipsychotics (medications for mental illness) such as quetiapine have an increased risk of death during treatment. Quetiapine is not approved by the Food and Drug Administration (FDA) for the treatment of behavioral problems in older adults with dementia. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a698019.html
(2) Scopolamine is used to prevent nausea and vomiting. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682509.html
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0839
(Tag F0839)
Could have caused harm · This affected 1 resident
Based on staff interview, facility document review and employee record review, it was determined that the facility staff failed to evidence maintenance of required certification for one of one CNA (ce...
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Based on staff interview, facility document review and employee record review, it was determined that the facility staff failed to evidence maintenance of required certification for one of one CNA (certified nursing assistant) record reviews.
The facility staff failed to provide the evidence of required certification for one CNA that was employed for greater than one year, CNA #1.
The findings include:
On 7/27/22 at approximately 12:00 PM, ASM (administrative staff member #1, the administrator and OSM (other staff member) #4 the personnel/payroll manager stated that the facility has only 1 (one) CNA that has been employed greater than one year, CNA #1.
A request was made for CNA #1's performance evaluation/annual review, CNA license and mandatory required education (abuse, neglect and dementia training).
On 7/27/22 at approximately 3:00 PM, ASM #2, the director of nursing provided CNA #1's certification. In a review of the certification for CNA #1, there was evidence of license lookup from the Virginia Department of Health Professionals dated 11/17/21 with the CNA certification expiration date as 2/28/22. Evidence was shown that license lookup dated 7/27/22 at 2:15 PM, with the expiration date of 2/28/23. Also provided was an online licensing payment receipt for CNA #1 for renew license process dated 5/24/22 at 2:34 PM.
An interview was conducted on 7/27/22 at approximately 3:00 PM with ASM #2. When asked what CNA #1 had worked between 2/28/22 and 5/24/22, ASM #2 stated, she is as needed staff, she did not work much.
On 7/27/22 at 4:45 PM, a request was made to provide the time cards/payroll for CNA #1 from 2/28/22 through 5/24/22.
On 7/28/22 at approximately 11:00 AM, ASM #1, the administrator and OSM (other staff member) #4, the personnel/payroll manager provided the payroll information for CNA #1. A sticky note was attached to the sheets revealing 293.75 hours. OSM #4 stated those are the hours worked for that time period.
On 7/28/22 at 11:50 AM, ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, a consultant, ASM #5, a consultant, and RN (registered nurse) #2, the infection prevention nurse were made aware of the findings.
The facility's policy Validation of Nursing License dated 1/16, revealed, Validation of Unlicensed Nursing Personnel Qualifications: All Nursing Assistants will provide the information specified below for verification of current listing, at the time of hire and upon renewal, as applicable.
No further information was provided prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and employee record review, it was determined that the facility staff failed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and employee record review, it was determined that the facility staff failed to provide annual required training for one of one CNAs (certified nursing assistants).
The facility staff failed to provide the required mandatory training for abuse, neglect, and dementia training for CNA #1.
The findings include:
On 7/27/22 at approximately 12:00 PM, ASM (administrative staff member #1, the administrator and OSM (other staff member) #4 the personnel/payroll manager stated that the facility has only one CNA that has been employed greater than one year, CNA #1.
A request was made for CNA #1's performance evaluation/annual review, CNA license and mandatory required education (abuse, neglect and dementia training).
On 7/27/22 at approximately 3:00 PM, ASM #2, the director of nursing provided CNA #1's performance review dated 2/24/22, education record and CNA certificate. In a review of the records for CNA #1, there were 1.50 hours of education from 11/22/21 through 4/20/22. There was no evidence of abuse, neglect and dementia training.
ASM #2 stated on 7/27/22 at approximately 3:00 PM, she (CNA #1) is behind on her education. She does not have those courses.
On 7/28/22 at 11:50 AM, ASM #1, the administrator, ASM #2, the director of nursing, ASM #3, the assistant director of nursing, ASM #4, a consultant, ASM #5, a consultant and RN (registered nurse) #2, the infection prevention nurse were made aware of the findings.
The facility assessment dated [DATE], revealed, Staff training/education and competencies: all staff-required in-service training. Evidence of application based on annual training requirement. Requirements (in part) include training on abuse/neglect/resident abuse prevention, dementia management, and combative residents.
The facility's Principle Mandatory Education-CNA 12 hours minimum, new orientation and annually reveals, Principle Dementia, A Day in the Life of [NAME]: A Dementia Experience and Resident Rights' are among courses listed.
No further information was provided prior to exit.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to provide safety equipment specifically a fire extinguisher in the designated smoking area for Res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to provide safety equipment specifically a fire extinguisher in the designated smoking area for Resident #36.
A list of smoking times revealed smoking times of 10:30 AM, 1:30 PM and 3:30 PM. Designated smoking area front patio/carport and gazebo off of C Hall Dining room.
Resident #36 was observed smoking on 7/26/22 at 1:30 PM in the front patio/carport area. Staff provided cigarettes and lighter to residents from the bag they brought with them. Three staff were present with residents as they smoked. Resident #36 did not exhibit any unsafe smoking behavior. Resident #36 wore a smoking apron. There was cigarette butt disposal containers available. There was no fire extinguisher available in the area.
Resident #36 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: congestive heart failure, diabetes and chronic kidney disease.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 6/20/22, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as being independent for bed, transfer, locomotion, dressing, eating, hygiene and bathing. The MDS annual assessment with ARD of 1/13/22, Section J: coded current tobacco use yes.
A review of the comprehensive care plan dated 8/23/20, revealed, FOCUS: Resident is a smoker or user of tobacco products. Resident will continue to smoke safely in designated areas thru next review. INTERVENTIONS: Evaluate resident's continued ability to smoke safely on a consistent and regular basis. Assist resident in obtaining smoking materials from secured storage area upon request.
A review of the smoking evaluation dated 4/25/22 at 11:24 AM, revealed the following, Resident is an unsafe smoker and requires direct supervision while smoking.
An interview was conducted on 7/26/22 at 12:00 PM with Resident #36. When asked how long he has smoked, while he has been a resident, Resident #36 stated, since I came here.
On 7/26/22 at 1:45 PM, an interview was conducted with OSM (other staff member) #3, the activities aide. When asked what safe guards were in place for residents to smoke, OSM #3 stated, they have to wear aprons, we keep their cigarettes and lights. We have a fire extinguisher in the gazebo location, but there are too many residents that smoke to use that location. This location is also covered and the residents have space between them.
On 7/27/22 at approximately 4:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, assistant director of nursing, were made aware of the findings.
According to the facility's policy Smoking Policy revision date 3/19, reveals, This facility allows smoking only in designated outdoor areas. Designated Outside Smoking Areas: This facility provides appropriate designated outside smoking areas for all individuals who desire to smoke. All areas where smoking is permitted have ashtrays of non-combustible material and safe design. Metal containers with self-closing cover devices into which ashtrays can be emptied are readily available in all areas where smoking is permitted. Additionally, smoking aprons, smoking blankets, and fire extinguishers are provided as safety measures.
No further information was provided prior to exit.
3. The facility staff failed to provide safety equipment, specifically a fire extinguisher, in the designated smoking area for Resident #38.
A list of smoking times revealed smoking times of 10:30 AM, 1:30 PM and 3:30 PM. Designated smoking area front patio/carport and gazebo off of C Hall Dining room.
Resident #38 was observed smoking on 7/26/22 at 1:30 PM in the front patio/carport area. Staff provided cigarettes and lighter to residents from the bag they brought with them. Three staff were present with residents as they smoked. Resident #38 did not exhibit any unsafe smoking behavior. Resident #38 wore a smoking apron. There was cigarette butt disposal containers available. There was no fire extinguisher available in the area.
Resident #38 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: congestive heart failure, chronic obstructive disease, atherosclerotic cardiovascular disease and tobacco use.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 6/24/22, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as being independent for bed, transfer, locomotion, walking, dressing, eating, hygiene and bathing. The MDS annual assessment with ARD of 12/15/21, Section J: coded current tobacco use yes.
A review of the comprehensive care plan dated 11/19/21, revealed, FOCUS: Resident is a smoker or user of tobacco products. Resident will continue to smoke safely in designated areas thru next review. INTERVENTIONS: Evaluate resident's continued ability to smoke safely on a consistent and regular basis. Supervised Smoker-unsafe. Assist resident in obtaining smoking materials from secured storage area upon request.
A review of the smoking evaluation dated 5/15/22 at 11:36 AM, revealed the following, Resident is an unsafe smoker and requires direct supervision while smoking.
An interview was conducted on 7/26/22 at 12:15 PM with Resident #38. When asked how long he has smoked, while he has been a resident, Resident #38 stated, for a while. When asked where he smokes, Resident #38 stated, we smoke out under the carport at the front of the building.
On 7/26/22 at 1:45 PM, an interview was conducted with OSM (other staff member) #3, the activities aide. When asked what safe guards were in place for residents to smoke, OSM #3 stated, they have to wear aprons, we keep their cigarettes and lights. We have a fire extinguisher in the gazebo location, but there are too many residents that smoke to use that location. This location is also covered and the residents have space between them.
On 7/27/22 at approximately 4:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, assistant director of nursing, were made aware of the findings.
According to the facility's policy Smoking Policy revision date 3/19, reveals, This facility allows smoking only in designated outdoor areas. Designated Outside Smoking Areas: This facility provides appropriate designated outside smoking areas for all individuals who desire to smoke. All areas where smoking is permitted have ashtrays of non-combustible material and safe design. Metal containers with self-closing cover devices into which ashtrays can be emptied are readily available in all areas where smoking is permitted. Additionally, smoking aprons, smoking blankets, and fire extinguishers are provided as safety measures.
No further information was provided prior to exit.
4. The facility staff failed to provide safety equipment specifically a fire extinguisher in the designated smoking area for Resident #5.
A list of smoking times revealed smoking times of 10:30 AM, 1:30 PM and 3:30 PM. Designated smoking area front patio/carport and gazebo off of C Hall Dining room.
Resident #5 was observed smoking on 7/26/22 at 1:30 PM in the front patio/carport area. Staff provided cigarettes and lighter to residents from the bag they brought with them. Three staff were present with residents as they smoked. Resident #5 did not exhibit any unsafe smoking behavior. Resident #5 wore a smoking apron. There was cigarette butt disposal containers available. There was no fire extinguisher available in the area.
Resident #5 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: hemiplegia, hemiparesis, neuropathy and hypertension.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 7/7/22, coded the resident as scoring a 14 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bed, transfer, locomotion, walking, dressing, hygiene and bathing; supervision for eating. The MDS annual assessment with ARD of 12/13/21, Section J: coded current tobacco use yes.
A review of the comprehensive care plan dated 7/1/20, revealed, FOCUS: Resident is a smoker at the facility and requires assistance to smoke safely. INTERVENTIONS: Evaluate resident's continued ability to smoke safely on a consistent and regular basis. Assist resident in obtaining smoking materials from secured storage area upon request.
A review of the smoking evaluation dated 5/15/22 at 11:33 AM, revealed the following, Resident is an unsafe smoker and requires direct supervision while smoking.
An interview was conducted on 7/26/22 at 2:15 PM with Resident #5. When asked how long she has smoked, while she has been a resident, Resident #5 stated, since I have been here. When asked how frequent she smokes, Resident #5 stated, two or three times a day.
On 7/26/22 at 1:45 PM, an interview was conducted with OSM (other staff member) #3, the activities aide. When asked what safe guards were in place for residents to smoke, OSM #3 stated, they have to wear aprons, we keep their cigarettes and lights. We have a fire extinguisher in the gazebo location, but there are too many residents that smoke to use that location. This location is also covered and the residents have space between them.
On 7/27/22 at approximately 4:30 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, assistant director of nursing, were made aware of the findings.
According to the facility's policy Smoking Policy revision date 3/19, reveals, This facility allows smoking only in designated outdoor areas. Designated Outside Smoking Areas: This facility provides appropriate designated outside smoking areas for all individuals who desire to smoke. All areas where smoking is permitted have ashtrays of non-combustible material and safe design. Metal containers with self-closing cover devices into which ashtrays can be emptied are readily available in all areas where smoking is permitted. Additionally, smoking aprons, smoking blankets, and fire extinguishers are provided as safety measures.
No further information was provided prior to exit.
Based on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to provide adequate wanderguard monitoring for one of 29 residents, Residents #22; and failed to ensure safety protocols were in place per facility policy for 3 of 3 residents smoking, Residents #36, #38, and #5.
The findings include:
1. The facility staff failed to check the placement of (R22's) wanderguard according to the physician's orders
(R22) was admitted to the facility with diagnoses that included but were not limited to: dementia (1).
(R22's) most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 06/2/2022, coded (R22) as scoring a 13 on the brief interview for mental status (BIMS) of a score of 0 - 15, 13 - being cognitively intact for making daily decisions. Section P Restraints and Alarms coded (R22) for a wander guard Used daily.
The physician's order for (R22) documented in part, WANDERGUARD- Check Location and expiration every shift. Date Order: 07/11/2022.
The comprehensive care plan for (R22) dated 12/04/2019 documented. FOCUS: RESIDENT CARE GUIDE Date Initiated: 12/04/2019. Under Interventions it documented in part, WANDERS - wander guard in place Date Initiated: 02/10/2022.
The facility's Wandering Risk Assessment dated 05/10/2022 for (R22) documented in part, Score: 5.0. I. NOTE: A resident who scores greater than 5 (five) is at risk for wandering.
The facility's Transmitter Testing Log dated June 22 (2022) documented, Expiration Date: Oct (October) 23(2023). Under the heading it documented, Day of Month; Transmitter Test OK; Transmitter Tested By and Comments. Review of the Transmitter Testing Log failed to document the facility's nursing shifts. Further review revealed missing check marks for transmitter tests on 06/04/2022, 06/11/2022, 06/12/2022, 06/18/2022, 06/19/2022, 06/25/2022 and on 06/26/2022.
The facility's Transmitter Testing Log dated July 22 (2022) documented, Expiration Date: Oct (October) 23(2023). Under the heading it documented, Day of Month; Transmitter Test OK; Transmitter Tested By and Comments. Review of the Transmitter Testing Log failed to document the facility's nursing shifts. Further review revealed missing check marks for transmitter tests on 07/02/2022, 07/03/2022, 07/10/2022, 06/18/2022, 07/15/2022, 07/16/2022, 07/17/202, 07/23/2022 and on 07/24/2022.
On 07/28/22 at approximately 8:04 a.m., an interview was conducted with ASM (administrative staff member) # 2, director of nursing. When asked to explain Expiration, location and every shift written on the physician's order for the wander guard as stated above ASM # 2 stated that expiration referred to the expiration date of wander guard, location referred to the resident wearing the wander guard and every shift referred to all three nursing shifts, 7:00 a.m. - 3:00 p.m., 3:00 p.m. - 11:00 p.m. and 11:00 p.m. to 7:00 a.m. When asked to interpret the blanks on the testing log as stated above ASM # 2 stated that they indicated it wasn't done. After reviewing the facility's Transmitter Testing Logs ASM # 2 stated that the location of (R22's) wander guard was being checked and not being done every shift. They further stated that the facility's form would need to be revised to reflect the physician's orders. After reviewing the comprehensive car plan for (R22's) wander guard as stated above ASM # 2 stated that the care plan should match the physician order for the wander guard.
On 07/28/2022 at approximately 11:00 a.m., ASM # 1, administrator and ASM # 2, were made aware of the findings.
No further information was provided prior to exit.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected multiple residents
Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to implement bed rail requirements for 4 of 29 residents in the survey sample, Residents...
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Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to implement bed rail requirements for 4 of 29 residents in the survey sample, Residents #21, #149, #13 and #22.
The findings include:
1. The facility staff failed to attempt alternatives prior to the use of Resident #21's (R21) bed rails, failed to assess R21 for the risk of entrapment from bed rails, failed to educate R21 or the resident's representative (RR) on the risks and benefits of bed rails and failed to obtain informed consent for the use of bed rails.
On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 5/24/22, the resident scored 5 out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely cognitively impaired for making daily decisions.
On 7/26/22 at 3:58 p.m., R21 was observed lying in bed with bilateral quarter bed rails in the upright position.
A review of R21's clinical record revealed a physical device evaluation dated 5/17/22 that failed to document the resident was offered appropriate alternatives prior to the use of bed rails, failed to document the resident was assessed for the risk of entrapment from bed rails, failed to document the risks and benefits of bed rails were reviewed with R21 or the RR, and failed to document informed consent was obtained. The evaluation documented n/a (not applicable) for all areas.
R21's comprehensive care plan dated 5/18/22 documented, Use of bed rails for increasing or maintaining current bed mobility or transfer ability. Muscle weakness, Paralysis.
On 7/27/22 at 12:45 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated a physical device evaluation should be completed for all residents who use quarter bed rails. RN #1 stated she did not know the purpose of the evaluation but she completed the evaluation for all residents upon admission and she wasn't sure but thought someone completes the evaluation for all residents each quarter. RN #1 stated she does educate residents or RPs on the risks and benefits of bed rails and documents this on the evaluation.
On 7/27/22 at 4:35 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.
On 7/28/22 at 7:44 a.m., an interview was conducted with ASM #2. ASM #2 stated a physical device evaluation should be done on admission and quarterly, and if criteria for use is met then quarter bed rails can be used. ASM stated some of the nurses may not realize quarter bed rails are classified as a physical device. ASM #2 stated residents should be assessed for other alternatives and this is sometimes done by the rehab staff (note- a review of R21's rehab documentation failed to reveal the rehab staff had assessed other alternatives). ASM #2 further stated residents should be assessed for the risk of entrapment, residents or their RPs should be provided education and informed consent should be obtained. ASM #2 stated this should be documented on the physical device evaluation.
The facility policy titled, SIDE RAIL GUIDELINES documented, Side rails may be used to enhance resident mobility and transfer to and from the bed .Resident injury or death is more likely to occur when attempts are made to get out of bed with the side rails raised. Injury may occur when a resident attempts to move through, between, or over side rails .
No further information was presented prior to exit.
2. The facility staff failed to attempt alternatives prior to the use of Resident #149's (R149) bed rails, failed to assess R149 for the risk of entrapment from bed rails, failed to educate R149 or the resident's representative (RR) on the risks and benefits of bed rails and failed to obtain informed consent for the use of bed rails.
R149's admission minimum data set assessment was not complete. A nursing admission evaluation documented R149 communicates needs and can be understood.
On 7/26/22 at 12:39 p.m., R149 was observed in bed with bilateral quarter bed rails in the upright position.
On 7/27/22 at 10:54 a.m., an interview was conducted with R149. R149 stated no staff had talked to the resident regarding bed rails or explained the risks and benefits of bed rails.
A review of R149's clinical record revealed a physical device evaluation dated 7/20/22 that failed to document the resident was offered appropriate alternatives prior to the use of bed rails, failed to document the resident was assessed for the risk of entrapment from bed rails, failed to document the risks and benefits of bed rails were reviewed with R21 or the RR, and failed to document informed consent was obtained. The evaluation was blank.
R149's baseline care plan dated 7/26/22 documented, Use of bed rails for increasing or maintaining current bed mobility or transfer ability. Muscle weakness.
On 7/27/22 at 12:45 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated a physical device evaluation should be completed for all residents who use quarter bed rails. RN #1 stated she did not know the purpose of the evaluation but she completed the evaluation for all residents upon admission and she wasn't sure but thought someone completes the evaluation for all residents each quarter. RN #1 stated she does educate residents or RPs on the risks and benefits of bed rails and documents this on the evaluation.
On 7/27/22 at 4:35 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.
On 7/28/22 at 7:44 a.m., an interview was conducted with ASM #2. ASM #2 stated a physical device evaluation should be done on admission and quarterly, and if criteria for use is met then quarter bed rails can be used. ASM stated some of the nurses may not realize quarter bed rails are classified as a physical device. ASM #2 stated residents should be assessed for other alternatives and this is sometimes done by the rehab staff (note- a review of R149's rehab documentation failed to reveal the rehab staff had assessed other alternatives). ASM #2 further stated residents should be assessed for the risk of entrapment, residents or their RPs should be provided education and informed consent should be obtained. ASM #2 stated this should be documented on the physical device evaluation.
No further information was presented prior to exit.
3. The facility staff failed to attempt alternatives prior to the use of Resident #13's (R13) bed rails, failed to assess R13 for the risk of entrapment from bed rails, failed to educate R13 or the resident's representative (RR) on the risks and benefits of bed rails and failed to obtain informed consent for the use of bed rails.
On the most recent MDS (minimum data set), a five day Medicare assessment with an ARD (assessment reference date) of 5/9/22, the resident scored 10 out of 15 on the BIMS (brief interview for mental status), indicating the resident was moderately cognitively impaired for making daily decisions.
On 7/26/22 at 12:31 p.m., R13 was observed in bed with bilateral quarter bed rails in the upright position.
A review of R13's clinical record revealed a physical device evaluation dated 5/2/22 that failed to document the resident was offered appropriate alternatives prior to the use of bed rails, failed to document the resident was assessed for the risk of entrapment from bed rails, failed to document the risks and benefits of bed rails were reviewed with R13 or the RR (resident representative), and failed to document informed consent was obtained. The evaluation documented none and n/a (not applicable) for these areas.
R13's comprehensive care plan dated 5/3/22 documented, Use of bed rails for increasing or maintaining current bed mobility or transfer ability. Muscle weakness, Safety in transfers.
On 7/27/22 at 12:45 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated a physical device evaluation should be completed for all residents who use quarter bed rails. RN #1 stated she did not know the purpose of the evaluation but she completed the evaluation for all residents upon admission and she wasn't sure but thought someone completes the evaluation for all residents each quarter. RN #1 stated she does educate residents or RPs on the risks and benefits of bed rails and documents this on the evaluation.
On 7/27/22 at 4:35 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.
On 7/28/22 at 7:44 a.m., an interview was conducted with ASM #2. ASM #2 stated a physical device evaluation should be done on admission and quarterly, and if criteria for use is met then quarter bed rails can be used. ASM stated some of the nurses may not realize quarter bed rails are classified as a physical device. ASM #2 stated residents should be assessed for other alternatives and this is sometimes done by the rehab staff (note- a review of R13's rehab documentation failed to reveal the rehab staff had assessed other alternatives). ASM #2 further stated residents should be assessed for the risk of entrapment, residents or their RPs should be provided education and informed consent should be obtained. ASM #2 stated this should be documented on the physical device evaluation.
No further information was presented prior to exit.
4. The facility staff failed to attempt alternatives prior to the use of Resident #22's (R22) bed rails and failed to assess R22 for the risk of entrapment from bed rails.
On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/2/22, the resident scored 14 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions.
On 7/26/22 at 2:02 p.m., R22 was observed lying in bed with bilateral quarter bed rails in the upright position.
On 7/27/22 at 8:00 a.m., an interview was conducted with R22. R22 stated the resident doesn't use the bed rails unless the resident is about to fall. R22 stated the staff had explained the risks and benefits of bed rails to the resident.
A review of R22's clinical record revealed a physical device evaluation dated 5/2/22 that failed to document the resident was offered appropriate alternatives prior to the use of bed rails, failed to document the resident was assessed for the risk of entrapment from bed rails, failed to document the risks and benefits of bed rails were reviewed with R13 or the RR (resident representative), and failed to document informed consent was obtained. The evaluation documented none and n/a (not applicable) for these areas.
R22's comprehensive care plan dated 12/4/19 documented, Use of bed rails for increasing or maintaining current bed mobility or transfer ability. Muscle weakness, Safety in transfers.
On 7/27/22 at 12:45 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated a physical device evaluation should be completed for all residents who use quarter bed rails. RN #1 stated she did not know the purpose of the evaluation but she completed the evaluation for all residents upon admission and she wasn't sure but thought someone completes the evaluation for all residents each quarter. RN #1 stated she does educate residents or RPs on the risks and benefits of bed rails and documents this on the evaluation.
On 7/27/22 at 4:35 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern.
On 7/28/22 at 7:44 a.m., an interview was conducted with ASM #2. ASM #2 stated a physical device evaluation should be done on admission and quarterly, and if criteria for use is met then quarter bed rails can be used. ASM stated some of the nurses may not realize quarter bed rails are classified as a physical device. ASM #2 stated residents should be assessed for other alternatives and this is sometimes done by the rehab staff (note- a review of R22's rehab documentation failed to reveal the rehab staff had assessed other alternatives). ASM #2 further stated residents should be assessed for the risk of entrapment.
No further information was presented prior to exit.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0909
(Tag F0909)
Could have caused harm · This affected multiple residents
Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to evidence documentation of current bed/side rail inspect...
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Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to evidence documentation of current bed/side rail inspection for 4 of 29 residents in the survey sample, Residents #43 (R43), #22 (R22), #35 (R35), and #13 (R13).
The findings include:
1. (R43) was observed lying in bed with the right and left upper bed rails raised on 07/26/22 at 2:28 p.m. and on 07/27/22 at 8:45 a.m.
(R43) was admitted to the facility with diagnosis that included but was not limited to: a history of falls.
(R43's) most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 06/27/2022, coded (R43) as scoring a 14 out of 15 on the brief interview for mental status (BIMS) which indicated the resident was cognitively intact for making daily decisions.
On 7/27/22 at 12:23 p.m., an interview was conducted with OSM (other staff member) #5, maintenance director. OSM #5 presented a work history report that documented monthly bed inspections; the last inspection was done on 7/4/22. OSM #5 stated he conducts a monthly inspection of all beds that consists of making sure the electrical portion of the head and foot works, checking to see if the mattress needs to be replaced, inspecting the frames and making sure the rails move up. OSM #5 stated he does not inspect the beds for any possible areas of entrapment. OSM #5 stated an outside company inspects the beds and completes a report every six months but he did not know if the company inspects the beds for possible areas of entrapment. A copy of the most recent report was requested.
On 7/27/22 at 1:20 p.m., ASM (administrative staff member) #2, director of nursing, provided a copy of the bed inspection report from the outside company. The report was dated 2/26/19 and did not contain documentation that the company inspected any beds for possible areas of entrapment.
On 07/28/2022 at approximately 11:00 a.m., ASM # 1, administrator and ASM # 2, were made aware of the findings.
No further information was provided prior to exit.
2. (R22) was observed lying in bed with the right and left upper bed rails raised on 07/26/22 at 2:02 p.m. and on 07/27/22 at 8:50 a.m.
(R22) was admitted to the facility with diagnosis that included but was not limited to: a history of falls.
(R22's) most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 06/02/2022, coded (R22) as scoring a 13 out of 15 on the brief interview for mental status (BIMS) which indicated the resident was cognitively intact for making daily decisions.
On 7/27/22 at 12:23 p.m., an interview was conducted with OSM (other staff member) #5, maintenance director. OSM #5 presented a work history report that documented monthly bed inspections; the last inspection was done on 7/4/22. OSM #5 stated he conducts a monthly inspection of all beds that consists of making sure the electrical portion of the head and foot works, checking to see if the mattress needs to be replaced, inspecting the frames and making sure the rails move up. OSM #5 stated he does not inspect the beds for any possible areas of entrapment. OSM #5 stated an outside company inspects the beds and completes a report every six months but he did not know if the company inspects the beds for possible areas of entrapment. A copy of the most recent report was requested.
On 7/27/22 at 1:20 p.m., ASM (administrative staff member) #2, director of nursing, provided a copy of the bed inspection report from the outside company. The report was dated 2/26/19 and did not contain documentation that the company inspected any beds for possible areas of entrapment.
On 07/28/2022 at approximately 11:00 a.m., ASM # 1, administrator and ASM # 2, were made aware of the findings.
No further information was provided prior to exit.
3. (R35) was observed lying in bed with the right and left upper bed rails raised on 07/27/22 at 8:08 p.m. and at 11:05 a.m.
(R35) was admitted to the facility with diagnosis that included but was not limited to: dementia.
(R35's) most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 06/18/2022, coded (R35) as scoring a 4 out of 15 on the brief interview for mental status (BIMS) which indicated the resident was severely impaired of cognition for making daily decisions.
On 7/27/22 at 12:23 p.m., an interview was conducted with OSM (other staff member) #5, maintenance director. OSM #5 presented a work history report that documented monthly bed inspections; the last inspection was done on 7/4/22. OSM #5 stated he conducts a monthly inspection of all beds that consists of making sure the electrical portion of the head and foot works, checking to see if the mattress needs to be replaced, inspecting the frames and making sure the rails move up. OSM #5 stated he does not inspect the beds for any possible areas of entrapment. OSM #5 stated an outside company inspects the beds and completes a report every six months but he did not know if the company inspects the beds for possible areas of entrapment. A copy of the most recent report was requested.
On 7/27/22 at 1:20 p.m., ASM (administrative staff member) #2, director of nursing, provided a copy of the bed inspection report from the outside company. The report was dated 2/26/19 and did not contain documentation that the company inspected any beds for possible areas of entrapment.
On 07/28/2022 at approximately 11:00 a.m., ASM # 1, administrator and ASM # 2, were made aware of the findings.
No further information was provided prior to exit.
4. 3. (R13) was observed lying in bed with the right and left upper bed rails raised on 07/26/22 at 12:31 p.m.
(R13) was admitted to the facility with diagnosis that included but was not limited to: thoracic (upper and middle back) vertebrae compression fracture.
(R13's) most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 05/09/2022, coded (R13) as scoring a 10 out of 15 on the brief interview for mental status (BIMS) which indicated the resident was moderately impaired of cognition for making daily decisions.
On 7/27/22 at 12:23 p.m., an interview was conducted with OSM (other staff member) #5, maintenance director. OSM #5 presented a work history report that documented monthly bed inspections; the last inspection was done on 7/4/22. OSM #5 stated he conducts a monthly inspection of all beds that consists of making sure the electrical portion of the head and foot works, checking to see if the mattress needs to be replaced, inspecting the frames and making sure the rails move up. OSM #5 stated he does not inspect the beds for any possible areas of entrapment. OSM #5 stated an outside company inspects the beds and completes a report every six months but he did not know if the company inspects the beds for possible areas of entrapment. A copy of the most recent report was requested.
On 7/27/22 at 1:20 p.m., ASM (administrative staff member) #2, director of nursing, provided a copy of the bed inspection report from the outside company. The report was dated 2/26/19 and did not contain documentation that the company inspected any beds for possible areas of entrapment.
On 07/28/2022 at approximately 11:00 a.m., ASM # 1, administrator and ASM # 2, were made aware of the findings.
No further information was provided prior to exit.
Mar 2021
13 deficiencies
1 Harm
SERIOUS
(G)
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 interview, staff interview, facility document review and clinical record review it was determined that the fac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility document review and clinical record review it was determined that the facility failed to protect one of 35 residents in the survey sample from resident-to-resident abuse. On 2/28/21, Resident #37 and Resident #4 argued in their room which escalated to Resident #37 pushing his wheelchair into Resident #4's table causing a laceration to Resident #4's right lower leg that required treatment in a local emergency room and closure with 9 staples, resulting in harm.
The findings include:
Resident #4 was admitted to the facility with diagnoses including but not limited to chronic obstructive pulmonary disease (1), congestive heart failure (2) and major depressive disorder (3). Resident #4's most recent MDS (minimum data set), an annual assessment with an ARD (assessment reference date) of 3/1/21 coded Resident #4 as scoring a 15 on the BIMS (brief interview for mental status), 15- being cognitively intact for making daily decisions.
On 3/9/21 at approximately 3:10 p.m., an interview was conducted with Resident #4. Resident #4 was observed to have a gauze wrap dressing dated 3/9/21 on his right lower leg. When asked about the dressing on his right lower leg, Resident #4 stated that he was assaulted by their previous roommate, Resident #37 and had to go to the emergency room to get staples in his leg to close an injury. Resident #4 stated that Resident #37 was no longer in the facility because they got rid of him after that happened. Resident #4 stated that he had argued with Resident #37 over the television and that Resident #37 pushed his empty wheelchair through the privacy curtain into him causing the over bed table to cut his right lower leg. Resident #4 stated that the nurse had to apply pressure to the area and he had to go to the emergency room to get staples to the area.
The progress notes for Resident #4 documented in part the following:
- 2/17/2021 10:26 (10:26 a.m.) Note Text: Writer met with resident and advised that he would be getting a roommate today.
- 2/28/2021 16:25 (4:25 p.m.) Note Text: resident had been arguing with his roommate over the TV, his room mate was yelling & they were calling each other names, resident states he cannot stand the way his room mate talks to him & the way he [curse] on himself. Writer explained to resident that he can not help being incontinent (without control of) however, he should not yell at his roommate & curse at him. They should try to compromise with what to watch on the TV.
- 2/28/2021 16:40 (4:40 p.m.) Note Text: called to room Resident noted to be bleeding from a 8.5 cm (centimeter) laceration on the right lateral lower leg. Resident holding tissues on wound, large puddle of blood noted on the floor & in trash can. Resident had his leg propped on the trash can, blood dripping into it. Resident stated that his roommate pushed the w/c (wheelchair) on the other side of the curtain into his overbed table, which hit his leg. Roommates w/c [wheelchair] removed from the room, pressure applied to wound for several minutes to slow bleeding, wrapped with gauze. Explained to resident that he needed to go to the ER (emergency room) due to excessive bleeding, & for a tetanus shot. Resident still arguing, cursing & threatening with the room mate intermittently, yelling that he wanted to have the cops called on that piece of [curse] because he assaulted me Administrator made aware & stated that resident needed to go to a room on C-wing upon return from ER & he would straighten it out in the morning with both residents.
- 2/28/2021 17:01 (5:01 p.m.) Note Text: Resident sustained right lower extremity trauma (8.5 cm laceration) by contact with wheelchair. RN [registered nurse] supervisor applied pressure dressing. Received verbal order from [name of nurse practitioner] to send resident to ER. Report called. Bed hold policy sent with resident. Resident is own RR [responsible representative].
- 2/28/2021 20:40 (8:40 a.m.) Note Text: Returned to facility after receiving 9 staples and new orders for Keflex (antibiotic) 500 mg (milligrams) q (every) 12 hours x 10 days. Resident is own RR and is aware.
- 3/1/2021 13:02 (1:02 p.m.) Note Text: Resident stated that he wanted to file assault charges against roommate for injuring him causing 9 staples in lower leg. This writer notified [County Name] Sheriff Dept. Spoke with investigator several times. Also notified [Name of ombudsman] LTC (long term care) Ombudsman and [Name of staff] with APS (adult protective services). Awaiting return call from investigator with [County Name].
- 3/1/2021 17:31 (5:31 p.m.) Note Text: Investigator and deputy in to speak with resident.
The ED (emergency department) Note Physician for Resident #4 from [Name of Hospital] dated 2/28/2021, documented in part, .Chief complaint from [Name of facility] - verbal argument with roommate; knocked wheelchairs into each other; laceration to right lower leg; dressing on with controlled bleeding .This is a [age and sex of Resident #4] that presents to the emergency department with a laceration to the right lower extremity. He was cut to the lower leg with a metal part of the wheelchair. The wound was thoroughly irrigated, cleansed with Betadine, and closed with staple gun. Patient will be placed on oral antibiotics. His tetanus shot was updated. Patient will be discharged back to the facility .
Resident #37 was admitted to the facility with diagnoses including but not limited to Parkinson's disease (4), major depressive disorder and anxiety disorder (5). Resident #37's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/8/21 coded Resident #37 as scoring a 15 on the BIMS (brief interview for mental status), 15- being cognitively intact for making daily decisions. Section E documented Resident #37 failed to evidence documentation of any behavioral symptoms during the observation period.
Resident #37 no longer resided at the facility and could not be observed during the survey dates. The record was reviewed as a closed record.
The comprehensive care plan for Resident #37 dated 12/28/2020 documented in part, Problematic manner in which resident acts characterized by ineffective coping; verbal/ physical Aggression or Agitated, Combativeness related to: Anger, cursing, yelling at staff, threatening to hurt staff. Date Initiated: 12/22/2020, Created on: 12/22/2020, Revision on: 03/08/2021. The care plan further documented, Negative feelings regarding self and social relationships characterized by; low self esteem, anxiety, mistrust, conflict/anger, ineffective coping related to: displays of inappropriate social behavior exposing self to staff, inappropriate communication with staff through letters & email. Date Initiated: 01/04/2021, Created on: 01/04/2021, Revision on 03/08/2021.
The progress notes for Resident #37 documented in part the following:
- 12/20/2020 14:52 (2:52 p.m.) Note Text: CNA (certified nursing assistant) came to writer and stated that resident was cursing her. She stated that she set up a bed bath, she asked [Resident #37] to go ahead and get started washing his face to his waist. She then informed him that she will be right back because she had 2 call lights going off. About 10 mins (minutes) had passed and he put his call light on. When she went in the room and apologized for taking longer to het [sic] back to him he started cursing at her. She said he threatened to Kick my [curse words]. Then he stated he hopes that she become paralyzed. He also threatened to call the state and he has done it before. He also stated that he would refuse to feed himself so that CNAs would have to feed him because he pays good money to be here and he want his moneys worth. Housekeeper and another CNA heard him cursing and yelling.
- 12/21/2020 08:37 (8:37 a.m.) Note Text: This writer and Clinical Care Coordinator went in to speak with resident. Staff reported that resident this weekend was cursing them, calling staff MF and F you. Also threatening staff. This writer and Clinical Care Coordinator explained to resident this behavior was unacceptable and if continued we would have to discharge. Explained that there are other ways of communicating with staff other than threatening and cursing staff. Resident replied, I will call state and report yall for abuse. I know how it works. Stated I will just walk to the door and fall and sue yall. Resident stated that he would also call the LTC (long-term care) Ombudsman. This writer provided resident with the cell number to [Name of Ombudsman] LTC Ombudsman. Resident got out of bed and pushed bedside table toward door as walking.
- 12/21/2020 08:57 (8:57 a.m.) Note Text: After speaking with social worker and clinical care coordinator resident became angry and got up out of the bed pushed his bedside table into the hallway. Very unsteady gate.
- 12/23/2020 12:06 (12:06 p.m.) Note Text: This writer and AR in to speak with resident regarding DSS (Department of Social Services) stating that his insurance will not cover his LTC (long term care) stay. Resident stated that he would call his father. Resident's sister called and stated that resident can not return to live with her or the father. Stated that the property manager also stated that he is not allowed on property. Sister stated something to do with indecent exposure.
- 12/23/2020 13:21 (1:21 p.m.) Note Text: Was given note from CNA [Name of CNA] that resident gave her. Note entails resident's personal phone number and email note reads I missed you, signed by resident. CNA states resident asked her why she didn't call him, CNA responded to resident stating that would be inappropriate and was illegal. Resident wasn't happy with her comment. No further gestures at this time, CNA was informed that 2 staff members should be present when caring for resident.
- 12/23/2020 14:19 (2:19 p.m.) Note Text: Received call from LTC Ombudsman regarding that she received a voicemail from resident stating that he is not allowed to have friends here. Explained to [Name of Ombudsman] (LTC Ombudsman) that resident was sending note to a CNA with his personal information on it such as email address, cell phone number and that CNA advised Clinical Care Coordinator. CNA stated to resident that this action was not acceptable.
- 12/30/2020 10:31 (10:31 a.m.) Note Text: Received fax from Harrisonburg DSS [department of social services] for resident to apply for Medicaid. Resident stated that the bank account and vehicle are in both his name and wife's name. This writer called [Name of staff] at Harrisonburg DSS at [Phone number] and left message to inquire how to obtain this information since the wife has a protective order against resident.
- 12/30/2020 12:18 (12:18 p.m.) Note Text: CNA asked this writer to speak with resident because resident wanted CNA to wash him. Resident is capable of washing himself. Resident writes notes and texts on his cell phone. CNA stated that resident makes a effort to expose himself to them. Resident also will put his hands behind his head while they are giving care. This writer spoke with resident and advised that he is capable of washing himself. When this writer left room resident was starting to bathe himself.
- 12/31/2020 09:54 (9:54 a.m.) Note Text: heard resident yelling at CNA. entered room, resident trying to make CNA leave room before she had finished cleaning him from a BM. he was talking about some shirts that had went to laundry and had not came back yet. told CNA to go buy me some more shirts. explained to resident that we would see about his shirts being found. he went on to say that therapy was not helping him, and that he would find somewhere else to go. this nurse explained that he could do some things for himself, that we were here to help him do what he was unable to do, he stated he was not going to wear a gown, resident has issues with exposing himself and attempting to have staff provide care in genital area when he is capable of doing this himself. When staff is entering room, resident will place both hands behind his head. Resident stated that we get paid to wait on him. Resident stated that he is going to stay naked, that would get somebody's attention. Stating that he has not been able to see his psychiatrist. states he is going to call the advocate. Was very rude and disrespectful with CNA and this nurse. Notified Social Worker of same.
- 12/31/2020 10:54 (10:54 a.m.) Note Text: Resident no longer on precautions so will be moved to [Room number on C hall]. Resident is aware and is own RR (resident representative).
- 1/12/2021 16:50 (4:50 p.m.) Note Text: CNA came to get this writer to listen to resident yell. CNA and this writer were at resident's door. Resident found on floor laying on right side. CNA stated that resident continues to make statements about throwing himself on the floor when he is mad. This writer called [Name of Physician] who gave verbal order to sent to ER (emergency room) for eval (evaluation) of fall and psych (psychiatric) eval. 911 called. This writer also spoke with LTC Ombudsman regarding resident. LTC Ombudsman stated that resident calls several times on multiple occasion.
- 1/13/2021 07:05 (7:05 a.m.) Note Text: resident returned from ER at this time. No new orders received.
- 1/13/2021 10:41 (10:41 a.m.) Note Text: Law enforcement officer in to serve protective order on resident from his wife.
- 1/13/2021 14:57 (2:57 p.m.) Note Text: This writer and DON (director of nursing) in to talk with resident. This writer advised resident that his behaviors were unacceptable. Explained to resident that as of now he also has no payer source, that his Medicaid has not been approved for LTC (long-term care). Advised that this writer has sent his information to several facilities due to resident wanted to transfer but because of his behavior, the other facilities refused to take resident due to his behaviors.
- 1/20/2021 07:55 (7:55 a.m.) Note Text: CNA reported that when she went to pick up resident's dinner tray, he had thrown it in the floor.
- 1/23/2021 14:14 (2:14 p.m.) Note Text: resident rang call bell for tray to be picked up. told him that CNA would be picking all trays up in a few minutes. Because she did not go in room right away he got angry and threw tray and urinal full of urine in floor in room. Told resident that was uncalled for. He stated he has a mental problem and he demands service right now. Stated that is what we are getting paid for. Stated he would call social services. Mad because he cannot go to bank and dmv. Explained to him that there was nothing that myself or CNA could do about that but that he did not have to act in the manner that he did.
- 1/27/2021 11:05 (11:05 a.m.) Note Text: CNA in to see this writer. Resident throwing tray in floor for CNA to clean up. Resident continues to have behavior issues. This writer received message to call [Name of Deputy] at sheriff's office due to resident needs to be served papers.
- 1/27/2021 15:11 (3:11 p.m.) Note Text: LPN (licensed practical nurse) requested this writer to come in to resident room as he had a conversation with him to address appropriate ways to address complaints. per staff on unit resident has been threatening to throw himself on the floor because the staff are not coming in rt (right) when he wants them to. This writer observed meal tray and trash all over the floor as the resident had thrown it. Resident was advised that as we have responsibilities toward him he also has responsibilities as a resident to behave appropriately. resident verbalized understanding.
- 1/29/2021 15:30 (3:30 p.m.) Note Text: Resident stated to staff that she did not want to change him. CNA had been in residents room most of day. CNA stated that she has changed him 6 time. Resident had soiled his brief and as soon as he did, he removed brief and threw soiled brief in floor. CNA stated that she was giving care to another resident at the time he soiled brief but resident did not give CNA time to get to his room. CNA on next shift was making rounds with CNA from 1st shift, resident started cursing 2nd shift CNA for no reason as she had just came in room to do reporting rounds.
- 2/9/2021 10:14 (10:14 a.m.) Note Text: Resident removed feces from brief and threw in the trash can. Resident made aware that CNA was coming to give care as soon as possible but resident removed feces and threw in trash can.
- 2/9/2021 10:14 (10:14 a.m.) Note Text: writer walking down hall heard resident yelling at CNA that he wanted her to give him a bath, writer went into room to inquire on what was going on, resident stated he needed an arbitrator, writer asked again what the problem was, he stated he wanted to file suit to make sure he received proper hygiene every day that the CNA's bathed him. writer informed resident that she would have can set up his bath water, that he was more than capable of bathing himself. He stated I didn't say I couldn't. Then he stated that he needed to be changed, CNA was in room to change him when he started yelling at her about the bath. Resident assured that the CNA would perform incontinent care on him and then set him up for bath.
- 2/17/2021 10:25 (10:25 a.m.) Note Text: This writer met with resident to advise would be moving to [Room number] and will have a roommate. Resident not on precautions.
- 2/23/2021 13:43 (1:43 p.m.) Note Text: Activity Director reported hearing resident call CNA racial slurs and cursing her. CNA stated that she was going to provide him care as soon as she put the tray on the cart. Resident continued to call CNA racial slur and curse her. This writer spoke with Administrator who went and advised resident that cursing and racial slurs would not be tolerated. Resident stated find me another facility. Administrator explained that we have attempted to but all facilities have declined due to resident's behavior.
- 2/23/2021 14:11 (2:11 p.m.) Note Text: Staff stated that resident continues to call CNA racial slurs and curse. Administrator again went to speak with resident and advise that this is not acceptable behavior.
- 2/28/2021 16:23 (4:23 p.m.) Note Text: resident arguing with his room mate over TV. Accused his roommate of being spoiled & babied by the staff. Stated he was going to beat his [curse] to his roommate Writer reminded resident that he was not able to ambulate or transfer alone. Writer encouraged resident to try to work toward compromise with the TV & share what programs are watched, perhaps take turns. Also explained to him that the staff provide his room mate with time to smoke because it is the roommates right to smoke. It is also the roommates right to have the staff do shopping for him, resident was encouraged to let the activity department know if he wanted items purchased for him at the store on resident shopping day, explained he needed to have funds in his account & that they could find that out for him on Monday. Writer encouraged resident to try to speak nicely & politely to his room mate & to other resident's & staff. Reminded him that polite people do not throw things & yell at others during conversation. Resident stated that he wanted to leave writer explained that the social service department has been trying to find alternate placement for him however due to his behaviors other facilitates are not agreeing to having him transfer there.
- 3/1/2021 10:00 (10:00 a.m.) Note Text: On 2/28/21 at approximately 1640 hours (4:40 p.m.) writer was called to resident's room. Resident's roommate [Resident #4] had sustained a 8.5cm (centimeter) laceration on his right lateral lower leg. The room mate [Resident #4] states that this resident [Resident #37] pushed the w/c (wheelchair) that was next to his bed (observed w/c on the left side of this resident's bed) into the privacy curtain pushing the overbed table into his leg. Roommate [Resident #4] yelling he was going to call the police; this resident [Resident #37] yelling I didn't do anything, I'm calling my dad to pick me up before the cops come. I'm not going to jail. Resident [Resident #37] observed to be rolling onto his side reaching for the w/c again. Writer removed w/c from the room & placed in the hallway & resident bed lowered to the floor for safety. Writer instructed resident to stop trying to roll out of the bed & to lay on his back & be still. No observable injury from altercation.
- 3/1/2021 16:20 (4:20 p.m.) Note Text: staff called code green and stated resident was lying on the floor. Upon entering room resident was lying on his back perpendicular to the bed below the foot of the bed. Resident stated THE POLICE DON'T BELIEVE I CAN'T WALK. Resident reports back pain. Resident was log Rolled and assessed. moving all extremities. resident was assisted back into bed by staff. Bed in low position. RN (registered nurse) returned to room with equipment to obtain vitals- resident had his legs thrown over the side of the bed and stated he was leaving. Assisted resident back in to bed. Resident has no where to go and is at risk to harm himself or others.
- 3/1/2021 16:20 (4:20 p.m.) Note Text: MD [Name of medical doctor] was notified of incident. Resident to be sent to ER [emergency room] for evaluation of back pain post fall and for mental health eval as there is concern for his safety. 911 was called for transport to er, report was called to [Name of Staff] at [Name of Hospital] er. Resident expressed to RN he was concerned about missing dinner as that happened the last time he went to the er. Resident then became more agitated and stated he was going to leave AMA (against medical advice) because we want to send him to jail.
Resident is unable to get himself to the door and has no place to go. Explained to resident that we are sending him to the ER for concern for his safety. Rescue squad arrived and resident consented to go to the ER .
- 3/1/2021 17:31 (5:31 p.m.) Note Text: Investigator and Deputy in to speak with resident [Resident #37] regarding incident of 2/28/21.
- 3/2/2021 10:32 (10:32 a.m.) Note Text: [NAME] County Deputy in to serve resident [Resident #37] with assault charges on another resident [Resident #4]. Also was served a protective order against him taken out by his wife. Resident [Resident #37] after deputy left threw leg over side of bed. This writer in to speak with resident that stated he did not bother the other resident today. Explained that it was from the other day when he caused the other resident [Resident #4] to have to have 9 staples in leg.
- 3/2/2021 11:34 (11:34 a.m.) Note Text: Received report from Housekeeping Supervisor and CNA that resident stated that he wanted to kill himself and get it over with. Writer asked resident if he had a plan. Received no response. Reported incident to ADON (assistant director of nursing). MD (medical doctor) made aware. Resident to be sent to ER.
The psychiatric med management note dated 1/8/2021 for Resident #37 documented in part, .Reports that he does get angry and yell at times but has not thrown anything recently. Reports he has in the past thrown things out of frustration .He can also be verbally aggressive. He has thrown his table in the past .Social history: Pt is married with children. Reports they are separated. Reports he does not get a long well with his family. Reports his wife has a restraining order against him because, I have anger issues and it upset her. Reports he did not hit her. Family does not visit .
The psychiatric med management note dated 1/22/2021 for Resident #37 documented in part, .Reports he did yell at staff last evening because his urinal was not close enough. He did not throw anything. He denies any recent sexual behaviors .
The psychiatric med (medical) management note dated 2/5/2021 for Resident #37 documented in part, .He was seen today for a f/u (follow up) for moderate intermittent depression, anxiety, sexual behaviors, and verbal abuse that have been ongoing since admission .He can also be verbally aggressive. He has thrown his table in the past. Staff report that they have set limits and behaviors have overall improved. per staff, his wife has a restraining order against him for assault. Family will also not take him back due to him exposing himself to family and children in the past .If unable to maintain safety, please send to the ED (emergency department) for evaluation. Discussed behaviors with pt (patient) who agrees there is better ways to handle his frustration and will attempt talking with staff. Maintain sexual precautions .
On 3/10/2021 at approximately 2:00 p.m., an interview was conducted with OSM (other staff member) #5, social services. OSM #5 stated that each morning they had a meeting with the administrator and other members of the interdisciplinary team. OSM #5 stated that when a resident needed to be moved to another room they discussed the best placement and potential room mate for the resident in the meetings. OSM #5 stated that they talked about which residents they thought would have common interests and get along when assigning room mates. OSM #5 stated that Resident #37 was admitted to the C hallway in a private room and was on quarantine for the required amount of time. OSM #5 stated that after the quarantine period was over Resident #37 was moved into the room with Resident #4 on the A hallway for long term care where Resident #4 was already residing. OSM #5 stated that Resident #37 started displaying inappropriate behaviors a few days after they were admitted . OSM #5 stated that Resident #37 displayed verbally abusive behaviors to staff and exposed himself to female staff but they did not think that those behaviors would transfer to a resident. OSM #5 stated that they had hoped that Resident #37 and Resident #4 would get along because they were both cognitively intact and may have shared common interests. OSM #5 stated that they had sent out requests to other facilities at Resident #37's request for transfer but none would accept them due to his behaviors. OSM #5 stated that Resident #4 had a history of yelling at another resident and slamming doors. OSM #5 stated that when a resident to resident incident occurred the staff were to immediately intervene and separate the residents. When asked if Resident #37's behaviors were taken in to consideration when placing him in the room with Resident #4, OSM #5 stated that they thought that the residents would get along. OSM #5 stated that there were other empty beds on 2/17/21 and Resident #37 could possibly have been placed in a room by himself.
On 3/10/21 at approximately 2:34 p.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that on 2/28/21 she was asked to go to Resident #37 and Resident #4's room because a staff member could hear them arguing about the television from the hallway. RN #1 stated that when she entered the room the residents were not talking and the curtain was pulled between them. RN #1 stated that she told the residents that they had been arguing about the television and then they began arguing again. RN #1 stated that they talked about compromise on TV shows and both residents seemed to agree on the idea so she left the room to document the incident. RN #1 stated that she went to the nurses station and started documenting and was called back to the room by another staff member a few minutes later. RN #1 stated that when she entered the room Resident #4 had their leg over the trashcan and was bleeding. RN #1 stated that when she entered the room the second time Resident #37 and Resident #4 were arguing again. RN #1 stated that Resident #37 was lying in bed smiling and watching TV. RN #1 stated that staff had reported to them that both Resident #37 and Resident #4 had been bickering all day but had not shown any physical aggression. RN #1 stated that the incident occurred near the end of the day shift. RN #1 stated that the first thing she did was to maintain safety so she sent Resident #4 to ER and stayed in room until the ambulance arrived. RN #1 stated that if Resident #4 had not been sent to the ER, she would have separated the two residents at that time. When asked about the progress note dated 2/28/2021 at 4:23 p.m. which documented Resident #37 threatening to beat his (Resident #4's) [curse], immediately prior to the physical altercation, RN #1 stated that she had reminded Resident #37 that they could not get out of bed to beat anyone's [curse]. RN #1 stated that in hindsight, it was a threat to Resident #4 and she should have separated the residents when they were arguing. RN #1 stated that she did not think Resident #37 was physically capable of moving as well as he did or being able to cause the injury to Resident #4. RN #1 stated that she thought Resident #37 was angry and just talking as he frequently did and was not able to follow through on any physical violence.
The facility daily census documented the following:
- 43 empty beds in the facility, 13 empty beds on A hall and 20 empty beds on C hall on 2/15/2021.
- 42 empty beds in the facility, 12 empty beds on A hall and 20 empty beds on C hall on 2/16/2021.
- 41 empty beds in the facility, 9 empty beds on A hall and 24 empty beds on C hall on 2/17/2021.
- 42 empty beds in the facility, 9 empty beds on A hall and 24 empty beds on C hall on 2/18/2021.
- 40 empty beds in the facility, 8 empty beds on A hall and 24 empty beds on C hall on 2/19/2021.
The FRI (facility reported incident) dated 3/1/2021 documented in part, .Resident to resident altercation with injury, physician contact/intervention and/or transfer to hospital. Resident [Name of Resident #37] was involved with resident [Resident #4] regarding TV and Cable channels. [Resident #37] pushed wheelchair against bedside table causing injury to [Resident #4]. [Resident #4] was sent to ER where he was treated for a laceration. Residents were separated Physician notified and police, Commonwealth Attorney and ombudsman called. The five-day follow up report to the FRI dated 3/5/2021 documented in part, . [Resident #4] was sent out to the E.R. for evaluation and treatment. Upon his return, he was placed in a private room away from [Resident #37]. The [NAME] County Sheriffs department was notified and a complaint was filed by [Resident #4] against [Resident #37]. Papers were served on [Resident #37] for assault on 3/2/21 .See attached POC .
The attached plan of correction summary documented a detailed summary of the incident details describing the residents involved, a summary of actions taken by the facility to prevent a recurrence, the facility procedure for monitoring the plan of correction and the person responsible for implementing the plan of correction. The Final Compliance date documented was 3/2/2021.
On 3/10/21 at approximately 12:30 p.m., a request was made to ASM (administrative staff member) #2, the director of nursing for all documentation and investigation for the resident-to-resident incident on 2/28/21 for Resident #4 and Resident #37. ASM #2 stated that the facility had completed a FRI (facility reported incident) with investigation and had completed a plan of correction including education, interviews with residents, staff abuse testing, audits and the plan to monitor the plan of correction. ASM #2 stated that they would provide the evidence for review.
On 3/10/2021 at approximately 1:30 p.m., ASM #2, the director of nursing presented a binder, which documented the fol[TRUNCATED]
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 staff interview, facility document review, and clinical record review, it was determined that the facility staff failed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to evidence notification to the ombudsman of a resident discharge from the facility for two of 35 residents in the survey sample, Residents #41 and #2.
The facility staff failed to evidence written notification to the ombudsman for Resident #41's and Resident #2's transfer/discharge to a sister facility on 1/28/21.
The findings include:
1. The failed to evidence ombudsman was not notified of Resident #41's transfer/discharge to a sister facility on 1/28/21.
Resident #41 was admitted to the facility on [DATE] with a recent readmission on [DATE], with diagnoses that included but were not limited to: high blood pressure, stroke (abnormal condition in which hemorrhage or blockage of the blood vessels of the brain leads to oxygen lack and resulting symptoms - sudden loss of ability to move a body part [as an arm or parts of the face], or to speak, paralysis weakness or if severe, death) (1) and dementia (a progressive state of mental decline, especially memory function and judgement, often accompanied by disorientation.) (2).
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 2/16/2021, coded the resident as scoring an 8 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired to make daily cognitive decisions. The resident was coded as requiring extensive assistance of one staff member for moving in the bed. The resident was coded as not moving in her room or unit during the lookback period. In Section G0600 - Mobility Devices, the resident was coded as using a wheelchair.
A review of Resident #41's census information sheet revealed that she was discharged from the facility on 1/28/21, and readmitted on [DATE].
A review of Resident #41's clinical record revealed a progress note dated 2/12/21. The progress note stated the resident had been discharged to a sister facility due to a COVID-19 (3) diagnosis on 1/28/21, and was being readmitted on [DATE] to her home facility.
Further review of Resident #41's clinical record failed to reveal evidence that the ombudsman was notified of Resident #41's discharge.
On 3/11/21 at 2:00 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the clinical consultant, and ASM #4, the regional vice-president, were informed of these concerns. ASM #3 was asked about the process staff follows when a resident is discharged from a facility - even if it is a transfer/discharge to a sister facility. ASM #3 stated the staff was working to expedite getting residents out of the facility where they were and getting to the accepting facility as soon as possible. She stated there were many pieces of documentation and many phone calls involved in the discharge/transfer process. ASM #3 stated, We made a packet of information, which should have included all of the regulatory paperwork. She stated, however, that the facility did not retain the paperwork packet. She also stated that the facility could not produce evidence that the ombudsman had been notified of the transfer/discharge.
A review of the facility policy, Discharge and Transfer, revealed, in part: Discharge and/or transfer to other medical facilities will be effected only when medically appropriate as indicated by the attending physician .When a resident is transferred or discharged to a hospital or to a nursing home, a copy of an approved transfer and referral record and a copy of any additional medical information, as requested by the facility receiving the resident, will accompany him/her.
No further information was provided prior to exit.
REFERENCES
(1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 114.
(2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124.
(3) Coronaviruses are a large family of viruses found in many different species of animals, including camels, cattle, and bats. The new strain of coronavirus identified as the cause of the outbreak of respiratory illness in people first detected in Wuhan, China, has been named SARSCoV-2. (Formerly, it was referred to as 2019-nCoV.) The disease caused by SARS-CoV-2 has been named COVID-19. This information was obtained from the website:
https://www.nccih.nih.gov/health/in-the-news-coronavirus-and-alternative-treatments.
2. The failed to evidence ombudsman was not notified of Resident #2's transfer/discharge to a sister facility on 1/28/21.
Resident #2 was admitted to the facility 5/17/2015 and was recently readmitted on [DATE] with diagnoses that included but were not limited to: dementia (a progressive state of mental decline, especially memory function and judgement, often accompanied by disorientation.)(1), high blood pressure and schizophrenia (Any of a group of mental disorders characterized by gross distortions of reality, withdrawal of thought, language, perception and emotional response) (2).
The most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 3/2/2021, coded Resident #2 as having no difficulty with short or long-term memory difficulties. The resident was coded as requiring extensive assistance of one staff member for moving in the bed. Resident #2 was coded as requiring limited assistance of one staff member for moving in their room or unit. In Section G0600 - Mobility Devices, the resident was coded as using a wheelchair.
A review of Resident #2's clinical record revealed a progress note dated 2/23/21. The progress note stated the resident had been discharged to a sister facility due to a COVID-19 (3) diagnosis on 1/28/21, and was being readmitted on [DATE] to her home facility.
Further review of Resident #2's clinical record failed to reveal evidence that the ombudsman was notified of Resident #2's transfer/ discharge on [DATE].
On 3/11/21 at 2:00 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the clinical consultant, and ASM #4, the regional vice-president, were informed of these concerns. ASM #3 was asked about the process staff follows when a resident is discharged from a facility - even if it is a transfer/discharge to a sister facility. ASM #3 stated the staff was working to expedite getting residents out of the facility where they were and getting to the accepting facility as soon as possible. She stated there were many pieces of documentation and many phone calls involved in the discharge/transfer process. ASM #3 stated, We made a packet of information, which should have included all of the regulatory paperwork. She stated, however, that the facility did not retain the paperwork packet. She also stated that the facility could not produce evidence that the ombudsman had been notified of the transfer/discharge.
No further information was provided prior to exit.
(1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124.
(2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 522.
(3) Coronaviruses are a large family of viruses found in many different species of animals, including camels, cattle, and bats. The new strain of coronavirus identified as the cause of the outbreak of respiratory illness in people first detected in Wuhan, China, has been named SARSCoV-2. (Formerly, it was referred to as 2019-nCoV.) The disease caused by SARS-CoV-2 has been named COVID-19. This information was obtained from the website:
https://www.nccih.nih.gov/health/in-the-news-coronavirus-and-alternative-treatments
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 staff interview, facility document review, and clinical record review, it was determined that the facility staff failed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to evidence bed hold policy notification to the resident or the RR (resident representative) prior to or at the time of transfer/ discharge for two of 35 residents in the survey sample, Residents #41 and #2.
The findings include:
1. Resident #41 was transferred/ discharged from the facility on 1/28/21. The facility staff failed to evidence that the resident or the RR (resident representative) was provided written notification of the bed hold policy prior to or at the time of transfer.
Resident #41 was admitted to the facility on [DATE] with a recent readmission on [DATE], with diagnoses that included but were not limited to: high blood pressure, stroke (abnormal condition in which hemorrhage or blockage of the blood vessels of the brain leads to oxygen lack and resulting symptoms - sudden loss of ability to move a body part [as an arm or parts of the face], or to speak, paralysis weakness or if severe, death) (1) and dementia (a progressive state of mental decline, especially memory function and judgement, often accompanied by disorientation.) (2).
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 2/16/2021, coded the resident as scoring an 8 on the BIMS (brief interview for mental status) score, indicating the resident was moderately impaired to make daily cognitive decisions. The resident was coded as requiring extensive assistance of one staff member for moving in the bed. The resident was coded as not moving in her room or unit during the lookback period. In Section G0600 - Mobility Devices, the resident was coded as using a wheelchair.
A review of Resident #41's census information sheet revealed that she was discharged from the facility on 1/28/21, and readmitted on [DATE].
A review of Resident #41's clinical record revealed a progress note dated 2/12/21. The progress note stated the resident had been discharged to a sister facility due to a COVID-19 (3) diagnosis on 1/28/21, and was being readmitted on [DATE] to her home facility.
Further review of Resident #41's clinical record failed to reveal evidence that the resident or the RR received any information about the facility's bed hold policy.
On 3/11/21 at 2:00 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the clinical consultant, and ASM #4, the regional vice-president, were informed of these concerns. ASM #3 was asked about the process staff follows when a resident is discharged from a facility - even if it is a transfer/discharge to a sister facility. ASM #3 stated the staff was working to expedite getting residents out of the facility where they were and getting to the accepting facility as soon as possible. She stated there were many pieces of documentation and many phone calls involved in the discharge/transfer process. ASM #3 stated, We made a packet of information, which should have included all of the regulatory paperwork. She stated, however, that the facility did not retain the paperwork packet. ASM #1 stated, We did bed holds for them, but could not evidence the resident or RR was informed of the bed hold policy.
A review of the facility policy, Discharge and Transfer, revealed, in part: Discharge and/or transfer to other medical facilities will be effected only when medically appropriate as indicated by the attending physician .When a resident is transferred or discharged to a hospital or to a nursing home, a copy of an approved transfer and referral record and a copy of any additional medical information,, as requested by the facility receiving the resident, will accompany him/her.
No further information was provided prior to exit.
REFERENCES
(1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 114.
(2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124.
(3) Coronaviruses are a large family of viruses found in many different species of animals, including camels, cattle, and bats. The new strain of coronavirus identified as the cause of the outbreak of respiratory illness in people first detected in Wuhan, China, has been named SARSCoV-2. (Formerly, it was referred to as 2019-nCoV.) The disease caused by SARS-CoV-2 has been named COVID-19. This information was obtained from the website:
https://www.nccih.nih.gov/health/in-the-news-coronavirus-and-alternative-treatments.
2. Resident #2 was transferred/ discharged from the facility on 1/28/21. The facility staff failed to evidence that the resident or the RR (resident representative) was provided written notification of the bed hold policy prior to or at the time of transfer.
Resident #2 was admitted to the facility 5/17/2015 and was recently readmitted on [DATE] with diagnoses that included but were not limited to: dementia (a progressive state of mental decline, especially memory function and judgement, often accompanied by disorientation.)(1), high blood pressure and schizophrenia (Any of a group of mental disorders characterized by gross distortions of reality, withdrawal of thought, language, perception and emotional response) (2).
The most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 3/2/2021, coded the resident as having no difficulty with short or long-term memory difficulties. The resident was coded as requiring extensive assistance of one staff member for moving in the bed. Resident #2 required limited assistance of one staff member for moving in their room or unit. In Section G0600 - Mobility Devices, the resident was coded as using a wheelchair.
A review of Resident #2's clinical record revealed a progress note dated 2/23/21. The progress note stated the resident had been discharged to a sister facility due to a COVID-19 (3) diagnosis on 1/28/21, and was being readmitted on [DATE] to her home facility.
Further review of Resident #2's clinical record failed to reveal evidence that the ombudsman was notified of Resident #2's discharge.
On 3/11/21 at 2:00 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the clinical consultant, and ASM #4, the regional vice-president, were informed of these concerns. ASM #3 was asked about the process staff follows when a resident is discharged from a facility - even if it is a transfer/discharge to a sister facility. ASM #3 stated the staff was working to expedite getting residents out of the facility where they were and getting to the accepting facility as soon as possible. She stated there were many pieces of documentation and many phone calls involved in the discharge/transfer process. ASM #3 stated, We made a packet of information, which should have included all of the regulatory paperwork. She stated, however, that the facility did not retain the paperwork packet. ASM #1 stated, We did bed holds for them, but could not evidence the resident or RR was informed of the bed hold policy.
No further information was provided prior to exit.
(1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124.
(2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 522.
(3) Coronaviruses are a large family of viruses found in many different species of animals, including camels, cattle, and bats. The new strain of coronavirus identified as the cause of the outbreak of respiratory illness in people first detected in Wuhan, China, has been named SARSCoV-2. (Formerly, it was referred to as 2019-nCoV.) The disease caused by SARS-CoV-2 has been named COVID-19. This information was obtained from the website:
https://www.nccih.nih.gov/health/in-the-news-coronavirus-and-alternative-treatments
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, facility document review and clinical record review, it was determined the facility staff failed to d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, facility document review and clinical record review, it was determined the facility staff failed to develop and / or implement the comprehensive care plan for one of thirty five residents in the survey sample, Resident #99. The facility staff failed to develop and implement a comprehensive care plan to address post-operative care for Resident #99.
The findings include:
Resident #99 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: right total knee replacement (surgical replacement of knee joint with a prosthetic) (1), diabetes mellitus (inability of insulin to function normally in the body) (2) and hypertension (high blood pressure) (3).
The most recent MDS (minimum data set) assessment, a Medicare 5 day with an ARD (assessment reference date) of 3/10/21, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring supervision for bed mobility, hygiene, bathing, dressing, locomotion and walking. Resident #99 was coded as independent in eating. A review of MDS Section H- bowel and bladder coded the resident as always continent for bowel and bladder.
A review of Resident #99's medical diagnosis dated 3/4/21, documented in part, Rank: Primary diagnosis, Clinical Category: major joint replacement, Description: aftercare following joint replacement surgery. A review of Resident #99's nursing admission evaluation dated 3/4/21, documented in part, Right knee post surgical scar. Review of nursing progress note dated 3/4/21 at 12:10 PM, documented in part, Dressing covering post surgical site (right knee) clean, dry and intact.
A review of the comprehensive care plan failed to address or evidence documentation of post-operative care for Resident #99. An interview was conducted on 3/10/21 at 1:41 PM with LPN (licensed practical nurse) #1. When regarding the purpose of the comprehensive care plan. LPN #1 stated, It is how we take care of the resident. When asked about the care plan for a resident who is post knee replacement, LPN #1 stated, I would expect to see how they transfer, signs and symptoms of infections and pain control.
An interview was conducted on 3/10/21 at 2:15 PM with RN (registered nurse) #1 regarding the purpose of the comprehensive care plan. RN #1 stated, The plan drives the care of the residents with problems, goals and interventions. When asked about a comprehensive care plan for post-operative care, RN #1 stated, The care plan should include how to assist the resident with movement, pain relief measures and what signs and symptoms of infection you should look for.
On 3/10/21 at 4:30 PM ASM (administrative staff member) #1, the administrator, ASM #2, the director or nursing and ASM #3 the nurse consultant were informed of the above concerns.
The comprehensive care plan for Resident #99 was revised on 3/11/21. Review of the revised care plan revealed in part the following: Focus: At risk for infection related to surgical site status post right total knee replacement. Interventions: Treatments as ordered by physician, encourage resident to drink sufficient fluids and observe for signs/symptoms of infection to include increased temperature, loss of congestion, change in mental status. Notify physician for evaluation and/or intervention for redness, swelling to right lower extremity.
A review of the facility's policy Resident Care Plan dated 11/13/17, documented in part, It is the policy of the facility to provide a written resident-centered care plan based upon physician's orders, the assessment of the resident's needs and preferences, and pre-admission screening and resident review.
No further information was provided prior to exit.
References:
1. Barron Dictionary of Medical Terms, 7th edition, Rothenberg and Kaplan, page 319.
2. Barron Dictionary of Medical Terms, 7th edition, Rothenberg and Kaplan, page 160.
3. Barron Dictionary of Medical Terms, 7th edition, Rothenberg and Kaplan, page 282.
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 resident interview, clinical record review, staff interview and facility document review it was determined facility sta...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, clinical record review, staff interview and facility document review it was determined facility staff failed to revise the comprehensive care plan for one of 35 residents in the survey sample, Resident #33. Resident #33 returned from the emergency room on 1/8/21 with a splint (immobilizer) in place to the right leg and non-weight bearing status, which was not addressed on Resident #33's comprehensive care plan.
The findings include:
Resident #33 was admitted to the facility with diagnoses that included but were not limited to cerebral infarction (1), hemiplegia (2), hemiparesis (3) affecting right dominant side, and vitamin D deficiency (4).
Resident #33's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 2/20/2021, coded Resident #33 as scoring a 15 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 15- being cognitively intact for making daily decisions. Section G coded Resident #24 as requiring extensive assistance of two persons for transfers and extensive assistance of one person for personal hygiene and toileting. Section J coded Resident #33 as having one fall with major injury.
On 3/9/21 at approximately 2:30 p.m., an interview was conducted with Resident #33. Resident #33 was observed in their wheelchair with a splint wrapped in a compression bandage on the right lower leg beginning above the right knee. Resident #33 stated that she fell in the bathroom when the CNA (certified nursing assistant) was assisting her back to the wheelchair. Resident #33 stated that she was not sure if the wheelchair was locked, that it slid back on her and she fell to her knees. Resident #33 stated that she went to the emergency room the next day after an x-ray was done and she was seeing a specialist about the leg.
The physician orders dated 3/1/21-3/31/21 for Resident #33 documented in part,
- Check Dorsalis Pedel [sic] pulse (pulse in foot) BID (twice a day) (Right leg FX (fracture)).
- Continue Cadalac splint. FYI (for your information).
- NWB (non- weight bearing) RLE (right lower extremity) x 8 weeks (for eight weeks). Dx (diagnosis) Right tib/fib (tibia/fibula) (long bones in the lower leg) FX. FYI.
The progress notes for Resident #33 documented in part,
- 1/7/2021 15:32 (3:32 p.m.) Late Entry: Note Text: On 1/7/21, resident was assisted to her knee while attempting to transfer to her wheelchair. MD (medical doctor) made aware with note in communication log. Resident is her own RR (resident representative).
-1/8/2021 11:24 (11:24 a.m.) Late Entry: Note Text: called to room by CNA (certified nursing assistant) stating resident is crying and complaining of right leg hurting. Writer entered room and resident in bed, when writer attempted to straighten leg in bed to assess it resident grimacing and crying that it hurt. Resident explained that when she fell yesterday that her leg went behind her. On assessment, swelling noted to right lower extremity mid shin to foot, area of pain beginning mid shin. Resident able to flex and retract foot without difficulty. Writer able to palpate pulses proximal and distally to pain point of shin. Writer called MD (medical doctor) to update her on findings and to request xray of tib/fib (tibia/fibula). Telephone order received and passed to floor nurse, [Name of nurse], LPN (licensed practical nurse). Resident is her own RR [resident representative].
- 1/8/2021 13:31 (1:31 p.m.) Late Entry: Note Text: Writer went to reassess resident, upon entering room resident up in wc (wheelchair) propelling self in room, swelling remains and she states pain is a little better. Informed her that they should be coming to do the xray, she verbalized understanding.
- 1/8/2021 22:09 (10:09 p.m.) Note Text: Xray results of right lower leg: fracture of proximal fibula and distal tibia. Advised nurse to sent [sic] to ER (emergency room) for further treatment.
- 1/9/2021 06:15 (6:15 p.m.) Note Text: Return from [Name of hospital] by transport. Resident in [Room number]. Resident awake and alert. Oriented x3 (person, place and situation). Long Splint to Rt. (right) leg. [Name of nurse practitioner], NP call and reported x-ray of leg done results Fracture x 2 at tib/fib knee and rt. ankle. Resident to be Non-weight bearing to Rt. leg. Long splint to Rt. leg do not remove. Ortho [orthopedic] consult as soon as possible. Monitor for compartment syndrome (5). Spouse [Name of spouse] made aware.
- 2/9/2021 10:41 (10:41 a.m.) Note Text: Care plan meeting held. RN (registered nurse), SW (social worker), Dietary and resident. Resident and team have no issues at this time. Resident is her own RR. Resident is a FULL CODE. Resident stated that she is eating and sleeping good. Enjoys watching cooking shows on TV.
The Radiology Results Report for Resident #33, dated 1/8/2021 documented in part, .Impression: There are acute fractures of the proximal fibula and distal tibia seen .
The Emergency Documentation for Resident 33, dated 1/8/2021 documented in part, .Patient received a full posterior splint with ankle stirrup additional splinting based on the above fractures. It is recommended and the nursing home was notified that the patient would need to be non-weightbearing along with referral to orthopedics as soon as possible .
The orthopedic Report of Consultation for Resident #33, dated 1/18/2021 documented in part, .Recommendations: Continue Cadalac splint that she already has on. Keep clean and dry. No weight bearing RLE [right lower extremity] x 8-12 weeks (for eight to twelve weeks). Tylenol as needed for pain- pt (patient) states this helps most of the time. Check DP (dorsalis pedis) pulse BID (twice a day). Pt may sit in wc (wheelchair) with B (both) leg rests, R (right) one elevated .
The orthopedic Report of Consultation for Resident #33, dated 2/4/2021 documented in part, .Continue splint for 4 (four) more weeks, keep clean and dry .NWB (non-weightbearing) RLE 4-8 more weeks .
The fall investigation for Resident #33, dated 1/7/2021 documented in part, .Nursing description: Called to resident's room by CNA (certified nursing assistant) to assist with resident. Observed resident kneeling in front of her wheelchair in her bathroom. Resident Description: I tried to get in the chair and it slid back. I landed on my knee. No injuries observed at time of incident . The fall investigation further documented, .CNA [Name of CNA] stated that she was assisting resident to wheelchair from toilet; resident crossed her feet and began to let herself down, CNA was not able to keep her from falling, due to the position of residents feet, so she assisted resident to the floor to her knees. States her legs were crossed under her . The fall investigation documented an incident report dated 1/7/2021, witness statements dated 1/9/21 and an investigational summary dated 1/7/21-2/27/21 (due to continued falls).
The comprehensive care plan dated 2/5/2021, for Resident #33 documented in part, Risk for falls characterized by multiple risk factors related to: impaired balance, impaired mobility, decreased safety awareness, falls from w/c (wheelchair) (2/11/21 & 2/27/21), Date Initiated: 03/19/2020. Revision on: 02/28/2021. Under Interventions, it documented in part, Assist resident to negotiate barriers as necessary. Date Initiated: 01/11/2021 . The care plan failed to evidence documentation regarding the interventions put in place after Resident #33's fractures to the right lower leg.
On 3/11/21 at approximately 10:37 a.m., an interview was conducted with RN (registered nurse) #2, MDS coordinator. RN #2 stated that they were notified of resident changes in condition in the morning meetings. RN #2 stated that daily care plan updates were completed by the interdisciplinary team and were reviewed by them quarterly. RN #2 stated that when a resident had a fall an investigation was completed and an intervention was added to the care plan to prevent a reoccurrence. RN #2 reviewed the comprehensive care plan for Resident #33 and stated that she did not see any documentation regarding the non-weight bearing status, splint or fracture of the right leg addressed. RN #2 stated that the splint immobilizer should have been addressed on the care plan.
On 3/11/21 at approximately 11:44 a.m., an interview was conducted with LPN (licensed practical nurse) #2, regarding purpose of the comprehensive care plan. LPN #2 stated that the care plan was for staff to know what to do for the specific resident. LPN #2 stated that the care plan also contained a care guide, which helped the CNA (certified nursing assistant) know how to care for the resident. LPN #2 stated that care plans were updated or revised when there was a change in condition. LPN #2 stated that when a resident had a fall the care plan was reviewed and they would add any interventions put into place. LPN #2 stated that when a resident had any fall with injury, or a new weight bearing status they would update the care plan to reflect it. LPN #2 stated that when residents return to the facility from the emergency room the documentation was reviewed and the orders and care plan were updated. LPN #2 stated that any nurse could update the care plan.
A review of the facility policy, Resident Care Plan dated Revision 11/13/2017 documented, It is the policy of the facility to provide a written resident-centered care plan based upon physician's orders, the assessment of the resident needs and preferences, and pre-admissions screening and resident review (PASRR) . The policy further documented, The resident care plan will be an ongoing process and will include current problems and/or needs identified from a complete assessment .
On 3/11/21 at approximately 2:00 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the regional vice president were made aware of the above concern.
No further information was presented prior to exit.
References:
1. Cerebrovascular disease, infarction or accident is a stroke. When blood flow to a part of the brain stops. A stroke is sometimes called a brain attack. If blood flow is cut off for longer than a few seconds, the brain cannot get nutrients and oxygen. Brain cells can die, causing lasting damage. This information was obtained from the website: https://medlineplus.gov/ency/article/000726.htm .
2. Hemiparesis - Paralysis is the loss of muscle function in part of your body. This information was obtained from the website: https://medlineplus.gov/paralysis.html.
3. Hemiplegia- also called: Hemiplegia, Palsy, Paraplegia, Quadriplegia. Paralysis is the loss of muscle function in part of your body. It happens when something goes wrong with the way messages pass between your brain and muscles. Paralysis can be complete or partial. It can occur on one or both sides of your body. It can also occur in just one area, or it can be widespread. This information was obtained from the website: https://medlineplus.gov/paralysis.html.
4. Vitamin D deficiency- Vitamin D helps your body absorb calcium. This information was obtained from the website: https://medlineplus.gov/vitamind.html.
5. Compartment syndrome- Acute compartment syndrome is a serious condition that involves increased pressure in a muscle compartment. It can lead to muscle and nerve damage and problems with blood flow. This information was obtained from the website: https://medlineplus.gov/ency/article/001224.htm
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to pr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined the facility staff failed to provide respiratory care consistent with professional standards of practice for two of thirty five residents in the survey sample, Resident #47 and Resident #24.
1. The facility staff failed administered oxygen to Resident #47 without a physician order for oxygen.
2. The facility staff failed to provide respiratory services in a sanitary manner for Resident #24. The facility staff stored a nebulizer (1) mask and a yankauer suction catheter (2) uncovered on the nightstand in Resident #24's room.
The findings include:
1. Resident #47 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: chronic obstructive pulmonary disease [COPD] (non-reversible lung disease) (1), syncope (brief loss of consciousness due to temporary insufficient flow of blood to the brain) (2) and atrial fibrillation (rapid and random contraction of atria of the heart) (3).
The most recent MDS (minimum data set) assessment, an annual assessment with an ARD (assessment reference date) of 2/10/21, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring supervision for bed mobility, transfer, hygiene, eating and walking. Resident is independent in locomotion, dressing and bathing. A review of MDS Section H- bowel and bladder coded the resident as always continent for bowel and bladder. Section O- oxygen therapy while a resident was coded as Yes.
On 3/9/21 at 3:25 PM, 3/10/21 at 8:00 AM and 3/10/21 at 2:10 PM., observations of Resident #47 revealed the resident was receiving oxygen via a nasal cannula connected to an oxygen concentrator that was running. The oxygen flow meter was observed set at 3 liters.
A review of the physician orders for Resident #47 dated 2/4/21-3/09/21, failed to evidence physician orders for oxygen therapy.
Review of Resident #47's nursing admission dated 2/4/21 at 9:27 PM, documented in part, Special treatments: Oxygen therapy- 3 liters per minute continuous.
Review of Resident #47's nursing progress note dated, 3/9/21 at 3:17 PM, documented in part, Respiratory- oxygen via nasal cannula. A review of the respiratory care evaluation for Resident #47 dated 3/9/21 at 1:00 AM, documented in part, Oxygen vial nasal cannula, oxygen saturation 97%. Rate of oxygen 3 liters per minute.
A review of the comprehensive care plan for Resident #47 dated 12/4/19 documented in part, Focus: Potential for or actual ineffective breathing pattern related to COPD (chronic obstructive pulmonary disease) with emphysema, respiratory failure. Interventions: Oxygen therapy as ordered.
An interview was conducted on 3/10/21 at 1:41 PM with LPN (licensed practical nurse) #1 regarding Resident #47. LPN #1 stated, She [Resident #47] has been cleared from observation status and has been moved back to her original room.
An interview was conducted on 3/10/21 at 2:15 PM with RN #1, regarding Resident #47 and the administration of oxygen. RN #1 stated, Yes she (Resident #47) has been moved but I don't have her paperwork. I will have to call the unit she transferred from, as they haven't brought her paper chart, so I cannot tell you how much oxygen she is on. RN #1 was then observed calling LPN #1. RN #1 then stated, There isn't an order for the oxygen.
On 3/10/21 at 2:30 PM, RN #1 stated, Resident #47 gets shortness of breath with exertion and walking to the bathroom but at rest is tolerating two liters per minute. I will leave a message for the physician to order the oxygen, maybe she can give us parameters for two liters or three liters.
On 3/10/21 at 2:20 PM, RN #1 was accompanied to Resident #47's room. Resident #47 was observed receiving oxygen via nasal cannula connected to the concentrator that was running. RN #1 observed Resident #47's oxygen concentrator flow meter that was set at three liters per minute. At this time Resident #47 was interviewed. When asked if she changed the oxygen setting, Resident #47 stated, Oh, I never touch it. RN #1 was then observed adjusting the oxygen setting to 2 liters per minute.
On 3/10/21 at 2:56 PM RN #1 presented a physician order for Resident #47 that documented in part, Oxygen two liters to three liters, titrate for shortness of breath and shortness of breath with exertion.
On 3/10/21 at 4:30 PM ASM (administrative staff member) #1, the administrator, ASM #2, the director or nursing and ASM #3 the nurse consultant were informed of the above concerns.
On 3/9/21, ASM #2 stated that the professional standards followed are the facility policy and procedures. A request was made for a policy for obtaining and implementing orders. No policy was provided.
No further information was provided prior to exit.
References:
1. Barron Dictionary of Medical Terms, 7th edition, Rothenberg and Kaplan, page 120.
2. Barron Dictionary of Medical Terms, 7th edition, Rothenberg and Kaplan, page 551.
3. Barron Dictionary of Medical Terms, 7th edition, Rothenberg and Kaplan, page 54.
2. The facility staff failed to provide respiratory services in a sanitary manner for Resident #24. The facility staff stored a nebulizer (1) mask and a yankauer suction catheter (2) uncovered on the nightstand in Resident #24's room.
Resident #24 was admitted to the facility with diagnoses that included but were not limited to chronic obstructive pulmonary disease (3) and anemia (4).
Resident #24's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 1/25/2021, coded Resident #24 as scoring a 9 on the staff assessment for mental status (BIMS) of a score of 0 - 15, 9- being moderately impaired for making daily decisions. Section O documented Resident #24 receiving oxygen while a resident at the facility.
On 3/9/21 at approximately 11:44 a.m., an interview was attempted with Resident #24 in their room. Observation of Resident #24's room revealed a suction machine on top of the nightstand to the left of the bed. A yankauer suction was observed attached to the suction machine and was observed lying on the nightstand uncovered. The yankauer suction was observed touching the surface of the nightstand. A nebulizer machine was observed on the nightstand with a nebulizer administration kit containing a facemask attached to the machine. The nebulizer mask was observed uncovered and lying on the nightstand touching the suction machine and the nightstand table surface. When asked if the staff used the suction and the nebulizer, Resident #24 nodded in confirmation.
Additional observations of Resident #24's room on 3/9/21 at 2:20 p.m., revealed the findings above. Observations on Resident #24's room on 3/10/21 at 9:00 a.m. and 3/10/21 at 11:45 a.m. revealed the findings above.
The physician's orders dated 3/1/21-3/31/21 for Resident #24 documented in part,
- Duoneb Ipratropium/Sol (solution) Albuterol 1 premixed unit via nebulizer every four hours as needed for wheezing. 02/21/19.
- Suction PRN (as needed). 2/24/21.
The MAR (medication administration record) dated 2/1/21-2/28/21 for Resident #24 documented in part, Suction prn. The MAR documented Resident #24 being suctioned X3 (three times) on 2/1/21.
The progress notes for Resident #24 documented in part the following:
- 2/23/2021 06:45 (6:45 a.m.) Note Text: Resident presenting with moist, rattle cough. Suctioned x 3 (three times) for copious amounts of thick clear sputum. Airway cleared, coughing greatly decreased. PRN (as needed) nebulizer applied for 15 minutes, with good effect. Resting quietly at this time. SpO2% (oxygen saturation) @2L/NC (at two liters per nasal cannula) -97%, no cyanosis (bluish discoloration of skin) observed. Nail beds remain pink with good cap refill. Oral care provided.
- 1/23/2021 14:20 (2:20 p.m.) Note Text: LEGACY CARE PROVIDER RECERTIFICATION NOTE; Federally mandated required provider visit, based on the resident's date of admission, for evaluation of chronic medical conditions and current status. [Resident #24] is an [Age and Sex of Resident #24] long term care resident who has chronic obstructive pulmonary disease. He has a nonproductive cough and shortness of breath at rest. He requires continuous oxygen via nasal cannula for his activities of daily living and sleep. He denies any wheezing, orthopnea (5) or pain with inspiration (inhaling).
The comprehensive care plan for Resident #24 dated 2/2/2021 documented in part,
- Risk for fluid output exceeding intake characterzed [sic] by fluid volume deficit; dry skin and mucous membranes, poor skin turgor and integrity related to: altered intake process, uncontrolled health conditions Date Initiated: 11/09/2020.
- [Resident #24] has care deficit pertaining to the teeth or oral cavity characterized by; altered oral mucous membrane; teeth/gums related to: declining health condition, medication, oxygen, respiratory treatments, need for occasional suctioning Date Initiated: 12/13/2019.
- Potential for or Actual Ineffective Breathing Pattern: COPD Date Initiated: 03/12/2019 Created on: 03/12/2019.
On 3/10/21 at approximately 3:00 p.m., an interview was conducted with LPN (licensed practical nurse) #3. When asked about nebulizer administration, LPN #3 stated that the nebulizer was stored in a plastic bag when not in use. LPN #3 stated that the purpose of the plastic bag was to keep it clean and free of germs. When asked about yankauer suction storage, LPN #3 stated that they were stored in a plastic bag when not in use to keep them clean and prevent contamination.
On 3/10/21 at 3:10 p.m., LPN #3 observed Resident #24's room. LPN #3 stated that she saw the problem. LPN #3 stated that the yankauer suction was uncovered and touching the surface of the nightstand and the nebulizer mask was uncovered and touching the surface of the nightstand and the suction machine. LPN #3 stated that she would remove the uncovered respiratory equipment.
On 3/9/21 at approximately 10:30 a.m., ASM (administrative staff member) #2, the director of nursing stated that the facility used their policies and procedures as their standard of practice.
On 3/11/21 at approximately 2:30 p.m., a request was made to ASM (administrative staff member) #2, the director of nursing for the policy for storage of nebulizer and suction equipment when not in use and oxygen administration.
On 3/12/21 at approximately 10:40 a.m., ASM #2 stated via email that the facility did not have a policy for the storage of nebulizer and suction equipment when not in use and provided the oxygen administration policy for review.
On 3/10/2021 at approximately 4:30 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing and ASM #3, the facility consultant were made aware of the findings.
No further information was provided prior to exit.
Reference:
1. Nebulizer - a device used to aerosolize medications for delivery to patients. Taken from Encyclopedia & Dictionary of Medicine, Nursing & Allied Health -Seventh Edition, [NAME]-[NAME], page 1182.
2. Yankauer suction- a rigid suction tip used to aspirate secretions from the oropharynx. This information was obtained from the following website: Yankauer suction catheter. (n.d.) Medical Dictionary for the Health Professions and Nursing. (2012). Retrieved March 15 2021 from https://medical-dictionary.thefreedictionary.com/Yankauer+suction+catheter
3. Chronic obstructive pulmonary disease (COPD) - disease that makes it difficult to breath that can lead to shortness of breath. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/copd.html.
4. Anemia - low iron. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/anemia.html.
5. Orthopnea- breathing difficulty while lying down is an abnormal condition in which a person has a problem breathing normally when lying flat. The head must be raised by sitting or standing to be able to breathe deeply or comfortably. This information was obtained from the website: https://medlineplus.gov/ency/article/003076.htm
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 staff interview, facility document review and clinical record review, it was determined that the facility staff failed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to ensure the provision of dialysis services, consistent with professional standards of practice, the comprehensive person-centered care plan for one of 35 residents, Resident #7. The facility staff failed to evidence ongoing communication and collaboration with the dialysis center for Resident #7.
The findings include:
Resident #7 was admitted to the facility on [DATE]. Resident #7's diagnoses included but were not limited to: end stage renal disease (inability of the kidneys to excrete wastes and function in the maintenance of electrolyte balance (1), mental disorder (any disorder of the mind such as disturbance of perceptions, memory and emotional equilibrium) (2) and hypertension (high blood pressure) (3).
Resident #7's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/15/20, coded the resident as scoring a 07 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is severely impaired cognitively. A review of the MDS Section G-functional status coded the resident as requiring extensive assistance for bed mobility, locomotion and dressing, total dependence for hygiene, bathing and eating. A review of MDS Section H- bowel and bladder coded the resident as always incontinent for bowel and bladder.
A review of the nursing progress notes documented the following in part:
-3/4/21 at 11:21 AM, documented in part, Returned to facility at 9:35 AM with dressing intact, no bleeding or drainage noted. Condition of shunt site: + (positive) bruit and thrill, alert and oriented per his norm.
- 3/6/21 at 9:58 AM, documented in part, Returned to facility from dialysis via patient transport in stable condition. No acute distress noted.
Resident #7's comprehensive care plan dated 3/27/20, documented in part, Focus: End state renal disease: at risk for complications due to hemodialysis. The Interventions: dated 3/27/20, documented, Dialysis (Tuesday, Thursday, Saturday). Assess resident upon return from dialysis treatment and notify physician of any significant changes.
A review of the dialysis communication forms for Resident #7 from 1/2/21-3/11/21, a period of 30 Tuesday, Thursday and Saturday dialysis treatments, evidence that 13 out of 30 (43%) of the dialysis communication forms were missing.
An interview was conducted on 3/11/21 at 10:50 AM with LPN (licensed practical nurse) #1. When asked the purpose of the dialysis communication form, LPN #1 stated, It is to communicate the resident's vital signs and any current issues or concerns. When asked the purpose of communication from the dialysis center on the form, LPN #1 stated, They communicate vital signs, weight, medications given and any issues or concerns.
An interview was conducted on 3/12/21 at 10:20 AM with ASM (administrative staff member) #2, the director of nursing. When asked the purpose of the dialysis communication form, ASM #2 stated, It is for sharing of information about the resident between the two facilities. When asked if there were any additional dialysis, communication forms than those sent, ASM #2 stated, No, there are not.
On 3/11/21 at 11:50 AM, ASM (administrative staff member) #1, the administrator, ASM#2 , the director of nursing, ASM#3, the clinical consultant , and ASM#4, the regional vice president were made aware of the above concern.
According to the facility's dialysis contract dated 5/19/11 which documents in part, The facility shall ensure that all appropriate medical and administrative information accompany all residents at the time of transfer or referral to the Center.
No further information was presented prior to exit.
References:
(1) Barron Dictionary of Medical Terms, 7th edition, Rothenberg and Kaplan, page 498.
(2) Barron Dictionary of Medical Terms, 7th edition, Rothenberg and Kaplan, page 363.
(3) Barron Dictionary of Medical Terms, 7th edition, Rothenberg and Kaplan, page 282.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected 1 resident
Based on staff interview, employee record review and facility document review, it was determined the facility staff failed to perform an annual performance review for four of 12 CNAs (certified nursin...
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Based on staff interview, employee record review and facility document review, it was determined the facility staff failed to perform an annual performance review for four of 12 CNAs (certified nursing assistants), CNA #1, CNA #2, CNA #3, and CNA #4.
The findings include:
An email requesting the CNA annual performance reviews was sent to ASM (administrative staff member) #1, the administrator, and ASM #2, the director of nursing on 3/9/2021 at 4:10 p.m. On 3/9/2021, 6:09 p.m. ASM #2 replied by email and documented, Employees have not had evaluations d/t (due to) continuous DON (director of nursing) turnover. I am presently in the process of beginning them.
CNA #1 was hired on 8/30/2017. The last annual performance evaluation was completed on 5/31/2019.
CNA #2 was hired on 11/16/1996. The last annual performance evaluation was completed on 5/3/2019.
CNA #3 was hired on 10/5/1918. There was no annual performance evaluation in the employee record.
CNA #4 was hired on 2/6/1991. The last annual performance evaluation was completed on 5/31/2019.
An interview was conducted with ASM #2, the director of nursing (DON), on 3/10/2021 at 1:08 p.m. When asked who is responsible for the CNA annual performance reviews, ASM #2 stated that she was responsible. ASM #2 stated she had gotten a list a week or two ago from human resources as to who needed annual performance reviews and was going to start them but hasn't gotten to them. When asked when she started as the DON, ASM #2 stated February 1, 2021. When asked why they had not been completed prior to now, ASM #2 stated due to the turnover of the DON position and the pandemic.
A request was made on 3/11/2021 at 2:21 p.m. for a policy and procedure on annual performance reviews. An email dated 3/12/2021 at 10:40 a.m. documented they did not have a policy on annual performance reviews.
ASM #2 was made aware of the above findings on 3/10/2021 at 1:15 p.m. ASM #1, the administrator, was made aware of the above concern on 3/12/2021 at 9:48 a.m.
No further information was provided prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation and staff interview it was determined that the facility staff failed to ensure expired medications and medical supplies were not available for use in one of one medication rooms o...
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Based on observation and staff interview it was determined that the facility staff failed to ensure expired medications and medical supplies were not available for use in one of one medication rooms observed, (the B/A medication storage room) and in one of one medication carts observed, (300 Hall medication cart).
The findings include:
On 03/09/21 at approximately 3:10 p.m., an observation of the B/A medication storage room was conducted in the presence of ASM [administrative staff member] # 2, director of nursing. Observation of the inside of a wall cabinet on the far right wall when entering the room, revealed two 10 mL [milliliter] vials of sterile water [1] located on the top shelf of a cabinet. The two 10 mL vials of sterile water were labeled with an expiration date of 03/01/2021, and were available for use.
Observation of a wall cabinet directly to the right of the of the medication storage room door when entering the room revealed one full, unopened bottle of Aspirin [2], 325 mg [milligrams], 100 count tablets with an expired date of February 2021, available for use.
Observation of a shelf on the back wall of the medication storage room of revealed one Female Cath [catheter] Kit With Gloves and Swabs with an expired date of 2021-01-31 [January 31, 2021], available for use.
On 03/09/2021 at approximately 3:30 p.m., an interview with ASM # 2 was conducted regarding the above items found in the medication room. ASM # 2 stated that the above items should have been removed.
On 03/10/21 at approximately 8:11 A.m., an observation of the facility's 300 Hall medication cart was conducted with LPN (licensed practical nurse) # 1. Observation of the medication cart drawer labeled Eye Drops revealed the following: one 2.5 ml eye drop bottle of Xalatan available for use. Observation of the bottle documented an open date of 1/24/20. Further observation of the bottle documented, Expires 6 weeks after opening. An interview was conducted with LPN # 1 at this time. LPN #1 agreed that the eye drops were expired and should have been removed from the medication cart.
On 03/10/2021 at approximately 8:25 a.m., an interview was conducted with ASM # 2, director of nursing. After examining the bottle of Xalatan, ASM # 2 stated that the bottle was approximately half full. When asked to describe the procedure staff follows to make sure expired medications are not available for use ASM # 2 stated, The third shift nurses are to go through the med [medication] carts and the medication rooms every day and remove any expired medication. They use a checklist to mark off what expired. If a nurse sees an expired medication in their cart they should remove it too.
On 03/10/2021 at approximately 10:00 a.m. ASM (administrative staff member) # 1, the administrator, and SAM # 2, director of nursing were made aware of the findings.
No further information was provided prior to exit.
References:
[1] Free from germs. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000119.htm.
[2] Nonprescription aspirin is used to reduce fever and to relieve mild to moderate pain from headaches, menstrual periods, arthritis, colds, toothaches, and muscle aches. Nonprescription aspirin is also used to prevent heart attacks in people who have had a heart attack in the past or who have angina, reduce the risk of death in people who are experiencing or who have recently experienced a heart attack, prevent ischemic strokes, mini-strokes, prevent hemorrhagic strokes It works by stopping the production of certain natural substances that cause fever, pain, swelling, and blood clots. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a682878.html.
[3] Also known as Latanoprost. Used to treat glaucoma. Latanoprost comes as eye drops. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a697003.html
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 and staff interview it was determined facility staff failed to serve food in a sanitary manner.
The findings include:
On 03/09/20 at 12:00 p.m., an observation of the facility's k...
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Based on observation and staff interview it was determined facility staff failed to serve food in a sanitary manner.
The findings include:
On 03/09/20 at 12:00 p.m., an observation of the facility's kitchen was conducted during the plating of resident's lunch trays.
Observation of the ceiling above the right end of the steam table when standing behind the steam table, revealed a five blade ceiling fan mounted on the ceiling, operational, [turning] during the plating of resident's food.
After all the resident's food was plated at approximately 12:30 p.m., the OSM #1, the cook was asked to turn off the ceiling fan above the right end of the steam table. Observation of the fan blades and motor housing with OSM # 1, revealed that they had a coating of dust on them. In an interview with OSM # 1 they agreed with the findings that the fan blades and motor housing were coated in dust. OSM # 1 stated, I should've turned it off before I started to serve. Usually I turn the fan off when serving the trays. When asked why it gets turned off OSM # 1 stated, So the food doesn't cool down and not blow any dust.
On 03/10/2021 at approximately 10:00 a.m., ASM [administrative staff member] # 1, the administrator, ASM # 2, director of nursing, were made aware of the findings.
No further information was provided prior to exit.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to evidence documentation of current side rail assessments and consents for four of 35 residents in the survey sample, Residents #21, #10, #2, and #32.
The findings include:
1. Resident #21 was observed lying in bed with side rails up during the course of the survey. The facility failed to evidence a current side rail assessment and a current consent for the use of the side rails.
Resident #21 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: dementia (a progressive state of mental decline, especially memory function and judgement, often accompanied by disorientation.)(1), and pulmonary fibrosis (an increase in the formation of fibrous connective tissue, either normally as in scar formation, or abnormally to replace normal tissue especially in the lungs) (2).
The most recent MDS (minimum data set) assessment, quarterly assessment, with an assessment reference date (ARD) of 1/11/2021, coded the resident as scoring a 3 on the BIMS (brief interview for mental status) score, indicating she was severely impaired to make daily cognitive decisions. Resident #21 was coded as requiring extensive assistance for moving in the bed. For moving in the room or unit, the resident was coded as only having performed this once or twice during the lookback period with the assistance of one staff member. In Section G0600 - Mobility Devices, Resident #21 was coded as using a wheelchair.
On the following dates and times, Resident #21 was observed lying in bed with both side rails up: 3/09/21 at 3:22 p.m., 3/10/21 at 8:57 a.m., 3/11/21 at 9:46 a.m.
A review of Resident #21's comprehensive care plan 4/15/20 revealed, in part: Use of bed rails for increasing or maintaining current bed mobility or transfer ability. Muscle weakness, safety in transfer .Assess resident for risk of entrapment from bed rails periodically and as necessary .evaluate use of device periodically for continued effectiveness and appropriateness .use of bedrails to assist resident to increase ability to enter and exit the bed at highest practical mobility level .use of bedrails to assist resident to turn and reposition when in bed.
Further review of Resident #21's clinical record failed to reveal evidence of a current side rail assessment or consent for the use of side rails.
On 3/11/21 at 2:00 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the clinical consultant, and ASM #4, the regional vice-president, were informed of these concerns. ASM #2 stated an assessment was performed for resident safety on original admission, and then quarterly with each care plan conference. She stated if side rail use is indicated, they are put into place, and are documented on the resident's care plan. ASM #2 stated, I don't know there is a process for checking the side rails before they are put up. She stated the facility's side rail assessment had fallen off of the computer software for some of the residents.
A review of the facility policy, Side Rail Guidelines revealed, in part: Side rails may be used to enhance resident mobility and transfer to and from the bed, or as a restraining device to keep residents from voluntarily getting out of bed. Use of side rails as a restraint is prohibited unless they are necessary to treat a resident's medical symptoms. The policy did not address the facility's assessment process.
No further information was provided prior to exit.
REFERENCES
(1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124.
(2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 227.
2. Resident #10 was observed lying in bed with side rails up during the course of the survey. The facility failed to evidence a current side rail assessment and a current consent for the use of the side rails.
Resident #10 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Alzheimer's disease (a progressive loss of mental ability and function, often accompanied by personality changes and emotional instability.) (1) and Parkinson's disease (a slowly progressive neurological disorder characterized by resting tremor, shuffling gait, stooped posture, rolling motions of the fingers, drooling and muscle weakness, sometimes with emotional instability) (2).
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/21/2020, coded the resident as scoring a 3 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired to make daily cognitive decisions. Resident #10 was coded as requiring extensive assistance of one staff member for moving in the bed. For moving in the room or unit, the resident was coded as being totally dependent upon one staff member. In Section G0600 - Mobility Devices, the resident was coded as using a wheelchair.
On the following dates and times, Resident #10 was observed lying in bed with both side rails up: 3/9/21 at 3:26 p.m., 3/10/21 at 8:55 a.m., 3/11/21 at 9:48 a.m.
A review of Resident #10's comprehensive care plan, dated 10/24/18 and revised on 11/11/20, revealed, in part: Use of bed rails for increasing or maintaining current bed mobility or transfer ability. Muscle weakness, Parkinson's Disease .Check bed rails periodically for proper functioning .evaluate use of device periodically for continued effectiveness and appropriateness .use of bedrails to assist resident to increase ability to enter and exit the bed at highest practical mobility level.
Further review of Resident #10's clinical record failed to reveal evidence of a current side rail assessment or consent for the use of side rails.
On 3/11/21 at 2:00 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the clinical consultant, and ASM #4, the regional vice-president, were informed of these concerns. ASM #2 stated an assessment was performed for resident safety on original admission, and then quarterly with each care plan conference. She stated if side rail use is indicated, they are put into place, and are documented on the resident's care plan. ASM #2 stated, I don't know there is a process for checking the side rails before they are put up. She stated the facility's side rail assessment had fallen off of the computer software for some of the residents.
No further information was provided prior to exit.
REFERENCES
(1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 26.
(2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 437.
3. Resident #2 was observed lying in bed with side rails up during the course of the survey. The facility staff failed to evidence a current side rail assessment and a current consent for the use of the side rails.
Resident #2 was admitted to the facility 5/17/2015 and was recently readmitted on [DATE] with diagnoses that included but were not limited to: dementia (a progressive state of mental decline, especially memory function and judgement, often accompanied by disorientation.)(1), high blood pressure and schizophrenia (Any of a group of mental disorders characterized by gross distortions of reality, withdrawal of thought, language, perception and emotional response) (2).
The most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 3/2/2021, coded the resident as having no difficulty with short or long-term memory difficulties. Resident #2 was coded as requiring extensive assistance of one staff member for moving in the bed. Resident #2 was coded as requiring limited assistance of one staff member for moving in their room or unit. In Section G0600 - Mobility Devices, the resident was coded as using a wheelchair.
On the following dates and times, Resident #2 was observed lying in bed with both side rails up: 3/9/21 at 11:16 a.m., 3/10/21 at 9:03 a.m.
A review of Resident #2's comprehensive care plan dated 10/24/18 revealed, in part: Use of bed rails for increasing or maintaining current bed mobility or transfer ability. Safety in transfers .Assess resident for risk of entrapment from bed rails periodically and as necessary .Check bed rails periodically for proper functioning .evaluate use of device periodically for continued effectiveness and appropriateness .use of bedrails to assist resident to increase ability to enter and exit the bed independently.
Further review of Resident #2's clinical record failed to reveal evidence of a current side rail assessment or consent for the use of side rails.
On 3/11/21 at 2:00 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the clinical consultant, and ASM #4, the regional vice-president, were informed of these concerns. ASM #2 stated an assessment was performed for resident safety on original admission, and then quarterly with each care plan conference. She stated if side rail use is indicated, they are put into place, and are documented on the resident's care plan. ASM #2 stated, I don't know there is a process for checking the side rails before they are put up. She stated the facility's side rail assessment had fallen off of the computer software for some of the residents.
No further information was provided prior to exit.
REFERENCES
(1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124.
(2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 522.
4. Resident #32 was observed lying in bed with side rails up during the course of the survey. The facility failed to evidence a current side rail assessment and a current consent for the use of the side rails.
Resident #32 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Parkinson's disease (a slowly progressive neurological disorder characterized by resting tremor, shuffling gait, stooped posture, rolling motions of the fingers, drooling and muscle weakness, sometimes with emotional instability) (1), congestive heart failure (abnormal condition characterized by circulatory congestion and retention of salt and water by the kidneys) (2) and bipolar disorder (a mental disorder characterized by episodes of mania and depression) (3).
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 1/20/2021, coded the resident as scoring a 14 on the BIMS (brief interview for mental status) score, indicating the resident was capable of making daily cognitive decisions. Resident #32 was coded as requiring limited assistance of one staff member for moving in the bed. Resident #32 was coded as requiring supervision with set up assistance for moving in their room or unit. In Section G0600 - Mobility Devices, the resident was coded as using a wheelchair.
On the following dates and times, Resident #32 was observed lying in bed with both side rails up: 3/9/21 at 11:27 a.m., 3/11/21 at 8:52 a.m.
A review of Resident #32's comprehensive care plan, dated 12/29/17 and updated 12/14/20, revealed, in part: Use of bed rails for increasing or maintaining current bed mobility or transfer ability. Muscle weakness. Safety in transfers. Other: maintain independence with bed mobility .Assess resident for risk of entrapment from bed rails periodically and as necessary .Check bed rails periodically for proper functioning .evaluate use of device periodically for continued effectiveness and appropriateness .provide and review with resident and/or resident's representative the risks and benefits of the use of side rails.
Further review of Resident #32's clinical record failed to reveal evidence of a current side rail assessment or consent for the use of side rails.
On 3/11/21 at 2:00 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the clinical consultant, and ASM #4, the regional vice-president, were informed of these concerns. ASM #2 stated an assessment was performed for resident safety on original admission, and then quarterly with each care plan conference. She stated if side rail use is indicated, they are put into place, and are documented on the resident's care plan. ASM #2 stated, I don't know there is a process for checking the side rails before they are put up. She stated the facility's side rail assessment had fallen off of the computer software for some of the residents.
No further information was provided prior to exit.
REFERENCES
(1)Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 437.
(2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 138.
(3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 72.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0909
(Tag F0909)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to evidence documentation of current bed/side rail safety assessments for four of 35 residents in the survey sample, Residents #21, #10, #2, and #32.
The findings include:
1. Resident #21 was observed lying in bed with side rails up during the course of the survey. The facility failed to evidence a current bed/side rail safety assessment for the resident.
Resident #21 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: dementia (a progressive state of mental decline, especially memory function and judgement, often accompanied by disorientation.)(1), and pulmonary fibrosis (an increase in the formation of fibrous connective tissue, either normally as in scar formation, or abnormally to replace normal tissue especially in the lungs) (2).
The most recent MDS (minimum data set) assessment, quarterly assessment, with an assessment reference date of 1/11/2021, coded the resident as scoring a 3 on the BIMS (brief interview for mental status) score, indicating she was severely impaired to make daily cognitive decisions. Resident #21 was coded as requiring extensive assistance for moving in the bed, moving in the room or unit, the resident was coded as only having performed this once or twice during the lookback period with the assistance of one staff member. In Section G0600 - Mobility Devices, the resident was coded as using a wheelchair.
On the following dates and times, Resident #21 was observed lying in bed with both side rails up: 3/09/21 at 3:22 p.m., 3/10/21 at 8:57 a.m., 3/11/21 at 9:46 a.m.
A review of Resident #21's comprehensive care plan 4/15/20 revealed, in part: Use of bed rails for increasing or maintaining current bed mobility or transfer ability. Muscle weakness, safety in transfer .Assess resident for risk of entrapment from bed rails periodically and as necessary .evaluate use of device periodically for continued effectiveness and appropriateness .use of bedrails to assist resident to increase ability to enter and exit the bed at highest practical mobility level .use of bedrails to assist resident to turn and reposition when in bed.
Further review of Resident #21's clinical record failed to reveal evidence of a current bed/side rail safety assessment.
On 3/11/21 at 2:00 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the clinical consultant, and ASM #4, the regional vice-president, were informed of these concerns. ASM #2 stated, I don't know there is a process for checking the side rails before they are put up.
On 3/11/21 at 12:39 p.m., OSM (other staff member) #9, the maintenance director, was interviewed. When asked about bed and side rail safety inspections, he stated the facility contracts with an outside company to come into the facility and do these inspection. OSM #9 stated that neither he nor ASM #1, the administrator was aware of the name of that contract company, and that there was no way to contact the company before the survey ended.
A review of the facility policy, Side Rail Guidelines revealed, in part: Side rails may be used to enhance resident mobility and transfer to and from the bed, or as a restraining device to keep residents from voluntarily getting out of bed. Use of side rails as a restraint is prohibited unless they are necessary to treat a resident's medical symptoms. The policy did not address the facility's process for bed/side rail safety inspections.
No further information was provided prior to exit.
REFERENCES
(1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124.
(2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 227.
2. Resident #10 was observed lying in bed with side rails up during the course of the survey. The facility failed to evidence a current bed/side rail assessment for the resident.
Resident #10 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Alzheimer's disease (a progressive loss of mental ability and function, often accompanied by personality changes and emotional instability.) (1) and Parkinson's disease (a slowly progressive neurological disorder characterized by resting tremor, shuffling gait, stooped posture, rolling motions of the fingers, drooling and muscle weakness, sometimes with emotional instability) (2).
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 12/21/2020, coded the resident as scoring a 3 on the BIMS (brief interview for mental status) score, indicating the resident was severely impaired to make daily cognitive decisions. Resident #10 was coded as requiring extensive assistance of one staff member for moving in the bed. For moving in the room or unit, the resident was coded as being totally dependent upon one staff member. In Section G0600 - Mobility Devices, the resident was coded as using a wheelchair.
On the following dates and times, Resident #10 was observed lying in bed with both side rails up: 3/9/21 at 3:26 p.m., 3/10/21 at 8:55 a.m., 3/11/21 at 9:48 a.m.
A review of Resident #10's comprehensive care plan, dated 10/24/18 and revised on 11/11/20, revealed, in part: Use of bed rails for increasing or maintaining current bed mobility or transfer ability. Muscle weakness, Parkinson's Disease .Check bed rails periodically for proper functioning .evaluate use of device periodically for continued effectiveness and appropriateness .use of bedrails to assist resident to increase ability to enter and exit the bed at highest practical mobility level.
Further review of Resident #10's clinical record failed to reveal evidence of a current bed/side rail safety assessment.
On 3/11/21 at 2:00 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the clinical consultant, and ASM #4, the regional vice-president, were informed of these concerns. ASM #2 stated, I don't know there is a process for checking the side rails before they are put up.
On 3/11/21 at 12:39 p.m., OSM (other staff member) #9, the maintenance director, was interviewed. When asked about bed and side rail safety inspections, he stated the facility contracts with an outside company to come into the facility and do these inspection. OSM #9 stated that neither he nor ASM #1, the administrator was aware of the name of that contract company, and that there was no way to contact the company before the survey ended.
No further information was provided prior to exit.
REFERENCES
(1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 26.
(2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 437.
3. Resident #2 was observed lying in bed with side rails up during the course of the survey. The facility failed to produce a current bed/side rail assessment for the resident.
Resident #2 was admitted to the facility 5/17/2015 and was recently readmitted on [DATE] with diagnoses that included but were not limited to: dementia (a progressive state of mental decline, especially memory function and judgement, often accompanied by disorientation.)(1), high blood pressure and schizophrenia (Any of a group of mental disorders characterized by gross distortions of reality, withdrawal of thought, language, perception and emotional response) (2).
The most recent MDS (minimum data set) assessment, a significant change assessment, with an assessment reference date of 3/2/2021, coded the resident as having no difficulty with short or long-term memory difficulties. The resident was coded as requiring extensive assistance of one staff member for moving in the bed. Resident #2 required limited assistance of one staff member for moving in their room or unit. In Section G0600 - Mobility Devices, the resident was coded as using a wheelchair.
On the following dates and times, Resident #2 was observed lying in bed with both side rails up: 3/9/21 at 11:16 a.m., 3/10/21 at 9:03 a.m.
A review of Resident #2's comprehensive care plan dated 10/24/18 revealed, in part: Use of bed rails for increasing or maintaining current bed mobility or transfer ability. Safety in transfers .Assess resident for risk of entrapment from bed rails periodically and as necessary .Check bed rails periodically for proper functioning .evaluate use of device periodically for continued effectiveness and appropriateness .use of bedrails to assist resident to increase ability to enter and exit the bed independently.
Further review of Resident #2's clinical record failed to reveal evidence of a current bed/side rail safety assessment.
On 3/11/21 at 2:00 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the clinical consultant, and ASM #4, the regional vice-president, were informed of these concerns. ASM #2 stated, I don't know there is a process for checking the side rails before they are put up.
On 3/11/21 at 12:39 p.m., OSM (other staff member) #9, the maintenance director, was interviewed. When asked about bed and side rail safety inspections, he stated the facility contracts with an outside company to come into the facility and do these inspection. OSM #9 stated that neither he nor ASM #1, the administrator was aware of the name of that contract company, and that there was no way to contact the company before the survey ended.
No further information was provided prior to exit.
REFERENCES
(1) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 124.
(2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 522.
4. Resident #32 was observed lying in bed with side rails up during the course of the survey. The facility failed to produce a current bed/side rail assessment for the resident.
Resident #32 was admitted to the facility on [DATE] with diagnoses that included but were not limited to: Parkinson's disease (a slowly progressive neurological disorder characterized by resting tremor, shuffling gait, stooped posture, rolling motions of the fingers, drooling and muscle weakness, sometimes with emotional instability) (1), congestive heart failure (abnormal condition characterized by circulatory congestion and retention of salt and water by the kidneys) (2) and bipolar disorder (a mental disorder characterized by episodes of mania and depression) (3).
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an assessment reference date of 1/20/2021, coded the resident as scoring a 14 on the BIMS (brief interview for mental status) score, indicating the resident was capable of making daily cognitive decisions. The resident was coded as requiring limited assistance of one staff member for moving in the bed. Resident #32 was coded as requiring supervision with set up assistance for moving in their room or unit. In Section G0600 - Mobility Devices, the resident was coded as using a wheelchair.
On the following dates and times, Resident #32 was observed lying in bed with both side rails up: 3/9/21 at 11:27 a.m., 3/11/21 at 8:52 a.m.
A review of Resident #32's comprehensive care plan, dated 12/29/17 and updated 12/14/20, revealed, in part: Use of bed rails for increasing or maintaining current bed mobility or transfer ability. Muscle weakness. Safety in transfers. Other: maintain independence with bed mobility .Assess resident for risk of entrapment from bed rails periodically and as necessary .Check bed rails periodically for proper functioning .evaluate use of device periodically for continued effectiveness and appropriateness .provide and review with resident and/or resident's representative the risks and benefits of the use of side rails.
Further review of Resident #32's clinical record failed to reveal evidence of a current bed/side rail safety assessment.
On 3/11/21 at 2:00 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #3, the clinical consultant, and ASM #4, the regional vice-president, were informed of these concerns. ASM #2 stated, I don't know there is a process for checking the side rails before they are put up.
On 3/11/21 at 12:39 p.m., OSM (other staff member) #9, the maintenance director, was interviewed. When asked about bed and side rail safety inspections, he stated the facility contracts with an outside company to come into the facility and do these inspection. OSM #9 stated that neither he nor ASM #1, the administrator was aware of the name of that contract company, and that there was no way to contact the company before the survey ended.
No further information was provided prior to exit.
REFERENCES
(1)Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 437.
(2) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 138.
(3) Barron's Dictionary of Medical Terms for the Non-Medical Reader, 5th edition, Rothenberg and [NAME], page 72.
MINOR
(B)
Minor Issue - procedural, no safety impact
Assessment Accuracy
(Tag F0641)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to complete an accurate MDS (minimum data set) assessment for one of 35 residents, Resident #7. Resident #7's clinical record documented the resident received dialysis services, however Section O special treatments, procedures and programs of Resident #7's MDS, a quarterly assessment with an ARD (assessment reference date) of 12/15/20, coded the resident as No for dialysis while a resident.
The findings include:
Resident #7 was admitted to the facility on [DATE]. Resident #7's diagnoses included but were not limited to: end stage renal disease (inability of the kidneys to excrete wastes and function in the maintenance of electrolyte balance (1), mental disorder (any disorder of the mind such as disturbance of perceptions, memory and emotional equilibrium) (2) and hypertension (high blood pressure) (3).
Resident #7's most recent MDS, a quarterly assessment with an ARD (assessment reference date) of 12/15/20, coded that the resident as scoring a of 07 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident is severely impaired cognitively. A review of the MDS Section G-functional status coded the resident as extensive assistance for bed mobility, locomotion and dressing, total dependence for hygiene, bathing and eating. In Section H- bowel and bladder Resident #7 was coded as always incontinent for bowel and bladder function. A review of MDS Section O-special treatments, procedures and programs coded the resident as No for dialysis while a resident.
A review of the nursing progress notes dated 12/15/20 at 3:45 AM, documented in part, Resident out of facility at this time in route to scheduled dialysis. Informed dialysis center of facial swelling and refusal of meals. Resident left in good spirits and in stable condition.
A review of the nursing progress notes dated 12/15/20 at 9:45 AM, documented in part, Resident returned to facility from dialysis via patient transport. No acute distress noted.
An interview was conducted on 3/10/21 at 1:44 PM with RN (registered nurse) #2, the MDS coordinator, regarding the purpose of the MDS assessment. RN #2 stated, The MDS should reflect the resident's status. As long as an item such as dialysis has occurred in the previous 90 days, it should be checked on the quarterly MDS assessment. When ask to review Resident #7's quarterly MDS dated [DATE] Section O, RN #2 stated, Dialysis is marked no. That is incorrect coding; He has consistently received dialysis three times a week since he has been here.
On 3/11/21 at 9:45 AM, RN#2 stated, I corrected the dialysis coding on the MDS Section O for that resident P[Resident #7].
On 9/12/19 at 12:30 PM, ASM (administrative staff member) #1 (administrator), #2 (director of nursing), #3 (medical director), #4 (regional clinical coordinator), #5 (director of nursing for another facility) and #6 (regional quality assurance director) were made aware of the above concern.
No further information was presented prior to exit.
References:
(1) Barron Dictionary of Medical Terms, 7th edition, Rothenberg and Kaplan, page 498.
(2) Barron Dictionary of Medical Terms, 7th edition, Rothenberg and Kaplan, page 363.
(3) Barron Dictionary of Medical Terms, 7th edition, Rothenberg and Kaplan, page 282.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Virginia facilities.
- • 27% annual turnover. Excellent stability, 21 points below Virginia's 48% average. Staff who stay learn residents' needs.
Concerns
- • 38 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
Bottom line: Mixed indicators with Trust Score of 68/100. Visit in person and ask pointed questions.
✓ Report will be sent to your email
About This Facility
What is Wayland's CMS Rating?
CMS assigns WAYLAND NURSING AND REHABILITATION CENTER an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Virginia, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Wayland Staffed?
CMS rates WAYLAND NURSING AND REHABILITATION CENTER's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 27%, compared to the Virginia average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Wayland?
State health inspectors documented 38 deficiencies at WAYLAND NURSING AND REHABILITATION CENTER during 2021 to 2025. These included: 1 that caused actual resident harm, 35 with potential for harm, and 2 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Wayland?
WAYLAND NURSING AND REHABILITATION CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by PRINCIPLE LONG TERM CARE, a chain that manages multiple nursing homes. With 90 certified beds and approximately 43 residents (about 48% occupancy), it is a smaller facility located in KEYSVILLE, Virginia.
How Does Wayland Compare to Other Virginia Nursing Homes?
Compared to the 100 nursing homes in Virginia, WAYLAND NURSING AND REHABILITATION CENTER's overall rating (4 stars) is above the state average of 3.0, staff turnover (27%) is significantly lower than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Wayland?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Wayland Safe?
Based on CMS inspection data, WAYLAND NURSING AND REHABILITATION CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Virginia. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Wayland Stick Around?
Staff at WAYLAND NURSING AND REHABILITATION CENTER tend to stick around. With a turnover rate of 27%, the facility is 19 percentage points below the Virginia average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly. Registered Nurse turnover is also low at 22%, meaning experienced RNs are available to handle complex medical needs.
Was Wayland Ever Fined?
WAYLAND NURSING AND REHABILITATION CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Wayland on Any Federal Watch List?
WAYLAND NURSING AND REHABILITATION CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.