LYNCHBURG HEALTH & REHABILITATION CENTER
For profit - Limited Liability company
180 Beds
LIFEWORKS REHAB
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
28/100
#260 of 285 in VA
Photo by Lynchburg Health & Rehabilitation Center
Photo by Lynchburg Health & Rehabilitation Center
Photo by Lynchburg Health & Rehabilitation Center
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Last Inspection: September 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Lynchburg Health & Rehabilitation Center has received a Trust Grade of F, indicating significant concerns about its quality of care. It ranks #260 out of 285 facilities in Virginia, placing it in the bottom half of the state, and #7 out of 8 in Lynchburg City County, meaning only one local facility is rated lower. While the facility is showing improvement, as the number of issues dropped from 30 in 2024 to 4 in 2025, it still has a troubling history, including a critical incident where staff failed to ensure proper safety protocols for a resident. Staffing is a weakness here, with a low rating of 1 star and a turnover rate of 52%, which is slightly above the state average. On a positive note, the facility has not incurred any fines, indicating no recent compliance issues. However, there have been concerns raised about the dining arrangements, as residents reported that the main dining room has been closed and used for storage, affecting their mealtime experience.
- Trust Score
- F
- In Virginia
- #260/285
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 52% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Virginia facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 28 minutes of Registered Nurse (RN) attention daily — below average for Virginia. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 57 deficiencies on record. Higher than average. Multiple issues found across inspections.
28/100
Bottom 9%
Review needed
30 → 4 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 30 issues
2025: 4 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Virginia average (3.0)
Significant quality concerns identified by CMS
Staff Turnover: 52%
Near Virginia avg (46%)
Higher turnover may affect care consistency
Chain: LIFEWORKS REHAB
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 57 deficiencies on record
1 life-threatening
Apr 2025
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
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 notify the responsib...
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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 notify the responsible party of a change in condition for one of four residents in the survey sample (Resident #3).
The findings include:
The facility provided no notification to Resident #3's responsible party regarding a change in condition and subsequent transfer to the hospital.
Resident #3 (R3) was admitted to the facility following hospitalization with diagnoses that included end-stage liver disease, alcoholic cirrhosis of liver with ascites, pyothorax, sepsis with septic shock, bacteremia, MRSA (methicillin resistant staphylococcus aureus), hepatic encephalopathy, influenza, anemia, acute kidney failure, chronic peripheral venous insufficiency, alcohol-induced dementia, hypotension, history of pneumothorax, diabetes, and mood disorder. The minimum data set (MDS) dated [DATE] assessed R3 as cognitively intact.
R3's clinical record documented the resident was transported to the hospital on 2/25/25 due to a change in condition. The clinical record documented no notification to the resident's emergency contact/responsible party regarding the change in condition and transport.
On 4/8/25 at 3:15 p.m., the director of nursing (DON) was interviewed about notification to R3's responsible party (RP) regarding the resident's change in condition and transfer to the hospital on 2/25/25. The DON stated nursing assessed R3 with low blood pressure and altered mental status around 6:00 a.m. on 2/25/25. The DON stated R3 was sent to the hospital due to change of condition. The DON stated there was no notification to R3's responsible party regarding the resident's change and transfer. The DON stated she talked with the resident's RP later in the day on 2/25/25 and the RP reported that nobody had called informing her of the change/transfer. The DON stated nurses were expected to notify the listed emergency contact regarding changes in condition and the notification should have been documented in the clinical record.
On 4/8/25 at 8:30 a.m., the registered nurse (RN #3) who was unit manager during R3's stay was interviewed. RN #3 stated the resident was sent to the hospital around 6:00 a.m. on 2/25/25. RN #3 stated when she arrived at work, she noted that R3 had been sent to the emergency room. RN #3 stated she was not aware notification had not been made to the RP.
On 4/9/25 at 11:00 a.m., RN #1 that cared for R3 on 2/25/25 at the time of transfer was interviewed. RN #1 stated around 5:50 a.m., R3 was assessed with a low blood pressure and oxygen saturations varying from 83% to 90%. RN #1 stated he attempted to call the on-call provider with no answer and then called the on-call nurse manager who instructed him to send the resident to the emergency room. RN #1 stated emergency services were called, and the resident was transported to the emergency room prior to 6:30 a.m. RN #3 stated he did not call or notify the resident's listed RP of the change in condition/transfer. RN #3 stated he communicated R3's transfer during shift change and thought the day shift nurses would make notification to the RP.
The facility's policy titled Significant Change of Condition (effective 1/29/24) documented, .A licensed nurse will assess the patient for signs and symptoms of change of condition .Responsible party will be notified of a change in condition .
This finding was reviewed with the administrator, assistant administrator and regional nurse consultant during a meeting on 4/9/25 at 2:50 p.m. with no further information presented prior to the end of the survey.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and facility document review, the facility staff failed to ensure a clean, homelike room environment fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and facility document review, the facility staff failed to ensure a clean, homelike room environment for one of four residents in the survey sample (Resident #3).
The findings include:
Resident #3 (R3) was admitted to the facility following hospitalization with diagnoses that included end-stage liver disease, alcoholic cirrhosis of liver with ascites, pyothorax, sepsis with septic shock, bacteremia, MRSA (methicillin resistant staphylococcus aureus), hepatic encephalopathy, influenza, anemia, acute kidney failure, chronic peripheral venous insufficiency, alcohol-induced dementia, hypotension, history of pneumothorax, diabetes, and mood disorder. The minimum data set (MDS) dated [DATE] assessed R3 as cognitively intact.
On 4/8/25 at 3:15 p.m., the director of nursing (DON) was interviewed about R3's room cleanliness. The DON stated R3's family member reported on 2/13/25 that the bed had not been made, and the room was not clean. The DON stated she went to R3's room and had the bed made/cleaned.
On 4/8/25 at 4:15 p.m., the housekeeping supervisor (other staff #4) was interviewed about any issues/concerns with the cleanliness of R3's room during February 2025. The housekeeping supervisor stated on 2/13/25, R3's family member reported the resident's room was not clean with trash in the floor, bed not made and sticky floors. The housekeeping supervisor stated he and two housekeepers went to R3's room. The housekeeping supervisor he observed the bed not made, trash in the floor and the floor was sticky. The housekeeping supervisor stated the housekeeper assigned to this room had reported she cleaned the room but had not. The housekeeping supervisor stated R3's room cleanliness was not up to standards. The housekeeping supervisor stated that nursing aides were responsible for making beds and providing clean linens. The housekeeping supervisor stated all resident rooms were supposed to the cleaned daily and that cleaning including mopping, emptying trash and cleaning the bathroom. The housekeeping supervisor stated rooms were cleaned as needed if there was an incident. The housekeeping supervisor again stated R3's room on 2/13/25 was not up to standards.
The facility's policy titled Method of Cleaning (undated) documented, .general cleaning practices, routine, and systems need to be in place and followed .Restrooms - address the same as a room, paying careful attention to the sink and commode .Check privacy curtain, linens and the overall condition of the room . Remove all debris from floors, counters, and edges .Remove all trash and replace liners as needed .mop floors using disinfecting neutral floor cleaner or quaternary disinfectant cleaner .
This finding was reviewed with the administrator, assistant administrator and regional nurse consultant during a meeting on 4/9/25 at 2:50 p.m. with no further information presented prior to the end of the survey.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, the facility staff failed to follow professional ...
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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 follow professional standards of quality for one of four residents in the survey sample (Resident #3).
The findings include:
Assessments and interventions implemented regarding a change in condition for Resident #3 were not recorded/documented.
Resident #3 (R3) was admitted to the facility following hospitalization with diagnoses that included end-stage liver disease, alcoholic cirrhosis of liver with ascites, pyothorax, sepsis with septic shock, bacteremia, MRSA (methicillin resistant staphylococcus aureus), hepatic encephalopathy, influenza, anemia, acute kidney failure, chronic peripheral venous insufficiency, alcohol-induced dementia, hypotension, history of pneumothorax, diabetes, and mood disorder. The minimum data set (MDS) dated [DATE] assessed R3 as cognitively intact.
R3's clinical record documented the resident was transferred to the hospital on 2/25/25 due to a change in condition. R3's clinical record included no documentation regarding the 2/25/25 change in condition or any assessments, interventions, communications leading to the transfer to the emergency department. A nursing note dated 2/25/25 at 8:57 a.m. documented the resident was sent to the emergency department on the prior shift.
On 4/8/25 at 3:15 p.m., the director of nursing (DON) was interviewed about any documentation of R3's change in condition/transfer that occurred on 2/25/25. The DON stated R3 experienced altered mental status and was transferred to the emergency department on 2/25/25 around 6:00 a.m. The DON stated the nurse caring for R3 at the time of the transfer did not document assessments of the resident, interventions or communications regarding the change in condition and transfer. The DON stated it was an expectation that nurses document in the clinical notes regarding any changes in condition, any assessments conducted and significant events such as hospital transfer.
On 4/9/25 at 11:00 a.m., registered nurse (RN) #1 that cared for R3 during the early morning shift on 2/25/25 was interviewed. RN #1 stated he assessed R3 on 2/25/25 around 12:30 a.m. with oxygen saturation at 93% and he applied the resident's oxygen. RN #1 stated he asked R3 about pain and the resident stated he had no pain. RN #1 stated the other vital signs were nothing unusual but he did not remember the vital sign readings other than the oxygen saturation. RN #1 stated he checked on R3 multiple times during the shift. RN #1 stated another set of vitals signs were obtained mid-shift and they were ok with improved oxygen saturation. RN #1 stated he did not remember the vital sign readings and he did not record them in the clinical record. RN #1 stated around 5:50 a.m., R3's blood pressure was assessed as low at 100/50, and oxygen saturations were varying between 83% to 90%. RN #1 stated he attempted to call the nurse practitioner but got no answer so informed the on-call nurse manager. RN #1 stated the nurse manager instructed him to send R3 to the emergency room due to the change in condition. RN #1 stated he did not document the vital signs taken during the shift, did not document the attempted communication to the provider or the call to the nurse manager. RN #1 stated he did not document any nursing notes about R3's change in condition or transfer. RN #1 stated after EMS transferred R3 to the hospital, he administered medications before the end of his shift at 7:00 a.m. RN #1 stated he communicated R3's change/transfer to the day shift at shift change. RN #1 stated he left at the end of his shift and stated, I just didn't document it. When asked if he considered a late entry of the events, RN #1 stated he was an agency nurse and had not worked at the facility since 2/25/25.
On 4/9/25 at 1:40 p.m., the regional nurse consultant (administration staff #4) was interviewed about lack of documentation regarding R3's change of condition/transfer. The regional nurse consultant stated nurses were supposed to document any assessments and changes in condition in the clinical record at the time of the events. The regional nurse consultant stated standards of practice included timely documentation of changes and events.
The facility's policy titled Significant Change of Condition (effective 1/29/24) documented, .A licensed nurse will assess the patient for signs and symptoms of change of condition .Notify provider and document in Progress Notes .
The Lippincott Manual of Nursing Practice 11th edition on page 15 documents regarding common departures from standards of nursing care, .A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation. This should be done at the time the care is rendered because passage of time may lead to a less than accurate recollection of the specific events . (1)
This finding was reviewed with the administrator, assistant administrator and regional nurse consultant during a meeting on 4/9/25 at 2:50 p.m. with no further information presented prior to the end of the survey.
(1) [NAME], [NAME] M. Lippincott Manual of Nursing Practice. Philadelphia: Wolters Kluwer Health/[NAME] & [NAME], 2019.
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
Medical Records
(Tag F0842)
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 a complete 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 a complete and accurate clinical record for one of four residents in the survey sample (Resident #3).
The findings include:
Resident #3's clinical record did not include documentation regarding assessments and interventions implemented related to a change in condition with subsequent transfer to the hospital.
Resident #3 (R3) was admitted to the facility following hospitalization with diagnoses that included end-stage liver disease, alcoholic cirrhosis of liver with ascites, pyothorax, sepsis with septic shock, bacteremia, MRSA (methicillin resistant staphylococcus aureus), hepatic encephalopathy, influenza, anemia, acute kidney failure, chronic peripheral venous insufficiency, alcohol-induced dementia, hypotension, history of pneumothorax, diabetes, and mood disorder. The minimum data set (MDS) dated [DATE] assessed R3 as cognitively intact.
R3's clinical record documented the resident was transferred to the hospital on 2/25/25 due to a change in condition. R3's clinical record included no documentation regarding the 2/25/25 change in condition or any assessments, interventions, communications leading to the transfer to the emergency department. A nursing note dated 2/25/25 at 8:57 a.m. documented the resident was sent to the emergency department on the prior shift.
On 4/8/25 at 3:15 p.m., the director of nursing (DON) was interviewed about any documentation of R3's change in condition/transfer. The DON stated R3 experienced altered mental status and was transferred to the emergency department on 2/25/25 around 6:00 a.m. The DON stated the nurse caring for R3 at the time of the transfer did not document assessments of the resident, interventions and/or communications regarding the change in condition and transfer. The DON stated nurses should document in the clinical notes regarding any changes in condition, any assessments conducted and significant events such as hospital transfer.
On 4/9/25 at 11:00 a.m., registered nurse (RN) #1 that cared for R3 during the early morning shift on 2/25/25 was interviewed. RN #1 stated he assessed R3 on 2/25/25 around 12:30 a.m. and his oxygen saturation was at 93% and he reapplied the resident's oxygen. RN #1 stated he asked R3 about pain and the resident stated he had no pain. RN #1 stated the other vital signs were nothing unusual but he did not remember the vital sign readings other than the oxygen saturation. RN #1 stated he checked on R3 multiple times during the shift. RN #1 stated around 5:50 a.m., R3's blood pressure was low at 100/50, and oxygen saturations were varying between 83% to 90%. RN #1 stated he attempted to call the nurse practitioner but got no answer so informed the on-call nurse manager. RN #1 stated the nurse manager instructed him to send R3 to the emergency room due to the change in condition. RN #1 stated he did not document the vital signs taken during the shift, did not document the attempted communication to the provider or the call to the nurse manager. RN #1 stated he did not document any nursing notes about R3's change in condition or transfer. RN #1 stated after EMS transferred R3 to the hospital, he administered medications before the end of his shift at 7:00 a.m. RN #1 stated he communicated R3's change/transfer to the day shift at shift change. RN #1 stated, I just didn't document it. When asked if he considered a late entry of the events, RN #1 stated he was an agency nurse and had not worked at the facility since 2/25/25.
On 4/9/25 at 1:40 p.m., the regional nurse consultant (administration staff #4) was interviewed about lack of documentation regarding R3's change of condition/transfer. The regional nurse consultant stated nurses were supposed to document any assessments and changes in condition in the clinical record.
The facility's policy titled Significant Change of Condition (effective 1/29/24) documented, .A licensed nurse will assess the patient for signs and symptoms of change of condition .Notify provider and document in Progress Notes .
This finding was reviewed with the administrator, assistant administration and regional nurse consultant during a meeting on 4/9/25 at 2:50 p.m. with no further information presented prior to the end of the survey.
Sept 2024
29 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation and staff interview, the facility staff failed to distribute meals in a manner to maintain and enhance a residents dignity affecting several residents on one of three units.
The ...
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Based on observation and staff interview, the facility staff failed to distribute meals in a manner to maintain and enhance a residents dignity affecting several residents on one of three units.
The findings included:
The facility staff failed to distribute meal trays in a manner to uphold resident's dignity.
On 9/9/24 at 12:58 p.m., the lunch meal was observed in the restorative room on the west wing. It was noted that R22 was sitting at a table with resident #9 (R9). R9 was served her meal and began eating. All the other residents in the dining room were served, including a tray sat between R22 and R9 for another resident who was not present in the dining room.
CNA #4 was the only staff member remaining in the dining room after the trays had been served, and she was sitting to assist in feeding resident #55. The surveyor identified several concerns with regards to the consistency of pureed foods. LPN #6 was asked to verify that residents who were served pureed foods were not given a pureed consistency of food. LPN #6 then removed R9's tray to take it to the kitchen to be prepared at the correct consistency. In doing so, it left R9 and R22 in the dining room with all the other residents eating their meal with no food for them to eat.
R22 was then observed to remove the coffee from the meal tray sitting between him and R9, as he had no beverages or food items. A few minutes later, R9 then removed the lid from the plate of food that had been put on the table between her and R22. CNA #4 came over and recovered the plate of food. The surveyor asked where R22's food was and CNA #4 said, it wasn't on the cart. At 1:18 p.m., R22 was served his meal tray that had been taken onto the unit in the meal cart.
On 9/9/24 at 1:22 p.m., the resident whose tray had been sat on the table between R22 and R9 came into the dining room and was assisted to the table where his food that had been sitting since 12:58 p.m. This was the same tray that R22 had removed the coffee from and R9 had removed the cover from.
On 9/10/24, during an end of day meeting with the facility administrator, director of nursing and corporate staff, the above findings were reviewed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
Could have caused harm · This affected 1 resident
Based on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure residents dignity was upheld for one resident, ...
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Based on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure residents dignity was upheld for one resident, (Resident #99 - R99) in a survey sample of 33 residents.
The findings included:
1. For R99, the facility failed to ensure the resident had adequate clothing and season approriate clothing to wear to ensure his dignity was maintained with regards to his personal appearance.
On 9/09/24 at 12:45 p.m., R99 stopped the surveyor in the hallway. R99 was sitting outside his room in the hall and told the surveyor, Look what they dress us in, and pointed to his clothing. R99 was observed to be dressed in a flannel shirt and denim jeans which were cut off at the ankles and torn up the back of the calf. R99 reported he has lived at the facility for five years and had nice clothes when he came in, but they are all gone and, They give me clothes left over from other people, but they don't even fit. R99 went on to say he had a doctor's appointment outside of the facility and had to go, saying, This is how I looked. At this point, R99's nurse asked if the surveyor was done with R99 because he had an appointment and she needed to take him.
On 9/10/24 at 8:41 a.m., R99 was interviewed in his room. R99 was observed to have the same clothes on he had on the prior day. R99 stated that all he has is winter clothes and that he must wear the same clothes for several days to stretch them out, because he is limited in what he has. When asked how this made him feel, R99 said, Horrible and like no one gives a [profanity]! Observations were made of R99's clothes in his closet, and it was noted he had 3 long-sleeve flannel shirts, a sweater, a winter coat, and two pair of denim pants. R99 pointed to a green pair of pants and said, They are 32, then pointed to the second pair of pants and said, They are 38, and I wear a 34. They have all of those jogging pants, but I carry a wallet, so I don't wear those. R99 reported he has family but hasn't seen them in a year. When asked if he had a bank account at the facility, R99 said he did but had very little funds.
On 9/11/24 at approximately 8:30 a.m., R99 was again visited in his room. R99 was observed wearing the same clothes he had been wearing over the two days prior.
On 9/11/24 at 9:03 a.m., an interview was conducted with the social services assistant (SSA). When asked what is done if a resident needs clothes, the SSA said, We look into if they have their own funds. I go to [housekeeping/laundry manager's name redacted] who oversees laundry. There is a large amount of clothing that is unclaimed and do not have names. I've gone to try to find clothing the size a resident may need or if items are missing, we try to find out when they disappeared. I am open to trying to assist them in buying clothes, we have a relationship with Walmart. I'm willing to go shopping. When asked about the residents who don't have money, the SSA said, I would go to administrator to see if there are extra funds. When informed of R99's clothing situation, the SSA said that he had not heard about that. The SSA accompanied the surveyor to R99's room and observed the clothing in the closet. The SSA said, I feel so bad for him. I will get to work on that right away.
On 9/11/24, during review of another survey task it was noted that R99 had a resident trust account with the facility that held a substantial amount of funds that could have been used to purchase R99 clothing. The surveyor made the SSA aware of this at approximately 11:30 a.m.
On 9/11/24 at 4:35 p.m., during an end of day meeting held with the facility administrator, director of nursing, and corporate staff the above findings were discussed.
On 9/12/24, at approximately 9:30 a.m., R99 was seen his in room wearing the same clothing as the three days prior. When questioned aboout this, R99 reported that no one had said anything else to him regarding the clothing situation.
No additional information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to issue an ABN (...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to issue an ABN (Advanced Beneficiary Notice) to one resident (Resident #107-R107) in a survey sample of three residents reviewed for such notices.
The findings included:
For R107, who remained a resident of the facility, the facility staff failed to issue an ABN, which would have afforded the resident the opportunity to decide if they wanted to continue to receive skilled services and assume the financial responsibility or have the fiscal intermediary make the coverage determination.
On 9/9/24, a sample of three residents was selected for review of beneficiary notices. According to the listing provided by the facility, R107 had remained in the facility following skilled services ending.
On 9/10/24, the facility staff provided the survey team with the beneficiary notices issued to each resident and noted R107 was not provided an ABN because .he was short-term and was supposed to discharge.
On 9/10/24 during a clinical record review, it was noted that R107 came off skilled care (Medicare Part A reimbursed stay) on 3/8/24, became self-pay on 3/9/24, and did not discharge from the facility until 8/28/24. R107 had been admitted to the facility on [DATE], and only used 45 of the 100 benefit days under Medicare Part A. According to the progress notes, a social services entry was made on 3/6/24 that read, Talked with daughter, [name redacted], in regards to apartment searching for her father. She stated that she has been continuing to look and would contact if she was in need of assistance for SWDC [social work/discharge] office. According to this note, the facility was aware that a discharge plan/location had not been yet arranged and the resident would remain at the facility.
On 9/10/24 at 11:25 a.m., an interview was conducted with the Corporate Social Worker and Discharge Planner, who formerly worked at the facility. When asked about R107's not being issued an ABN, the Corporate Social Worker said, He was supposed to go home. We had started things and things changed, where he stayed longer. He never left until sometime later. He was an in and out case, this wasn't the first time he had been with us, previously he had an APS [adult protective services] case open, then wasn't on APS. His daughter was here and would try to help with housing and transport. He would say he wanted to stay a few days. Never knew if he really wanted to stay or go. [Employee's name redacted of former social worker] did the NOMNC and was sure he [R107] would change his mind before we got there. We didn't think far enough ahead, his plan wasn't to be here. When questioned if the 3/6/24 progress note, noting that the daughter was still looking for housing, indicated the need for issuing an ABN, the Corporate Social Worker said, He didn't have his own house. He had been living with his daughter. She was going to help with finding a place in the community and I assume it didn't really work out that away. I think it was an oversight and we thought he would change his mind. That's how he was every time he was here.
On 9/10/24 at 2:08 p.m., an interview was conducted with the facility's director of social work and discharge planning (SWDC planner). The SWDC planner was asked about ABN's notices. The SWDC planner said, An ABN is when a long-term care patient is skilled and using Medicare benefits and switching back to long-term care, once they receive the NOMNC [notice of Medicare non-coverage] they also receive an ABN. When asked why the ABN is important, SWDC planner said, So they have the option, their choice. If they want their therapy to continue and they want to pay, it's their choice.
On 9/10/24, in the afternoon, the corporate social worker and discharge planner provided the survey team with R107's progress notes to indicate his plan was to discharge. The notes included an entry dated 1/26/24, entered by the corporate social worker which was titled, Discharge Planning Note. The note read, DCP [discharge planner] was made aware that resident wanted to discuss dc plans. DCP explained what a safe dc plan looks like and steps needed to be taken. [R107's name redacted] stated that he understood. DCP also explained that she would speak with DOR [director of rehab] and clinical team about what timeframe would be appropriate for a potential dc [discharge] in the near future.
There was another entry dated 1/31/24 by the corporate social worker and discharge planner in R107's chart. This note read, DCP spoke with resident for 45+ minutes today in regard to future dc plans. Resident states he does not recall any of our conversations previous to this point. Resident stated that he was frustrated. Writer explained that multiple conversations had been held between the two of them for the past several days. Resident stated guess I just forgot. DCP went through the process of a safe dc plan with resident. Resident then stated I don't need to tell you about where I'm going and that should be none of your concern. DCP notified ADON [assistant director of nursing] and NP [nurse practitioner] about situation.
The facility also provided two progress notes from a medical provider that indicated: . length of stay: 3-5 weeks and . length of stay: 2-4 weeks.
The facility policy dated 4/1/22, which was titled, Advanced Beneficiary Notice (ABN) was reviewed. The policy read in part, The Advanced Beneficiary Notice will be used to properly notify a Medicare Part A or Medicare Part B patient and/or Responsible Party of the clinical determination that the patient no longer meets the Medicare criteria for skilled services . 2. The social work and discharge planner or designee issues the notice to the beneficiary or their respresentative in person or by telephone of the upcoming non-coverage status based on clinical team recommendations .
CMS defines the use of the SNF ABN in the section 70.3 of the Medicare Claims Processing Manual in chapter 30 on page 84, it read, A SNF ABN is evidence of beneficiary knowledge about the likelihood of a Medicare denial, for the purpose of determining financial liability for expenses incurred for extended care items or services furnished to a beneficiary and for which Medicare does not pay. If Medicare is expected to deny payment (entirely or in part) on the basis of one of the exclusions listed in §70 of this chapter for extended care items or services that the SNF furnishes to a beneficiary, a SNF ABN must be given to the beneficiary in order to transfer financial liability for the item or service to the beneficiary. The table on page 85 stated, In the situation in which a SNF proposes to stop furnishing all extended care items or services to a beneficiary because it expects that Medicare will not continue to pay for the items or services that a physician has ordered and the beneficiary would like to continue receiving the care, the SNF must provide a SNF ABN to the beneficiary before it terminates such extended care items or services.
On CMS.gov, instructions on the SNF ABN form were reviewed. These instructions read in part, .Medicare requires Skilled Nursing Facilities (SNFs) to issue the SNF ABN to Original Medicare, also called fee-for-service (FFS), patients prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is: o not medically reasonable and necessary; or o considered custodial. The SNF ABN provides information to the patient so that s/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. SNFs must use the SNF ABN when applicable for SNF Prospective Payment System services (Medicare Part A) .
On 9/11/24, during an end of day meeting, the facility administrator and corporate staff were made aware of the above findings.
No further information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, clinical record review and facility documentation review, the facilit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to provide a homelike environment and clean medical equipment for resident use, affecting two residents (Resident #99- R99 and Resident #55- R55) in a survey sample of 33 residents.
The findings included:
1. For R99, the facility staff failed to provide the resident with a closet in good repair, as a door was missing.
On 9/9/24 at 12:45 p.m., R99 was visited in his room. Observations of the resident's room were made, and it was noted that the closet was missing a door. R99 was asked about the closet and R99 reported it had been like that ever since he moved into that room.
On 9/10/24 at 8:41 a.m., R99 was visited again in his room by the surveyor, and it was noted that the closet was still missing a door.
On 9/10/24 at 8:43 a.m., an interview was conducted with the certified nursing assistant (CNA #3). CNA #3 was asked about R99's closet not having a door and she confirmed it had been like that for months.
On 9/10/24 at 9:18 a.m., an interview was conducted with other employee #13 (OE#13). OE #13 confirmed that she was responsible for conducting daily rounds which included R99's room. OE #13 explained that she has a form that she notes any problems, the form is then taken to the morning meeting by the department director, and it is discussed with the entire management team. OE#13 confirmed that R99's closet had been missing a door for the duration of the time she had been doing the rounds, which was approximately two months.
On 9/10/24 at approximately 9:30 a.m., an interview was conducted with the unit manager. The unit manager said that R99 didn't have a closet door because they are getting new ones.
On 9/10/24, a clinical record review was conducted of R99's chart. According to the census tab of the chart, R99 had moved into the currently assigned room on 4/23/24.
On 9/11/24 at 9:18 a.m., an interview was conducted with the regional director of clinical services (RDCS). The RDCS confirmed that the managers make rounds daily which they call angel rounds. Then during the morning meeting any concerns identified are discussed and actions taken to resolve the identified concerns. The RDCS was asked to provide any evidence of when R99 closet, which was missing a door was first identified and what steps were taken to resolve it. The RDCS said this was unacceptable and she would ensure R99 was provided with a closet door.
On 9/11/24, in the afternoon, an interview was conducted with the facility's maintenance director. The maintenance director reported that R99's closet had been brought to his attention and he had a door he was going to install.
On the afternoon of 9/11/24, the facility's corporate staff provided the survey team with a copy of an email. The email read in part, our corporate cabinet shop has been making replacement doors and drawer fronts for the wardrobes since March of this year. We have approximately 20 more sets at the shop ready to be delivered when needed .
On 9/11/24, during an end of day meeting, the facility administrator, director of nursing and corporate staff was made aware of the above findings.
No additional information was provided.
2. Resident #55's wheelchair was dirty and in disrepair.
Resident #55 (R55) was admitted to the facility with diagnoses that included cerebral infarction, hypertension, cataracts, dysphagia, aphasia, dysarthria, dementia, psychotic disturbance, mood disturbance and anxiety. The minimum data set (MDS) dated [DATE] assessed R55 with severely impaired cognitive skills.
On 9/9/24 at 4:25 p.m., R55 was observed in a specialized, padded wheelchair in the day room. The covering on both arm cushions was torn/missing with white fabric exposed. The wheelchair was dirty with crumbs, dust, debris, and dried drip substances observed on the support bars and wheels.
On 9/10/24 at 2:50 p.m., accompanied by licensed practical nurse unit manager (LPN #3), R55's wheelchair was observed. The covering on both arms of the chair was torn/missing with white fabric visible. The wheelchair was observed with drips, crumbs, dust, and debris on the support bars and on the under-surface of the chair. The chair's seat cushion was worn with a patched area near the front of the cushion. LPN #3 was interviewed at this time about the condition of R55's wheelchair. LPN #3 stated that housekeeping was responsible for routine cleaning of resident equipment and that she would contact hospice about the needed chair repair.
On 9/10/24 at 4:50 p.m., accompanied by the housekeeping supervisor (other staff #7), R55's wheelchair was observed. The housekeeping supervisor was interviewed at this time about the torn arm coverings and dirty condition of the chair. The housekeeping supervisor stated housekeepers were responsible for cleaning resident equipment at the time of discharge. The housekeeping supervisor stated routine cleaning of resident equipment was assigned to third shift aides/nurses. The housekeeping supervisor stated resident equipment, including wheelchairs was usually cleaned in the shower rooms during the night shift. The housekeeping supervisor stated R55's wheelchair needed cleaning and repair. The housekeeping supervisor stated he was not sure who could repair or replace the arm cushions.
This finding was reviewed with the administrator, director of nursing and regional nurse consultants during a meeting on 9/10/24 at 5:15 p.m. with no further information presented prior to the end of the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to report an allegation of abuse to the state survey agency and other ...
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Based on resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to report an allegation of abuse to the state survey agency and other officials as required for an incident involving two residents (Resident #14 - R14 and Resident #99 - R99) in a survey sample of 33 residents.
The findings included:
For R14 and R99, who had a physical altercation, resulting in injury to R14, the facility staff failed to have credible evidence that the incident of abuse and the investigation results were reported to the state survey agency and other officials.
On 9/9/24 at 3:06 p.m., during an interview with R14, the resident reported that he had an incident with a prior roommate where the roommate was punching him and gave him a black eye. When asked what had happened to cause this, R14 said, He said the tv was too loud, but he never asked me to turn it down.
On 9/10/24, the facility was asked to provide evidence of all events they had reported and addressed since January 2024. Review of the files revealed a one-page document that noted an event on 2/21/24 that indicated R14 had bruising/abrasion to left eye. The event summary details were noted as .residents had a verbal altercation which resulted in [R99's name redacted] hand making contact with [R14's name redacted] left eye. There was no evidence that this incident was reported to the state survey agency, adult protective services, or law enforcement. The facility was asked to provide any other evidence of this incident being reported or investigated to the survey team.
On 9/10/24, a clinical record review was conducted of R14's chart. This review revealed a behavior progress note dated 2/21/24 at 6:10 p.m., that read, Writer was in the middle of doing med pass when yelling was heard down the hallway. Writer found resident in his bed with roommate nearby. Roommate had fallen on top of resident. Writer had asked what was going on, roommate said resident was running his mouth, resident had said something to roommate and then roommate had turned back and started punching resident in the face while on top of him. Male CNA was able to stand in between both residents enough to keep them from hitting each other any further. Was able to get roommate off resident and into chair. Separated both and called manager on duty. On 2/22/24, R14 was seen by the doctor who noted, . was involved in altercation yesterday and now has c/o left hand pain and swelling . left hand ecchymosis and soft tissue edema. mild ecchymosis of left orbit .Assessment and Plan: left hand pain- hand x-ray ordered. pain control with tramadol . X-rays were ordered of R14's left hand and elbow, which were negative for a fracture.
On 9/11/24, the regional director of clinical services (RDCS) provided the survey team with a few written statements from staff regarding the 2/21/24 incident between R14 and R99. The RDCS confirmed that she did not have any evidence that the event, nor the event summary was reported to the required agencies. The RDCS confirmed that the event summary should include the steps taken by the facility and should have all been reported to adult protective services, the state survey agency and police.
According to the facility provided witness statements of staff who witnessed and/or intervened during the resident-to-resident altercation, both residents sustained injury. According to a statement from a licensed practical nurse, it noted, Nurse was in the middle of med pass when noted there was yelling down the hall. Went to room and saw [R99's name redacted] standing by [R14's name redacted] bed. Saw [R99's] pants sliding off and he fell over onto [R14]. Asked what was going on. [R99] stated that [R14] was running his mouth. [R14] had said something to [R99] then [R99] started punching [R14] in the face, at least 7-8 times. [R14] was also punching, hit [R99] in the face twice. CNA [name redacted] stood in between as much as possible to stop the fight. Was able to remove [R99] and put him back in his wheelchair. Noted bleeding from [R14]'s nose and reddening to left eye. [R99] has a elongated red mark going from left eye to forehead.
Review of the facility's abuse policy titled; Reporting Requirements/Investigations was conducted. The policy read in part, 1. Immediately upon notification of any alleged violation involving abuse, neglect, exploitation, or mistreatments, including injuries of unknown source and misappropriation of resident property, the administrator will immediately report to the state agency, but not later than 2 hours after the allegation is made, if the events that caused the allegation involves abuse or results in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury. a. Notify the Adult Protective Services Agency, the local Ombudsman, and the appropriate local law enforcement authorities for any incident of patient abuse, mistreatment, neglect, or misappropriation of personal property or other reasonable suspicion of a crime . 2. The administrator and/or Director of Nursing will immediately initiate a thorough internal investigation of the alleged/suspected occurrence . 5. The administrator must thoroughly investigate and file a complete written report of the investigation of the submitted FRI [facility reported incident] to the state agency within five working days of the incident .
On 9/10/24, during an end of day meeting, the facility administrator and corporate staff were made aware of the above findings.
No additional information was provided.
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 documentation review, the facility staff failed to develop a comprehensive resident-centered care plan for one resident (Resi...
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Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to develop a comprehensive resident-centered care plan for one resident (Resident #49-R49) in a survey sample of 33 residents.
The findings included:
For R49, who had bilateral hand contractures, the facility staff failed to develop a comprehensive resident centered care plan to identify the contractures and interventions.
On 9/9/24 and 9/10/24, various observations were conducted of R49. R49 was noted on each observation to be non-verbal and had bilateral hand contractures. The resident was observed with no splint to the hands and no palm protectors.
On 9/10/24 at 2:49 p.m., an interview was conducted with the therapy director (TD). The TD reported that R49 was on therapy caseload previously. The TD noted from 11/17/22-11/23/22, R49 was on occupational therapy caseload, and they were concerned about hand contractures. The therapy director noted that they had noted, Palm guards to right and left hands up to 4 hours and he was tolerating them 8 hours without any signs or symptoms of redness. The therapy director noted that every three months they do an audit of splints and in June they noted the splint was cleaned and continue the splint schedule 7 days a week with skin checks every 2 hours.
During the above interview with the therapy manager, she was asked about the purpose of splints for contractures. She stated, to keep the hand open and not tight and closed. If they are tight, it can cause pressure, to keep minimally open, if tight a palm guard is to keep minimally open, to prevent pressure, moisture, anything like that in the hand.
On 9/10/24 at 3:01 p.m., a licensed practical nurse (LPN #4) accompanied the surveyor to R49's room. The nurse confirmed that R49 did not have any splint device in use, and none was found in the room.
On 9/10/24 at 3:07 p.m., an interview was conducted with the unit manager. The unit manager was asked about R49's splint. The unit manager said she recalled R49 had palm guards and reported sometimes the family takes them home and washes them.
On 9/10/24 a clinical record review was conducted. This review revealed that R49's care plan was not comprehensive as it did not address that the resident had hand contractures or the use of palm guards.
On 9/10/24 at 3:29 p.m., an interview was conducted with registered nurses (RN #2 and RN #5), both of whom were care plan coordinators. RN #5 explained that the care plan is a guide to facility staff to provide care to each resident that is individualized and should reflect their care needs. When asked if contractures would be indicated on the care plan RN #5 said yes.
On 9/10/24, during an end of day meeting held with the facility administrator, director of nursing and corporate staff it was discussed that R49's care plan was not comprehensive as it did not address the bilateral hand contractures.
No additional information as provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
2. For Resident #134 (R134) the facility staff failed to obtain a physician's order to apply Tubi grips (a compression type stocking) to bilateral lower extremities.
On 09/12/24 at 10:51 a.m., observa...
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2. For Resident #134 (R134) the facility staff failed to obtain a physician's order to apply Tubi grips (a compression type stocking) to bilateral lower extremities.
On 09/12/24 at 10:51 a.m., observation of Resident #134 (R134) was performed. R134 was observed with Tubi grips on bilateral lower extremities and was observed to have the Tubi grips on bilateral lower extremities throughout each of the four days of survey.
On 9/12/24 a clinical record review was conducted. R134 had no physician's order for Tubi grips to be applied to the bilateral lower extremities daily.
On 9/12/24 at 11:00 a.m. an interview was conducted with a licensed practical nurse, LPN# 2 (LPN2). LPN2 went in R134's room and verified that the resident had Tubi grips on her bilateral lower extremities. LPN2 verified that R134 had no order in her clinical record for Tubi grips.
On 9/12/24 at 11:15 a.m. interview was conducted with the regional director of clinical services (RDCS). The RDCS verified that R134 had no order in her clinical record for Tubi grips.
On 9/12/24 a review of facility documentation was conducted. A policy titled, Physician's Orders, read in part, .a licensed nurse will notify the physician requesting and/or verifying physician's orders.
On 9/12/24 at 11:25 a.m. the administrator and regional nurse consultant were made aware of the above concerns.
No new information was provided
3. For resident #49 (R49), who received nutrition through a gastronomy tube, the facility staff failed to follow professional standards of care by ensuring the resident's head was elevated while receiving tube feeding to minimize the risk of aspiration.
On 9/10/24 at 2:57 p.m., observations were conducted of R49 in his room. R49 was noted to be non-verbal and didn't react to verbal stimuli. R49 was observed to be lying flat in bed, with the tube feeding pump at the bedside running at a rate of 55 ml per hour.
On 9/10/24 at 3:01 p.m., the surveyor was accompanied to R49's room by a licensed practical nurse (LPN #4). LPN #4 confirmed that R49 had tube feeding infusing via peg tube and was positioned flat in the bed. LPN #4 elevated R49's head of the bed. When asked why this is important, LPN #4 said due to risk of aspiration.
On 9/10/24, a clinical record review was conducted of R49's chart. This review revealed R49's care plan noted a focus area that indicated, .dependence on TF [tube feeding] for nutrition and hydration . and the resident is at risk for complications related to the need for an enteral tube feeding . The interventions included but were not limited to, HOB [head of bed] elevated during feedings per order, pause feedings during personal care as indicated .
According to the physician orders, there was an active order which was entered 2/22/24 that read, Elevate HOB 30 to 45 degrees at all times during feeding and for at least 1 hour after the feeding is stopped. There was also an active order that read, Enteral Feed Order: every shift Osmolite 1.5 @ 55ml/hr. via peg tube for total volume of 1210 ml of formula (may hold feeding 1-2 hours per day for ADLS, therapy, etc.).
The facility policy titled, Enteral Feeding Tubes ws reviewed. The policy did not address the positioning of a resident while enteral feeding is infusing.
On 9/10/24, during an end of day meeting, the facility administrator, director of nursing and corporate staff was made aware of the above findings.
No additional information was provided.
Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to follow professional standards of practice for three of 33 residents in the survey sample. (Residents #268, #134, #49).
The findings include:
1. Resident #268 (R268) pressure ulcer dressing was not dated or initialed by the facility staff.
Diagnoses for R268 included; Pressure ulcer stage three, sepsis, diabetes, malignant neoplasm of rectum, and anemia. The most current MDS (minimum data set) was a five day assessment with an ARD (assessment reference date) of 9/2/24. R268 was assessed with a cognitive score of 15 indicating cognitively intact.
Review of R268's clinical record documented an order dated 9/6/24 to Cleanse sacrum wound with wound cleanser, apply medical grade honey and cover with a bordered foam every day shift. Review of R268's treatment administration record (TAR) indicated that the order was being carried out.
On 9/10/24 at 9:45 a.m. R268 was interviewed regarding dressing changes to sacrum. R268 said that the staff haven't been doing the dressing changes everyday and didn't think it was done the day before. R268 gave permission to view the dressing and wound.
On 9/10/24 at 10:16 a.m. license practical nurse (LPN #2) performed a dressing change to R268's sacrum. The dressing that was in place prior to performing the dressing change appeared clean and well intact, however it was not dated or initialed by the staff member that had completed the dressing change. The wound appeared to be clean and without drainage or odor. LPN #2 was asked about the dressing not being dated or initialed, LPN #2 verbalized the nurse should have dated and initialed the dressing at the time the dressing change was completed.
On 9/10/24 at 5:06 p.m. the above finding was presented to the administrator, director of nursing, and nurse consultant.
A facility policy titled General Wound Care/Dressing Changes was obtained and read in part 5. Licensed nurses will follow recognized standards of practice regarding dressing change(s), including date and initials on dressing.
No other information was presented prior to exit conference on 9/12/24.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, resident interviews, clinical record reviews and facility documentation the facility sta...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, resident interviews, clinical record reviews and facility documentation the facility staff failed to provide activities to meet the residents interest and needs for three residents, (Resident #92 (R92), Resident # 121 (R121) and Resident #149 (R149)) in a survey sample of 33 residents.
The findings included:
1. The facility staff failed to provide the activities as per the schedule and calendar posted in the resident's rooms.
On 9/9/24 at 2:00 p.m. an observation of activities was conducted. The activity on the calendar was courtyard social. During the observation, the only residents in the courtyard were the residents who smoked, and no activity staff was present in the courtyard for the social. The activity room had approximately six residents and they were listening to rap like music and coloring and the activity staff was sitting at a table in the back of the room. The activity staff were not interacting with the residents in the courtyard or in the activity room.
On 9/10/24 at 3:30 p.m. an observation was conducted of the activities. The calendar had that at 3:3 p.m., the scheduled activity was- The Fall Focus Group. There were only two residents in the activity room watching the television and no activity staff was interacting with the residents. There were no changes made on the activity calendar that a different activity was being conducted, nor that the scheduled activity had been cancelled.
On 9/11/24 at 10:44 a.m. an interview was conducted with R149. R149 stated, the calendar for activities never match what is going on in the activity room. I would like to attend but when I go there it is not the activity on the calendar. She stated, I like the activity staff but there needs to be more activities for interaction and socialization then just coloring all the time.
On 9/11/24 at 11:00 a.m. an observation was conducted, and music bingo was not being conducted at 11:00 a.m. per activity calendar and no changes were made on the calendar for a different activity to be conducted. The dry erase board listing the daily activities noted a change for the 2:00 p.m. activity and it noted a 911 Remembrance. Observations at 2:00 p.m., revealed the 911 remembrance activity was not being conducted, and several residents had come to the activity room for this activity and left due to this activity was not going on at the time scheduled. At 3:00 p.m. music bingo was on the activity calendar and there were approximately six residents in the activity room coloring and there were no changes made to the activity calendar and no interaction between the activity staff and residents.
On 09/11/24 at 3:21 p.m. an interview was conducted with the activity director. The activity director stated, we try to stay on schedule but there are times we don't. The activity director said that he invites residents to activities on room rounds but we don't always go to their rooms and invite the residents to each activity. He said that they depend on the nursing staff to get the residents to the activity and the calendar posted in their rooms. The surveyor let him know that all the activities on the calendar had not been conducted throughout the survey days and he stated, if the residents in the dayroom want to do another activity rather than the one on the calendar, then they will change the activity without letting all residents know. The activity director stated, we will just have to do better.
On 09/11/24 04:35 p.m. end of day meeting was held with the regional director of clinical services, the administrator, the director of nursing and the vice president of operations and the above concerns were discussed.
On 9/12/24 at 8:23 a.m. an interview was conducted with R149. R149 stated, I went to the activity room for the 911 Remembrance yesterday and it was not being done so several of us just left the room.
No new information was provided.
2. For resident #92 (R92), the facility staff failed to provide activities to meet the psychosocial well-being of the resident and in accordance with resident preferences.
On 9/9/24 at approximately 11:45 p.m., the surveyor was approached by a certified nursing assistant (CNA #3) who reported for the surveyor to not enter a room [which the CNA identified as R92's room]. CNA #3 reported the resident had behaviors and could be extremely combative.
On 9/9/24 at approximately 12:30 p.m., R92 was observed in his room. It was noted that the room was dark, the curtains were pulled, no lights were on, and the resident was sitting in a wheelchair in the middle of the room. The room was noted to be empty with no personal possessions, no television, no radio, no books, magazines or other things for the resident to do to occupy his time.
On 9/9/24 at approximately 2:30 p.m., facility activity staff were observed to deliver the resident a cup of Kool aide in his room.
On 9/10/24 and 9/11/24, various observations were conducted at varying times of the day, and on each observation R92 was noted to be sitting in the room in the dark. The lights in the room were off, the curtains were pulled, there was no television, radio or any other items to engage the resident in any type of leisure activity. Interviews were conducted with R92, and he was noted to confused. When asked what he liked to do to pass by time, he gave a non-sensical response.
On 9/9/24, in the afternoon, the maintenance assistant was asked about televisions. The maintenance assistant reported the facility does provide tv's and accompanied the surveyor to R92's room. When asked about the lack of a television the maintenance director reported that R92 had been challenging and went on to say that the resident had ripped two tv's off the wall and most recently had done this, the weekend prior.
On 9/10/24 and 9/11/24, a clinical record review was conducted of R92's chart. There were no progress notes with regards to R92 removing televisions from the wall.
On 9/11/24 at 2:09 p.m., an interview was conducted with two activity assistants, (Other Employee #15- OE15 and Other Employee #16- OE16), who were sitting at a table in the activity room coloring and talking to each other. When asked about R92, they said, snacks calm him down, he likes old school tv shows like [NAME] and sons, once in here if someone looks at him, he will go off. When the surveyor mentioned that R92 didn't have anything in his room, the activity assistants said, I don't see anyone come see him either and he doesn't have anything.
According to an activities assessment dated 6/4/24 and again on 7/23/24. Both assessments noted that R92 answered the following questions: how important is it to you to listen to music you like? How important is it to you to be around animals such as pets? and How important is it to you to do things with groups of people? How important is it to you to do your favorite activities? How important is it to you to go outside to get fresh air when the weather is good? How important is it to you to participate in religious services or practices? as being somewhat important. R92 reported on this same assessment that how important is it to you to keep up with the news? as being very important.
According to R92's care plan for activities, it read, The resident prefers or requires 1:1 activity due to being unable or unwilling to participate in other activities. The resident may engage in conversation occasionally. The interventions for this care plan focus area read, Provide 1:1 activities in the room or location that is the residents preference as needed and review activities preferences with the resident or resident representative if the resident is unable as needed. The activity care plan focus area and interventions were last revised on 1/22/24.
Review of R92's activity attendance record revealed that the resident had attended 12 activities in Sept, eight of which were snacks or hydration. Of the thirty activities R92 was listed at attending in the month of August, twenty-two were snacks or beverages being provided to the resident.
3. For resident #121 (R121), the facility staff failed to provide, invite and assist the resident to group activities based on her preferences.
On 9/9/24 at 2:51 p.m., an interview was conducted with R121. R121 reported she used to go to activities. The resident said they [the staff] would come around and get her but they no longer do that, so she just stays in her room tending to the baby, (she has a doll on her bed that she refers to as the baby).
On 9/10/24, a clinical record review was conducted of R121's chart. According to an Activities Assessment with an effective date of 7/11/24, with regards to R121's activity preferences were obtained by facility staff. According to that assessment, R121 was not assessed for her past activity interests as indicated by section 2, questions a-h not being answered.
According to R121's significant change MDS (minimum data set, an assessment tool) with an assessment reference date of 7/6/24, R121's activity preferences were recorded in section F. According to that assessment R121 felt it was very important to: listen to music you like, do your favorite activities, go outside to get fresh air when the weather is good, and to participate in religious services. R121 reported it was somewhat important to be around animals such as pets, and to do things with groups of people.
R121's care plan with a date of 1/26/24, read, 1:1 ACTIVITIES: the resident prefers or requires 1:1 activity due to being unable or unwilling to participate in other activities. The associated interventions read, provide 1:1 activities in the room or location that is the residents preference as needed and review activities preferences with the resident or resident representative if the resident is unable as needed.
There was an additional activity focus area on R121's care plan that was revised on 1/18/24, and read, Support the residents self-directed, independent leisure pursuits and activities. The resident likes music and dancing receives one on one activities 1-2 times weekly. Each of the interventions for this focus area were revised on 12/26/23, and read, Honor patient's preferences of leisure activities, provide meaningful involvement and sense of purpose, Support patient's preference to spend time alone and introspectively.
On 9/11/24 at 2:06 p.m., an interview was conducted with two of the activity assistants (OE15 and OE16). When asked about R121's attendance in activities, they said, she doesn't really come to activities anymore, we do one on ones.
Throughout the duration of the survey conducted 9/9/24-9/12/24, observations were made on each day, at varying times of the day of the activity programing. Each day two activity staff were observed in the activity room coloring with residents watching television, talking to each other and doing word search puzzles and coloring activities. On 9/
On 9/11/24 at 3:05 p.m., an interview was conducted with the activities director (AD). The AD was asked how residents know about activities or are invited. The AD said, the nurses and CNA's [certified nursing assistants] know we have activities and the calendar in the room is an invitation. When I do my room rounds, I tell them. The AD was asked if anyone goes around prior to the activity to let residents know what is taking place and assist them to the activity room and the AD said, nursing brings them down, most of the girls know what they want to do. When the AD was made aware that activities had been observed throughout the days of survey and scheduled activities were not provided at the scheduled times and the activity staff were observed coloring each time observations were made, the AD said, they were coloring pages to take to residents in their rooms and we try to stick to the calendar but if the residents want to do something different they will change it.
On the morning of 9/12/24, interviews were conducted with various nursing staff, which included three CNA's and one nurse. When asked if anyone goes around and invites the residents to activities or assists them in getting to the activity room, they reported that they [the nursing staff] assist residents who want to go.
Review of the job description for the Recreation Assistant was conducted. The Essential Duties & Responsibilities included but were not limited to, . communicates to residents and support staff the daily schedule of planned activities and ensure residents are transported safely and appropriately to and from activities .
The job description for the Director of Recreation was reviewed. It read in part, Essential Duties & Responsibilities . Direct all activity functions and services in the department, provide a plan of activities appropriate to the needs of the residents, complete a comprehensive resident activity assessment according to resident background, past and present leisure interests .
Review of the facility policy titled; Activities Programming was conducted. The policy read in part, 1. Activities programming must include a minimum of four activities per day, with three activities after 5 pm per week. These activities must: reflect the schedule, preferences, goals, choices, and rights of the patients . are productive, are age appropriate, are related to patient's previous work, life roles, life-long interests, culture, spiritual preference . are routine on consistent days, give the patient a sense of purpose or belonging, encourage independence and interaction .
On 9/12/24, during a mid-day meeting with the facility administrator, director of nursing and corporate staff the above concerns were discussed.
No additional information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on staff interview, and clinical record review, the facility staff failed to implement interventions for care/treatment of pressure ulcer for one of 33 residents in the survey sample (Resident #...
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Based on staff interview, and clinical record review, the facility staff failed to implement interventions for care/treatment of pressure ulcer for one of 33 residents in the survey sample (Resident #268).
The findings include:
Resident #268 (R268) had no treatment orders implemented for a pressure ulcer until seven days after the ulcer was identified.
Diagnoses for R268 included; Pressure ulcer stage three, sepsis, diabetes, malignant neoplasm of rectum, and anemia. The most current MDS (minimum data set) was a five day assessment with an ARD (assessment reference date) of 9/2/24. R268 was assessed with a cognitive score of 15 indicating cognitively intact.
R268's weekly skin assessments were reviewed. Out of 5 skin assessments completed from 8/31/24 through 9/11/24, three skin assessments (8/31/24, 9/6/24, and 9/11/24) document R268 having a stage three sacral pressure ulcer, and two skin assessments dated 9/2/24 and 9/9/24 did not have any documentation of the pressure ulcer. The skin assessments did indicate that the wound was improving.
A wound assessment report (from a wound clinic) with a date of service of 9/5/24 documented a stage three pressure ulcer to the sacrum was present upon admission and gave treatment orders.
Review of 268's physician orders documented an order dated 9/6/24 to Cleanse sacrum wound with wound cleanser, apply medical grade honey and cover with a bordered foam every day shift. According to the treatment administration record the treatments were started on 9/7/24. There were no other physician orders to treat the pressure ulcer prior to this order.
On 9/10/24 at 10:16 a.m. license practical nurse (LPN #2) performed a dressing change to R268's sacrum. The wound appeared to be the size of a nickel, clean and without drainage or odor.
On 9/12/24 at 10:28 a.m. the director of nursing (DON) and nurse consultant were interviewed regarding treatments of R268's pressure order. The DON and nurse consultant both reviewed R268's clinical record for treatment of the pressure ulcer and was unable to to find any treatments/physician orders prior to 9/6/24.
On 9/12/24 at 11:07 a.m. the above finding was presented to the administrator, director of nursing and nurse consultant.
No other information was presented prior to exit conference on 9/12/24.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
Based on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to provide services to maintain good foot health of two r...
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Based on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to provide services to maintain good foot health of two residents (resident #49-R49 and resident #30-R30) in a survey sample of 33 residents.
The findings included:
1. For R49 the facility failed to provide care and treatment to maintain good foot health as evidenced by the resident's toenails being approximately 3/4 of an inch long past the toes.
On 9/10/24 at 3:01 p.m., the surveyor is accompanied to R49's room by a licensed practical nurse (LPN #3). During review of the resident LPN pulled back the sheets, exposing R49's feet. It was noted that R49 had not had foot/nail care performed in a long time as evidenced by the nails extending approximately 3/4 of an inch past the end of the toes. LPN #3 confirmed and agreed that R49 was in need of toenail care.
Upon exit of the resident's room, LPN #3 was asked about nail care. LPN #3 said, we do reminders to the CNA's [certified nursing assistants] to trim nails and a podiatrist comes monthly.
On 9/10/24 at 3:07 p.m., an interview was conducted with the unit manager. The unit manager said the podiatrist comes every three months. When asked about nail care, the unit manager said, I usually get the nurses to check nails, usually about once every two weeks. I get them to cut, and CNA's can if they are not diabetic. The unit manager went on to report R49 had received a shower earlier in the day.
On 9/10/24 at approximately 3:10 p.m., an interview was conducted with the director of social services (DSS). The DSS confirmed that a podiatrist comes monthly, and she maintained that listing. The surveyor asked for a copy of the podiatry list for the year 2024.
On the afternoon of 9/10/24, the survey team was provided a listing of residents requested to be seen by the podiatrist. Review of the list noted that R49's name was not on the list any of the months in 2024. The list for May 15, 2024, noted 38 residents and of the 38, 24 were noted to refuse.
On 9/10/24, during an end of day meeting held with the facility administration and corporate staff the above concerns were discussed. They were also shown the podiatry list for May 2024, which noted 24 residents had refused. The assistant director of nursing (ADON) reported that the podiatrist was elderly and when he got tired or wasn't going to see anyone else, he would note refused and ask that they be put on the list the following month.
2. For R30, the facility staff failed to ensure the resident received routine foot care to maintain foot health.
On 9/11/24 at approximately 3 p.m., R30 was visited in her room. R30 reported that she had a sacral wound and confirmed she doesn't get out of bed. R30 agreed to the surveyor observing her feet. R30's toenails were noted to be extremely long and turning to curl under the toes.
On 9/11/24 at 3:43 p.m., the regional director of clinical services (RDCS) was asked to accompany the surveyor to R30's room. The RDCS observed R30's toenails and confirmed she was in need of nail care. Also, on the bottom/plantar of the resident's foot it was noted with extremely dry skin that appeared as a crust on the soles of both feet.
Upon exiting the resident's room, the RDCS asked the evening supervisor to see if he could cut R30's toenails and to add the resident to the podiatry list. The RDCS went on to say that they had been relying on the podiatrist to provide all toenail care but would be training nursing staff to do it going forward.
The podiatry list for 2024 was reviewed and revealed that R30 was never put on the list by facility staff to be seen by the podiatrist.
The facility's podiatry contract was reviewed, and it revealed no information with regards to the frequency of visits to the facility or number of residents that could be seen.
No additional information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and clinical record review, the facility staff failed to implement interventions for a re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and clinical record review, the facility staff failed to implement interventions for a resident with contractures, to prevent the worsening of contractures for one resident (Resident #49-R49) in a survey sample of 33 residents.
The findings included:
On 9/9/24 at 3:28 p.m., R49 was observed in bed. R49 was noted to be non-verbal and had bilateral hand contractures. The resident was observed with no splint to the hands and no palm protectors. R49's fingernails were observed to be long.
On 9/10/24 at 8:54 a.m., R49 was observed again, and no splint, palm guard or wash cloth was noted in the hands to prevent the worsening of the contractures.
On 9/10/24 at 2:49 p.m., an interview was conducted with the therapy director (TD). The TD reported that R49 was on therapy caseload previously. The TD noted from 11/17/22-11/23/22, R49 was on occupational therapy caseload, and they were concerned about hand contractures. The therapy director noted that they had noted, Palm guards to right and left hands up to 4 hours and he was tolerating them 8 hours without any signs or symptoms of redness. The therapy director noted that every three months they do an audit of splints and in June they noted the splint was cleaned and continue the splint schedule 7 days a week with skin checks every 2 hours.
During the above interview with the therapy manager, she was asked about the purpose of splints for contractures. She stated, to keep the hand open and not tight and closed. If they are tight, it can cause pressure, to keep minimally open, if tight a palm guard is to keep minimally open, to prevent pressure, moisture, anything like that in the hand.
On 9/10/24 at 2:57 p.m., R49 was observed again, and no palm guards or splint devices were in use.
On 9/10/24 at 3:01 p.m., a licensed practical nurse (LPN #4) accompanied the surveyor to R49's room. The nurse confirmed that R49 did not have any splint device in use, and none was found in the room. R49's right hand was opened by LPN #4 so that the surveyor could observe that the skin in the palm was intact. LPN #4 was unable to open R49's left hand due to the contracture for observations to be conducted.
On 9/10/24 at 3:07 p.m., an interview was conducted with the unit manager. The unit manager was asked about R49's splint. The unit manager said she recalled R49 had palm guards and reported sometimes the family takes them home and washes them.
On 9/10/24 at 3:12 p.m., the therapy manager was made aware that no palm guards were noted in R49's room. The therapy director stated she had added R49 to the schedule to be evaluated the following day.
On 9/10/24 a clinical record review was conducted. This review revealed that R49's care plan did not address that the resident had hand contractures or the use of palm guards.
Review of the Occupational Therapy Discharge summary dated [DATE], read in part, . Pt [patient] caregiver educated on techniques to decrease risk for skin breakdown and further contracture formation. Pt has responded favorably to OT [occupational therapy] skilled services and is expected to maintain gains made, per excellent implementation of RNP [restorative nursing program] .
The facility policy regarding contracture management was requested. A policy titled; In-Services was received. The policy indicated that therapy would provide education to staff regarding splint application and use of adaptive equipment.
On 9/10/24, during an end of day meeting held with the facility administrator, director of nursing and corporate staff the above findings were reviewed.
No additional information as provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure suction was in place for respiratory care of a tracheostomy for one of ...
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Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure suction was in place for respiratory care of a tracheostomy for one of 33 residents, Resident #159 (R159).
The findings include:
R159 did not have emergency suctioning device at bedside for the care of a tracheostomy.
Diagnoses for R159 included; Displacement of esophageal anti-reflux device (tracheostomy), chronic obstructive pulmonary disease, esophageal obstruction, cellulitis of abdominal wall, feeding tube The most current MDS (minimum data set) was a quarterly assessment, with an ARD (assessment reference date) of 7/2/24, which assessed R159 with a cognitive score of 15 out of 15 indicating intact cognition.
On 9/10/24 at 11:15 a.m., R159's room was observed for emergency suctioning due to R159 having a tracheostomy. There was no suctioning device observed. R159 was interviewed at this time and verbalized that there hadn't been any suctioning in the room and not having to use suctioning so far. When asked about the medical device inserted into the neck, R159 went on to say that the tracheostomy was needed to be able to breath.
On 9/10/24 at 11:28 a.m., registered nurse (RN #1) also observed R159's room for the suctioning equipment, due to the resident having the artificial airway. Confirming that no suctioning equipment was present for emergency use, RN #1 stated that she would get the suction set up.
On 9/10/24 at 5:06 p.m., the above finding was presented to the administrator, DON, and nurse consultant.
A policy titled Tracheostomy Care & Management was provided and read in part, 4. Emergency sterile tracheostomy equipment of the correct size will be available at the bedside.
5. Manual resuscitator (bag valve mask, Ambu bag) is readily available.
No other information was provided prior to exit conference on 9/12/24.
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 resident interview, staff interview, facility document review, and clinical record review, the facility failed to provi...
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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, the facility failed to provide physician ordered dialysis services and failed to share/communicate care provided during a dialysis treatment for one of thirty-three residents (Resident #2).
The findings include:
Resident #2 (R2) was admitted to the facility with diagnoses that included end stage renal disease (ESRD), gastroesophageal reflux disease, protein-calorie malnutrition, obstructive uropathy, anxiety, anemia, and COVID-19. The minimum data set (MDS) dated [DATE] assessed R2 as cognitively intact.
a) R2 missed two scheduled hemodialysis treatments due to lack of transportation to the dialysis center.
R2's clinical record documented a physician's order dated 9/1/24 for hemodialysis three times per week with scheduled days listed as Tuesday, Thursday and Saturday.
R2's clinical record documented R2 was diagnosed with COVID-19 on 8/26/24. The physician assessed R2 on 8/27/24, documented treatment of COVID-19 symptoms, and recommended continued hemodialysis as scheduled each Tuesday, Thursday and Saturday.
R2's clinical record documented no transfer for dialysis treatment on Tuesday, 8/27/24 as scheduled. The record included a change of condition note dated 8/29/24 documented, .Resident is covid positive, alert with intermittent confusion .Two scheduled dialysis missed due to transport issues . [NP] notified. New order received and noted to transport resident to [emergency department] .
R2's hospital Discharge summary dated [DATE] documented, .History of ESRD on dialysis Tuesday Thursday Saturday . She had 2 recent missed hemodialysis sessions due to dialysis transportation issues given COVID infection . Fortunately, not hyperkalemic . No respiratory distress and not hypoxemic. does not seem to warrant emergent dialysis. Admit under observation . Patient was seen in consultation by nephrology on 8/30 and underwent hemodialysis same day . underwent hemodialysis again on 8/31 to resume her usual hemodialysis. Patient has remained medically stable with COVID clearance on 9/1 .
R2 was discharged back to the nursing facility on 9/1/24 and resumed her hemodialysis schedule on Tuesday 9/3/24.
On 9/11/24 at 11:02 a.m., R2 was interviewed about the missed dialysis treatments on 8/27/24 and 8/29/24. R2 stated she missed two treatments in a row because the transport company refused to take her due to the COVID-19 diagnosis. R2 stated she had hemodialysis at a dialysis center each Tuesday, Thursday, and Saturday. R2 stated she had previously had no issues with transportation. R2 stated she was not aware that transportation was an issue until she got ready to get on the van on the morning of 8/27/24. R2 stated on Thursday (8/29/24) the transportation issue had not been resolved, so the nurse practitioner sent her to the hospital for evaluation and dialysis treatment. R2 stated she was still making urine and had no symptoms from the missed dialysis treatments. R2 stated her only symptoms when transferred to the hospital were cough and congestion related to COVID-19. R2 stated, They got me to the hospital before I had any problems.
On 9/11/24 at 11:09 a.m., the licensed practical nurse (LPN #7) caring for R2 was interviewed about the missed dialysis treatments. LPN #7 stated R2 went to dialysis on Saturday (8/24/24) and was diagnosed with COVID-19 on Monday (8/26/24). LPN #7 stated on Tuesday (8/27/24), she called the dialysis center and advised them of R2's COVID-19 diagnosis with the dialysis center confirming that the resident could come and complete the hemodialysis. LPN #7 stated when the transportation van showed up, the transport staff made R2 get off the van, and refused to take her to dialysis due to the COVID-19 diagnosis. LPN #7 stated the transport vendor indicated that R2 had to be transported via stretcher due to COVID + status. LPN #7 stated she understood the resident was going to dialysis on Thursday (8/29/24) but when Thursday came, there were no arrangements made for stretcher transport. LPN #7 stated the nurse practitioner was notified and sent the resident to the hospital on 8/29/24 for dialysis. LPN #7 stated R2 had coughing, and head congestion related to COVID-19 but did not exhibit any symptoms from the missed dialysis treatments.
On 9/11/24 at 1:30 p.m., the nurse practitioner (NP - other staff #4) caring for R2 was interviewed about the missed hemodialysis treatments. The NP stated she initially thought arrangements would be made for stretcher or whatever transport was needed due to COVID-19 status. The NP stated she sent R2 to the hospital on 8/29/24 to get hemodialysis because arrangements had not been made to transport the resident to the dialysis center. The NP stated R2 had COVID symptoms but was not in any type of distress. The NP stated R2 was still producing urine and had no symptoms from the missed hemodialysis treatments. The NP stated that she wanted the resident to get dialysis prior to any symptoms. The NP stated the resident's labs were at baseline and the resident did not require emergency dialysis upon arrival at the hospital on 8/29/24. The NP stated R2 had refused a treatment or two along the way and had no outcome from missed treatments. The NP stated transportation should be available so that dialysis treatments were not missed. The NP stated that transportation was part of patient care and had to be provided when needed. The NP stated arrangements should have been in place for COVID + residents so that care/services were not missed.
On 9/11/24 at 1:56 p.m., the transportation scheduler (other staff #5) was interviewed about R2's missed dialysis treatments on 8/27/24 and 8/29/24. The scheduler stated R2 had COVID-19, and the transport service was not set up for COVID. The scheduler stated for COVID + residents, a stretcher transport service was usually arranged. The scheduler stated that nobody made her aware R2 had COVID-19 until the transportation service refused to take her to dialysis on 8/27/24. The scheduler stated she tried to find a stretcher service on Wednesday (8/28/24) but was unable to make arrangements. The scheduler stated she had one contracted provider of stretcher service that handled COVID + residents. The scheduler stated she was not made aware ahead of time to make the necessary arrangements for R2's transport to dialysis.
On 9/11/24 at 2:27 p.m., the director of nursing (DON) was interviewed about R2's missed dialysis treatments. The DON stated all she knew was that transportation would not take the resident due to the COVID-19 + status. When asked about how COVID-19 + residents were to get required hemodialysis, the DON stated she was not sure and that the transportation vendors needed to take patients for needed treatments.
The Nursing Home Dialysis Transfer Agreement (2022) with R2's dialysis center documented concerning transportation, .Facility shall have the responsibility for arranging suitable transportation of the Designated Resident to and from Center, including the selection of the mode of transportation, qualified personnel to accompany the Designated Resident and transportation equipment usually associated with this type of transfer .
b) There was no communication from R2's dialysis center regarding the resident's status/response during hemodialysis on 9/5/24 and 9/10/24. There was no communication from the dialysis center to the facility regarding the administration of the medication Benadryl during R2's dialysis treatment on 9/10/24. Facility staff made no attempts to contact/communicate with the dialysis center in response to incomplete documentation on the communication sheets on these dates.
On 9/11/24 at 11:02 a.m., R2 was interviewed about her dialysis treatments. R2 stated she started itching during the dialysis session yesterday (9/10/24). R2 stated the dialysis nurse administered Benadryl during the session and the itching resolved.
R2's clinical record, including the dialysis communication form, made no mention that the resident was administered Benadryl during the 9/10/24 dialysis treatment.
R2's dialysis communication forms dated 9/5/24 and 9/10/24 documented no information from the dialysis center regarding the resident's status during and/or after the hemodialysis. Section B, to be completed by the dialysis center, had no information recorded in spaces provided for pre-dialysis weight, vital signs, lab results, meal eaten during treatment, medications administered, time dialysis started, time dialysis completed, post-dialysis weight, post-dialysis vital signs, occurrences during dialysis and signature of dialysis staff. The nursing facility nurse assessing R2 upon return from dialysis (section C on form) had not signed and/or dated either of these forms.
On 9/11/24 at 11:09 a.m., the licensed practical nurse (LPN #7) caring for R2 was interviewed. LPN #7 stated the dialysis communication forms were used to communicate/share information with the dialysis center. LPN #7 stated the facility completed the top section (section A), the dialysis center completed section B and then the facility completed/signed section C upon the resident's return from dialysis. LPN #7 stated she was not aware the dialysis center administered the resident Benadryl on 9/10/24. LPN #7 stated there was nothing documented from the dialysis center on 9/10/24.
On 9/11/24 at 2:27 p.m., the director of nursing (DON) was interviewed about the incomplete communication with R2's dialysis center. The DON stated the facility, and the dialysis center were supposed to document required information about each dialysis session that included care and/or medications provided. The DON stated if the dialysis center failed to record information about the session, nurses were expected to call the dialysis center for any needed information.
On 9/11/24 at 3:10 p.m., the DON stated she confirmed with the dialysis center that R2 was administered Benadryl during the 9/10/24 session for itching and that the center failed to communicate that information to the facility.
The facility's policy titled Hemodialysis (effective 1/29/24) documented regarding outpatient hemodialysis, .The Dialysis Communication Form will be initiated prior to sending patient for dialysis .Patient reports received from dialysis center will be uploaded to the medical record .
This finding was reviewed with the administrator, director of nursing, and regional nurse consultants during a meeting on 9/11/24 at 4:40 p.m. with no further information provided prior to the end of the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to attempt alternatives prior to implementing the use of bed rails for one r...
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Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to attempt alternatives prior to implementing the use of bed rails for one resident (Resident #49-R49) in a survey sample of 33 residents.
The findings included:
For R49, who was in a persistent vegetative state and had a fall, the facility staff applied bed rails without attempting other alternatives and without assessing the risk of entrapment.
On 9/9/24 and 9/10/24, R49 was visited in their room. R49 was noted to be non-verbal and did not respond to verbal stimuli. R49 was noted to be on an air mattress and had 1/8 length bed rails to both sides of the bed.
On 9/10/24, a clinical record review was conducted. This review revealed R49 had diagnosis which included, but were not limited to, persistent vegetative state, obstructive hydrocephalus, cerebral palsy, and cerebral infarction due to unspecified intracranial injury with loss of consciousness of unspecified duration.
According to a nursing note entry dated 7/26/24, R49 sustained a fall. The notes for that day read in part, Resident was lying in between the beds on his left side. No signs of pain or discomfort at this time, and This writer spoke with [R49's father's name redacted] to notify him of [R49's name redacted] fall. This writer informed patient's father that there were no injuries noted at this time but aware of new orders for x-rays. This writer also asked father if he consents to bed side rails. RP [responsible party] agreed.
A bed side rail tool was completed on 7/26/24 and it indicated the following: 1. Does the patient need bed rails for positioning and/or rising from supine to sitting/standing position as mobility enabler? yes. 2. bed rails are: indicated and serve as an enabler, 3. Are bed rails a patient/resident representative preference? yes . 7. Explain the plan and update the care plan and question 7 was blank. There was no evidence that the assessment included the risk of entrapment being assessed.
There was an additional bed side rail tool completed 8/21/24 that indicated the bed rails were not being used as an enabler.
Review of R49's care plan was conducted. According to the care plan, . Communication: resident is non-verbal . the resident is at risk for falls related to cognitive impairment, related to muscle weakness, chronic conditions . The interventions for the fall risk were noted as .anticipate and meet the resident's needs, broda chair as needed, grip safe to mattress, place bed in lowest position while resident is in bed. The care plan also indicated that R49 requires assistance with ADLS [activities of daily living] relate [sic] to history of deficits from a cva [cerebral vascular incident], inability to perform ADLs . 2 person assist for bed mobility . There was no indication that R49 was able to participate or provide any assistance to staff in his daily care.
On 9/11/24 at approximately 3:20 p.m., an interview was conducted with certified nursing assistant (CNA #3). CNA #3 reported to the surveyor that R49 did not talk and was total care for all care. CNA #3 said that when providing care and turning the resident, the mattress would slide on the bed frame. When asked if R49 can use the bed rails to assist with care, CNA #3 reported that R49 is not able to participate or assist with care in any way and is totally dependent upon staff.
On 9/11/24 at 4:18 p.m., the above concerns were shared with the regional director of clinical services (RDCS). The RDCS was shown the bed rail assessment and that it indicated R49 was able to use the rails as an enabler. The RDCS said, He leans. I don't know what else we could have done. The RDCS went on to say that R49 is able to use his arm/elbow to hold onto the railing during care. The RDCS accompanied the surveyor to R49's room and reported that R49 could talk. It was observed that R49 did not respond to the RDCS when she was talking to him. The RDCS checked the mattress and was not able to find the grip safe which was reportedly a non-skid surface, which is placed between the mattress and fitted sheet, to prevent the resident from sliding.
Review of the facility's event summary regarding R49's fall revealed that R49 was bed ridden, unable to give any description of the incident, and was found lying on his left side between the beds. No injuries were evident following the fall, but the medical provider ordered x-rays.
On the afternoon of 9/11/24, the facility's maintenance director accompanied the surveyor to R49's room. The maintenance director stated that he recalled installing the bed rails shortly after he started working at the facility, which was in July. The maintenance director was asked to provide a copy of the maintenance work order for the bed rails to be installed, as well as the bed and railing manufacturer's user manual(s).
A review of the facility's policy titled, bed system audits was conducted. The policy read in part, . 2. Maintenance will also conduct an intermittent audit immediately upon notification by nursing of any individual change of a bed frame, an assistive device, a mattress, or a bed rail. Maintenance and nursing will collaborate in order to identify gaps, ensure a tight fit of mattress to the bed system and, if appropriate, to inspect for mattress compressibility. 3. Any bed rail and/or mattress changes implemented and/or newly purchased separately from the bed frame system, will be assessed collaboratively for compatibility in width and length and with adherence to the manufacturer's recommendation and specifications .
On 9/11/24, during an end of day meeting, the above findings were shared with the facility administration and corporate staff.
On 9/12/24, the facility's administration notified the survey team they were unable to locate the maintenance work order of when the rail was requested to be installed. The facility also failed to provide the manufacturer's user manual for the bed and bed rails, as requested.
No additional information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to...
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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, the facility staff failed to ensure a medication was available for administration for one of thirty-three residents in the survey sample (Resident #79).
The findings include:
Resident #79 (R79) was admitted to the facility with diagnoses that included atherosclerotic heart disease, generalized anxiety, depression, polyneuropathy, atrial fibrillation, chronic pain, mild cognitive impairment, hypertension, anemia, and migraine headache. The minimum data set (MDS) dated [DATE] assessed R79 as cognitively intact.
On 9/9/24 at 12:38 p.m., R79 was interviewed about quality of care in the facility. R79 stated during this interview that she had recently missed doses of her anti-anxiety medication.
R79's clinical record documented a physician's order dated 2/23/24 for the medication Xanax 0.5 mg (milligrams) to be administered twice per day for management of anxiety.
R79's medication administration record documented the Xanax 0.5 mg was not administered as scheduled on 9/8/24 at 9:00 a.m. and on 9/8/24 at 5:00 p.m.
A nursing note dated 9/8/24 at 8:00 a.m. documented that the Xanax was not available, and nursing was unable to retrieve the medicine from the back-up supply. This note documented pharmacy and the nurse practitioner were notified. A nursing note dated 9/8/24 at 5:58 p.m. documented regarding the scheduled Xanax, .Medication not available. Rx [prescription] is on file at pharmacy and pharmacy states it will come on next run. Not able to remove out of Omnicell [back-up supply] .
On 9/11/24 at 2:03 p.m., licensed practical nurse (LPN #4) that cared for R79 on 9/8/24 was interviewed. LPN #4 stated the Xanax script had been faxed to the pharmacy twice during the week prior to 9/8/24. LPN #4 stated when she reported to work on Sunday (9/8/24) the Xanax had run out with no supply on the medication cart. LPN #4 stated she called pharmacy to get a code to retrieve an emergency dose and pharmacy stated an entire new script was required before a code could be issued. LPN #4 stated she left work on 9/8/24 at 3:00 p.m. and the medication nor a code for the back-up supply had been provided. LPN #4 stated she communicated about the unavailable Xanax to the evening shift nurse. LPN #4 stated the evening shift nurse documented the Xanax nor code were available on 9/8/24 for the 5:00 p.m. dose.
On 9/11/24 at 2:23 p.m., the unit manager (LPN #3) was interviewed about R79's unavailable Xanax. LPN #3 stated nurses tried to get the required scripts to pharmacy prior to running out of the medication. LPN #3 stated pharmacy did not send the medication and nurses were unable to get a code to retrieve the medication from the back-up supply.
On 9/11/24 at 2:35 p.m., the director of nursing (DON) was interviewed about R79's missed Xanax. The DON stated she did not know why pharmacy failed to provide the medication timely. The DON stated nurses were expected to let the nurse practitioner know about unavailable medicines and print out scripts for the provider to sign.
The facility's policy titled Medication Unavailability (effective 1/29/24) documented, .A licensed nurse discovering a medication on order that is unavailable will initiate appropriate steps to ensure medical treatment is provided as ordered .A licensed nurse will notify the provider of the unavailability of medication and discuss an alternative order, if necessary .If alternate medication is ordered and is not available, the licensed nurse will activate the backup pharmacy process .
This finding was reviewed with the administrator, director of nursing and regional nurse consultants during a meeting on 9/11/24 at 4:40 p.m. with no further information provided prior to the end of the survey.
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, staff interview and facility document review, the facility staff failed to label an insulin pen when opened on one of three units (West unit).
The findings include:
On 9/11/24 at...
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Based on observation, staff interview and facility document review, the facility staff failed to label an insulin pen when opened on one of three units (West unit).
The findings include:
On 9/11/24 at 3:53 p.m., accompanied by licensed practical nurse (LPN) #5, medications stored in cart #2 on the [NAME] unit were inspected. Stored in the medication cart was an opened Fiasp (insulin aspart) flextouch insulin pen labeled for a current resident. The insulin pen had no date written on the label indicating when the pen was opened. LPN #5 was interviewed at this time about the storage of opened insulin pens. LPN #5 stated all insulin pens were supposed to be dated when opened.
The facility's policy titled Storage of Medications (revised 08/2024) documented, .When the manufacturer has specified a usable duration after opening (i.e. beyond use date), the nurse shall place a 'date opened' sticker on the medication and record the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days from opening, unless the manufacturer recommends another date or regulations/guidelines require different dating .
Fiasp manufacturer's prescribing information documented the Fiasp FlexTouch pen should be discarded 28 days after opening if stored at room temperature or if refrigerated. (1)
This finding was reviewed with the administrator, director of nursing and regional nurse consultants during a meeting on 9/11/24 at 4:40 p.m. with no further information provided prior to the end of the survey.
(1) Fiasp insulin aspart. Prescriber information. NovoCare. 9/13/24.
https://www.novocare.com/diabetes/products/fiasp.html.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview, and clinical record the facility staff failed to provide food in acco...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview, and clinical record the facility staff failed to provide food in accordance with the menu for one, (Resident #39, R39) out of 33 residents in the survey sample.
The findings included:
The facility staff failed to serve R39 the food that was on her menu ticket at lunch time.
R39 was admitted to the facility on [DATE]. Diagnoses for R39 included but are not limited to unspecified protein-calorie malnutrition. R39's Minimum Data Set (an assessment protocol), with an Assessment Reference Date of 6/17/24, coded R39 with moderate cognitive impairment.
On 9/9/24 the R39's meal ticket read in part, .Mechanical advanced/chopped baked pork chop - 4oz, mushroom gravy - 2 oz, mechanical advanced/chopped orange twist - 1 Ea, steamed summer squash - 1/2 cup, black eyed peas- 4 oz, dinner roll - 1 ind, and margarine - 1 pkt.
On 9/9/24 at 12:37 p.m. an observation of the lunch time meal was conducted. During the observation, R39's meal tray was missing mushroom gravy 2 oz, black-eyed peas 4 0z and mechanical advanced/chopped baked pork chop 4 oz and magic cup was not on the ticket or meal tray, which were listed onthe meal ticket. The only food items on R39's tray was the squash and a roll.
On 9/9/24 at 12:37 p.m. an interview was conducted with R39. R39 stated, Things are always missing from my meal.
On 9/9/24 at 1:06 p.m. an interview was conducted with a certified nursing assistant, CNA#2 (CNA2). CNA2 stated, It happens often that we don't have on here what should be on the tray. We will go to the dietary and sometimes it is replaced but most of the time they say they don't have it.
On 9/11/24 a clinical record review was conducted. R39's dietary order was Regular diet, Dysphagia Advanced texture, Thin Liquids consistency, magic cup at lunch, which was an active order since 7/17/24.
On 9/10/24 at 5:02 p.m. an end of the day meeting was conducted with the regional director of clinical services, administrator, vice president of operations, and the director of nursing, during which the above concerns were discussed.
09/11/24 at 2:52 p.m. an interview was conducted with the dietary manager. The dietary manager stated, Some pork chops appeared not to have gravy, but they did have some, even though you couldn't see it on the tray. I don't know why but the other items should have been on the tray.
No new information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
Based on observation, resident interview, and staff interviews the facility staff failed to provide food preferences for one of 33 residents. Resident # 69 (R69) was not provided side salads as reques...
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Based on observation, resident interview, and staff interviews the facility staff failed to provide food preferences for one of 33 residents. Resident # 69 (R69) was not provided side salads as requested.
The findings include:
Diagnoses for R69 included; Diabetes, and obesity. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 7/2/24. R69 was assessed with a cognitive score of 15 indicating cognitively intact.
During an interview conducted on 9/09/24 at 11:40 a.m. R69 verbalized concerns regarding food preferences saying we are no longer getting side salads like we used to. R69 went onto say the dietary manager is saying we no longer are providing salads as an option. R69 mentioned being a diabetic and prefers to have fresh fruits and vegetables.
On 9/11/24 at 11:37 a.m. the dietary manager (other staff, OS #2) was interviewed. OS #2 said that corporate had recently changed to a different seasonal menu, and corporate office were no longer purchasing salad ingredients due to the change in the new menu.
The kitchen refrigerator and dry food storage were observed with fresh lettuce, peppers, onions, celery, and shredded cheese. When asked about these items, OS #1 said that these items are for ingredients for meals. OS #1 went onto say that R69 could have a chef salad as a substitute for a meal but corporate has stopped side salads.
On 9/11/24 at 4:41 p.m. the above finding was presented to the administrator, director of nursing, nurse consultant, and vice president of operations. The vice president shook his head and verbalized the resident should be allowed to get a side salad.
No other information was presented prior to exit conference on 9/12/24.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
3. The facility staff failed to apply Resident 149's ted hose every morning and signed it off in the treatment administration record daily as being completed.
On 9/9/24 at 3:33 p.m. an observation was...
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3. The facility staff failed to apply Resident 149's ted hose every morning and signed it off in the treatment administration record daily as being completed.
On 9/9/24 at 3:33 p.m. an observation was made of R149 sitting outside without ted hose on bilateral extremities. R149 was wearing ankle socks and tennis shoes.
On 09/10/24 at 11:00 a.m. an observation was made of R149. R149 was walking around the nursing units at the facility and was not wearing her ted hose. R149 was wearing bedroom slippers.
On 9/11/24 at 10:44 a.m. an observation was made of R149. R149 was observed walking around the facility hallways with flip flops on and ted hose were being worn.
On 09/12/24 at 8:25 a.m. an interview was conducted with a licensed practical nurse, LPN # 2 (LPN2). LPN2 walked with the surveyor to R149's room and there was no ted hose in R149's room. LPN2 confirmed that R149's had no ted hose on bilateral lower extremities.
On 9/12/24 at 8:25 a.m. an interview was conducted with R149 concerning her ted hose. R149 stated that she only had the black socks that the supply clerk gave her because she was unable to find ted hose at the store, so the supply clerk bought these socks. R149 stated, I forget some days to put the socks on.
On 9/12/24 a clinical record review was conducted. The treatment administration record (TAR) showed the nurses signed off daily on the order that read, apply ted hose in the AM and remove in the PM every 12 hours for Swelling. The TAR was signed off on 9/9/24, 9/10/24 and 9/11/24 that the order was completed, indicating the ted hose were applied.
On 9/12/24 at 10:25 a.m. the administrator and regional nurse consultant were made aware of the above concerns.
No new information was provided.
2. For resident #30, R30, who had mental health diagnosis, the clinical record was incomplete and didn't accurately reflect that a level II pre-admission screening for mental health had been halted and not completed.
On 9/10/24, a clinical record review was conducted of R30's chart. This review revealed diagnosis that included, but were not limited to, suicidal ideation, bipolar disorder, major depressive disorder, anxiety disorder, and Alzheimer's disease.
On 9/10/24 a clinical record review was conducted. According to the pre-admission screening, the level 1 screening for mental illness, intellectual disability or related conditions, indicated that a level 2 assessment was warranted.
According to R30's care plan, it noted, Resident has a Level II PASRR. However, the level II PASRR was not able to be located within the chart.
On 9/11/24, the facility administration was notified during an end of day meeting and again on the morning of 9/12/24, that the survey team wanted to see R30's level II pre-admission screening resident review form.
On 9/12/24 at approximately 9:30 a.m., during an interview with the social services director (SSD), the SSD received a telephone call, and she was noted to be requesting the information with regards to R30's level II PASRR.
On 9/12/24 at approximately 10:30 a.m., the survey team was provided with a letter from the department of behavioral health and developmental services division with the Commonwealth of Virginia that indicated the level II screening for R30 had been halted. The reason noted was the individual has a primary diagnosis of an organic disorder, dementia (including Alzheimer's disease) and does not have a diagnosis of ID [intellectual disability]. The letter was dated 9/11/2020. Upon being handed the document, the regional director of clinical services confirmed that the document had not been a part of R30's clinical chart and they had called to get the information faxed to the facility.
On 9/12/24 at approximately 11 a.m., during a meeting held with the facility administration and corporate staff, the above findings were reviewed.
No additional information was provided.
Based on staff interview and clinical record review, the facility staff failed to provide a complete and accurate clinical record for three of thirty-three residents in the survey sample (Resident #268, #30 and #149).
The findings include:
1. Resident 268's (R268) sacral wound was not properly identified on daily skilled progress notes and skin assessments.
Diagnoses for R268 included; Pressure ulcer stage three, sepsis, diabetes, malignant neoplasm of rectum, and anemia. The most current MDS (minimum data set) was a five day assessment with an ARD (assessment reference date) of 9/2/24. R268 was assessed with a cognitive score of 15 indicating cognitively intact.
Review of R268's daily skilled progress notes dated 8/31/24 through 9/7/24 documented no wounds. Another skilled progress note dated 9/7/24 indicated there was a sacral wound. On 9/8/24 two skilled notes were entered one of the notes indicating there was a wound the other indicting there were no wounds. A skilled progress note dated 9/9/24 again indicated there was not a wound.
R268's weekly skin assessments were then reviewed. Out of 5 skin assessments completed from 8/31/24 through 9/11/24, three skin assessments (8/31/24, 9/6/24, and 9/11/24) document R268 having a stage three sacral pressure ulcer, and two skin assessments dated 9/2/24 and 9/9/24 did not have any documentation of the pressure ulcer.
A wound assessment report (from a wound clinic) with a date of service of 9/5/24 did document a stage three pressure ulcer to the sacrum was present upon admission and gave treatment orders.
On 9/11/24 at 4:41 p.m. the above finding was presented to the administrator, director of nursing (DON) and nurse consultant. The DON verbalized R268 did have a pressure ulcer to the sacrum upon admission.
On 9/12/24 at 9:15 a.m. the nurse consultant verbalized that the facility has recognized problems with improper skin assessments and is currently working on education.
No other information was presented prior to exit conference on 9/12/24.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, staff interviews, clinical record review and facility documentation review the facility staff failed to provide a negative urinalysis prior to removing contact isolation for one ...
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Based on observation, staff interviews, clinical record review and facility documentation review the facility staff failed to provide a negative urinalysis prior to removing contact isolation for one resident, Resident #134 (R134) in a survey sample of 33 residents.
The findings included:
The facility staff failed to obtain a negative urine after completion of the antibiotic therapy for ESBL (Extended-spectrum beta-lactamases) before discontinuing contact isolation precautions.
On 9/9/24 at 11:00 a.m. a tour of the facility south nursing unit was conducted. R134 had an enhanced barrier isolation sign on the outside of the room door.
On 9/12/24 at 8:39 a.m. an interview was conducted with license practical nurse, LPN#2 (LPN2). LPN2 said she remembered R134 being on contact isolation precautions for ESBL (extended spectrum beta-lactamase) when she was admitted . LPN2 said that when R134 moved to the room she is in now, that she was on enhanced barrier precautions. LPN2 stated the protocol for ESBL is, they have to stay in room if incontinent, we have to recheck a urine after antibiotic is completed and they can come off isolation after a clear urine.
On 9/12/24 at 8:46 a.m. an interview was conducted with the infection preventionist, RN #3 (RN3). RN3 said that when someone is admitted with ESBL that if labs were done, I collect the results, set up room with appropriate bins and any antibiotics gets plugged in for sensitivities. ESBL needs one negative culture to be able to come off isolation. We try to obtain the urinalysis 24 hours after antibiotic is completed. RN3 said that the enhanced barrier sign on the resident's room was not for R134, it was for the previous resident in that room.
On 9/12/24 a clinical record review was conducted. R134's progress note written by the nurse practitioner and read in part, . ESBL UTI- Plan: Is receiving cephalexin 500 mg 4 times a day through7/23. Infection caused by extended spectrum beta-lactamase producing bacteria. Z16.12: Extended spectrum beta lactamase (ESBL).
On 9/12/24 R134's care plan was reviewed and read in part, .Isolation/ Precautions: the resident required isolation/precautions related to ESBL in urine created on 7/16/24.
On 9/12/24 a clinical record review was conducted. R134's physician orders had an order that read in part, .cephalexin oral capsule 500 mg give 1 capsule by mouth four times a day every 7 days related to urinary tract infection.
On 9/12/24 at 10:16 a.m. a meeting with the administrator and regional director of clinical services (RDCS) was conducted. The above concerns were discussed. The RDCS stated, I am unable to find a follow up urine on the resident. No follow up urine results were in R134's clinical record.
On 9/12/24 a review of the facility documentation was conducted. The facility policy titled, Extended Spectrum Beta-Lactamase, read in part, .Contact precautions in addition to standard precautions in accordance with physician orders and patient's condition, Patients will remain on TBP's [transmission base precautions] until they have been off antibiotics and depending on the original positive site, have had negative cultures as indicated: Urine: one negative culture.
No new information was provided.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
Based on observation, staff interview, and resident interview, the facility failed to accommodate the resident's preference to dine in the dining room affecting multiple residents on three of three un...
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Based on observation, staff interview, and resident interview, the facility failed to accommodate the resident's preference to dine in the dining room affecting multiple residents on three of three units.
The findings included:
The facility staff failed to have their main dining room available for the residents to have their meals.
On 9/9/24, during the initial tour of the facility, the main dining room was observed to be used as a storage area and not being used for residents dining.
On 9/10/24, at 2:00 p.m., during a resident council meeting conducted with eight residents, all of the residents in attendance were complaining about not having the dining room open for use during mealtimes. Resident # 6, Resident # 19, Resident # 109, Resident # 64, Resident # 69, Resident #65, Resident #58, and Resident #38 were complaining about how long the dining room had been closed off to the residents and that it was being used as a storage area.
On 9/10/24 at 3:15 p.m, Resident #64 stated,It was nice when we all could get together and talk in the dining room at meals, but now it is just a warehouse.
On 9/10/24 at 3:15 p.m., Resident #69 stated, I miss being with everyone in the dining area and it is a shame they just put boxes and things in there where we cannot use it anymore For about 3 months, it's been this way.
On 9/10/24 at 3:325 p.m., the director of nursing and regional director of clinical services were asked about the lack of resident access to the dining room. It was stated that arrangements were being made to have the boxes removed from the dining area and it would be opened back up as soon as the boxes and equipment were moved out of the area.
09/10/24 05:02 p.m., an end of day meeting was held with regional director of clinical services, vice president of operations, administrator, and the director of nursing, during which the above concerns were discussed with the administration staff of the facility.
On 9/11/24 at 10:44 a. m, Resident #149 stated, I really think we need a place to eat other than our room for socialization. It can get depressing, just staying in your room all the time.
On 9/12/24, the facility provided the survey team with evidence that they had ordered a shipping container to have onsite to store the items that were currently being stored in the dining room.
Throughout the four days of survey, the dining room was observed to be unaccessible for the residents to use.
No additional information was provided.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0568
(Tag F0568)
Could have caused harm · This affected multiple residents
Based on Resident interview, staff interview, and facility documentation review, the facility staff failed to provide Residents with quarterly statements of their trust account/bank accounts and faile...
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Based on Resident interview, staff interview, and facility documentation review, the facility staff failed to provide Residents with quarterly statements of their trust account/bank accounts and failed to allow residents to readily access their trust funds, affecting all 140 residents with trust accounts.
The findings included:
On 9/10/24, an interview was conducted with Resident #14- R14. During the interview, R14 expressed that he doesn't get any kind of statement regarding his trust account.
On 9/10/24 at 2 p.m., a group interview was conducted with eight residents (Resident # 6, Resident # 19, Resident # 109, Resident # 64, Resident # 69, Resident #65, Resident #58, and Resident #38).When asked about trust account statements, the residents reported that they did not receive any kind of statement regarding their trust fund accounts. These residents also verbalized concerns that they can only withdraw funds from their trust account for two hours, Monday through Friday, and no longer have weekend access.
On 9/10/24 at approximately 4:28 p.m., observations noted a sign posted near the front reception desk that read, Bank Hours: Monday-Friday 10am-12pm. Closed Saturday and Sunday. Thank you, Business Office.
On 9/10/24 at approximately 4:30 p.m., an interview was conducted with other employee #9 (OE9), who was the front office assistant and who distributed resident's trust funds. OE9 explained that residents can access their money Monday through Friday from 10 a.m., until 12 noon. When asked about weekend access, OE9 said that they no longer do that and that they had sent out a letter to notify the residents. During the interview with OE9, the business office manager (BOM) walked up and joined in the conversation. When asked about account statements, OE9 stated that when residents withdraw money, she can let them know how much they have left. The BOM added that the statements go directly to the residents from the resident fund management system (RFMS). The BOM stated that the facility doesn't send out any statements.
On 9/11/24 at 11:26 a.m., a telephone call was placed to RFMS, and the surveyor spoke with a representative regarding statements. The RFMS representative stated that each facility can choose if they receive the statements monthly or quarterly. The RFMS representative accessed their records and reported that this facility was set up to receive the statements quarterly. When asked if RFMS sends the statements to the residents, the RFMS representative said, They are made available to the facility and if the residents receive a copy is up to the facility. We don't mail them out to residents or families.
On 9/11/24 at 11:40 a.m., an interview was conducted with the business office manager (BOM). The BOM was asked about the banking hours changing and why they decided on two hours per day Monday through Friday. The BOM said, It had a lot to do with speaking with other facilities and how their banking is handled. We were also trying to manage resident funds and the money we receive. We have residents that come daily and get their max out. [OE9's name redacted] is the guard-dog on that and keeps track of who comes daily and for their safety and to keep them from having the money we were going through doing it 7 days a week. We were doing it to manage the money better because we were constantly running out of money.
During the above interview with , When asked if the facility had met with the residents and gotten their input on this change, the BOM stated, No, to be honest, we did not. And as residents came up, we were notifying them. The BOM was asked to provide the surveyor with a copy of the letter that was sent out. The BOM went on to say, We also had some staffing challenges, we had part-timers, and we were trying to limit how many hands were in the money.
The clinical record for R14 was reviewed. There was no evidence that the resident had received a trust account statement.
A review of the facility policy titled, Quarterly PFA [personal fund account] Statements, dated 6/1/22, was conducted. This policy read in part, A quarterly written Patient Trust Fund and Burial Trust Fund, if applicable, statement is issued to the patient or to his or her designated representative .
The facility policy dated 6/1/22, which was titled, Banking Hours was reviewed. This policy read in part, 1. The center will establish banking hours to allow patients to have access to their patient funds for at least two hours during regular business working hours, and for a reasonable time on Saturdays and Sundays . 4. The center will establish a secure procedure for Saturday and Sunday patient access to cash withdrawals.
On 9/10/24, during an end of day meeting, the facility Administrator, director of nursing, and corporate staff were made aware of the above findings.
No additional information was received.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For resident #49 (R49), the facility staff failed to review and revise the care plan to reflect a fall and bed rails that wer...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For resident #49 (R49), the facility staff failed to review and revise the care plan to reflect a fall and bed rails that were in use.
On 9/9/24 and 9/10/24m R49 was visited in his room. R49 was noted to be non-verbal and did not respond to verbal stimuli. R49 was noted to be on an air mattress and had 1/8 length bed rails to both sides of the bed.
On 9/10/24, a clinical record review was conducted. This review revealed R49 had diagnosis which included, but were not limited to persistent vegetative state, obstructive hydrocephalus, cerebral palsy, and cerebral infarction due to unspecified intracranial injury with loss of consciousness of unspecified duration.
According to a nursing note entry dated 7/26/24, R49 sustained a fall. The notes for that day read in part, Resident was lying in between the beds on his left side. No signs of pain or discomfort at this time, and This writer spoke with [R49's father's name redacted] to notify him of [R49's name redacted] fall. This writer informed patient's father that there were no injuries noted at this time but aware of new orders for x-rays. This writer also asked father if he consents to bed side rails. RP [responsible party] agreed.
Review of R49's care plan was conducted. The care plan did not indicate that R49 had fallen on 7/26/24 and did not indicate the bed rails.
On 9/12/24 at 9 a.m., an interview was conducted with the registered nurse (RN #5), who was a care plan coordinator for the facility. RN #5 reported that the care plan is developed by assessment, talking with the resident, family and staff to get the best plan of care for the residents. It helps staff know task involved and serves as a guide. RN#5 stated that falls are discussed daily during a clinical meeting and then the care plan is updated. She stated, we need to put interventions on the care plan as part of the care of the patient, it's how to keep them safe and what to look for.
On 9/12/24, during a late morning meeting with the facility administrator, director of nursing and corporate staff, the above concerns were discussed.
No additional information was provided.
3. For resident #30, R30, who had mental health diagnosis, the care plan was not revised to indicate that a level 2 pre-admission screening for mental health had been halted and not completed.
On 9/10/24, a clinical record review was conducted of R30's chart. This review revealed diagnosis that included, but were not limited to, suicidal ideation, bipolar disorder, major depressive disorder, anxiety disorder, and Alzheimer's disease.
On 9/10/24 a clinical record review was conducted. According to hospital records dated 4/10/24, that were under the documents tab of the chart, R30 was hospitalized with suicidal ideation prior to admission to this facility. According to the pre-admission screening, the level 1 screening for mental illness, intellectual disability or related conditions, indicated that a level 2 assessment was warranted.
According to R30's care plan, it noted, Resident has a Level II PASRR. However, the level II PASRR was not able to be located within the chart.
On 9/11/24, the facility administration was notified during an end of day meeting and again on the morning of 9/12/24, that the survey team wanted to see R30's level II pre-admission screening resident review form.
On 9/12/24 at approximately 10:30 a.m., the survey team was provided with a letter from the department of behavioral health and developmental services division with the Commonwealth of Virginia that indicated the level II screening for R30 had been halted. The reason noted was the individual has a primary diagnosis of an organic disorder, dementia (including Alzheimer's disease) and does not have a diagnosis of ID [intellectual disability]. The letter was dated 9/11/2020. Upon being handed the document, the regional director of clinical services confirmed that the document had not been a part of R30's clinical chart and they had called to get the information faxed to the facility.
On 9/12/24 at approximately 11 a.m., during a meeting held with the facility administration and corporate staff, the above findings were reviewed.
No additional information was provided.
4. Resident #66's care plan was not revised to reflect the intervention of heel protectors (bunny boots) for skin integrity.
The findings include:
Diagnoses for R66 included; Dementia, diabetes, osteoarthritis, and failure to thrive. The most current MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 8/8/24. R66 was assessed with a cognitive score of 00 indicating severe cognitive impairment.
Review of R66's clinical record evidenced a physicians order dated 8/8/24 for Bunny boots bilaterally while in bed. R66's care plan was also reviewed and did not evidence interventions for bunny boots.
On 9/10/24 multiple observations were made between 8:30 a.m. and 10:30 a.m. of R66 lying in bed without bunny boots in place. The bunny boots were observed on the bed-side dresser.
On 9/10/24 at 10:39 a.m. license practical nurse (LPN #1) was asked to observe R66's heels while R66 was still in bed. LPN #1 observed R66 without heel protectors and when asked LPN #1 verbalized unawareness of the heel protector order. It was explained to LPN #1 the possible reason for not knowing about the order was because the order did not indicate documentation was needed (on the TAR, Treatment Administration Record) to ensure the bunny boots were in place.
On 9/10/24 at approximately 2:00 p.m. review of R66's orders indicated the bunny boot order had been updated and entered in a way that the order transferred to the TAR. Review of R66's care plan also was updated to include bunny boots.
On 9/10/24 at 3:29 p.m. registered nurse (RN #2, MDS coordinator) was interviewed regarding the intervention of bunny boots added to the care plan on 9/10/24. RN #2 reviewed the care plan and verbalized that it appeared that the director of nursing (DON) had updated the skin integrity care plan to include bunny boots on 9/10/24 and the care plan should have been updated when the order was placed on 8/8/24.
On 9/11/24 at 4:41 p.m. the above finding was presented to the administrator, DON and nurse consultant.
No other information was presented prior to exit conference on 9/12/24.
Based on resident interview, staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan for four of thirty-three residents in the survey sample (Residents #49, #66, #30 and #131).
The findings include:
1. Resident #131's plan of care of was not revised with interventions in place for trauma related care.
Resident #131 (R131) was admitted to the facility with diagnoses that included urinary tract infection, major depressive disorder, post-traumatic stress disorder, diabetes, spinal stenosis, anxiety and anemia. The minimum data set (MDS) dated [DATE] assessed R131 as cognitively intact.
R131's clinical record documented a trauma assessment 4/19/24 indicating the resident had history of physical abuse, verbal abuse and misappropriation of personal property by an ex-boyfriend. The trauma assessment documented no other source of trauma and identified the resident's trauma was related to fear that the ex-boyfriend would enter the facility and harm her.
R131's plan of care (revised 8/21/24) documented the resident reported history of trauma related to an ex-boyfriend that had assaulted her and stole her money. The care plan identified the trigger related to the resident's trauma history was that the ex-boyfriend would enter the facility and cause harm. The care plan interventions to prevent/minimize distress/anxiety from past traumatic experiences included refer to psych service as needed, schedule familiar staff with resident and trauma screen as indicated. The plan of care included no individualized interventions about preventing the ex-boyfriend from entering the facility or visiting the resident.
On 9/10/24 at 2:11 p.m., the certified nurses' aide (CNA #1) caring of R131 was interviewed about any interventions related to the trauma history. CNA #1 stated she was aware the resident had an ex-boyfriend that was not supposed to visit. CNA #1 stated the ex-boyfriend's picture and name were posted at the reception desk and staff were not supposed to let him in the facility.
On 9/10/24 at 2:23 p.m., the licensed practical nurse unit manager (LPN #8) was interviewed about interventions related to R131's traumatic stress disorder. LPN #8 stated the ex-boyfriend was not permitted to visit the resident or enter the facility. LPN #8 stated the ex-boyfriend's picture was posted at the front desk so staff could identify him and prevent his entrance. LPN #8 stated the interdisciplinary team was responsible for updating care plans. LPN #8 stated he was not sure why the interventions in place were not on the care plan.
On 9/10/24 at 2:30 p.m., R131 was interviewed about interventions implemented by facility staff to prevent stress/fear related to her trauma history. R131 stated the ex-boyfriend tried to visit her once since her admission and this person was stopped at the front desk and denied entrance. R131 stated the ex-boyfriend had made no further attempts to contact or visit her. R131 stated, Staff have done a good job keeping him [ex-boyfriend] away. R131 stated she felt safe in the facility and relieved that she no longer had to deal with the ex-boyfriend.
On 9/11/24 at 8:19 a.m., the service ambassador (other staff #6) working at the entrance desk was interviewed about interventions regarding R131's ex-boyfriend. The service ambassador was aware that R131's ex-boyfriend was not to enter the facility or visit the resident. The service ambassador pointed to a picture with name posted on the front desk. The service ambassador stated if this person attempted to enter the facility, she was to ask him to leave and if he would not leave, she was to call the police.
On 9/11/24 at 8:36 a.m., the regional registered nurse (RN #2) responsible for MDS/care planning, was interviewed about R131's care plan not listing interventions in place regarding trauma care. RN #2 stated the interdisciplinary team was responsible for updates to care plans. RN #2 stated that social services was usually responsible for the trauma related care plan interventions.
On 9/11/24 at 8:38 a.m., the social worker (other staff #3) was interviewed about R131's care plan not including interventions in place regarding trauma care. The social worker stated the care plan should be updated to include the interventions in place to prevent trauma related stress. The social worker stated R131's trauma assessment was last completed on 4/19/24 and the last formal care plan meeting took place on 7/10/24. The social worker stated the interventions in place should be on the plan of care.
This finding was reviewed with the administrator, director of nursing and regional nurse consultants during a meeting on 9/11/24 at 4:40 p.m. with no further information provided prior to the end of the survey.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. For Resident #149, the facility staff failed to follow a physician's order to apply ted hose every morning.
Resident #149 (R1...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. For Resident #149, the facility staff failed to follow a physician's order to apply ted hose every morning.
Resident #149 (R149) was admitted to the facility on [DATE]. R149's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 7/28/24 coded R149 with no cognitive impairment.
On 9/9/24 at 3:33 p.m. an observation was made of R149 sitting outside without ted hose on bilateral extremities. R149 was wearing ankle socks and tennis shoes.
On 09/10/24 at 11:00 a.m. an observation was made of R149. R149 was walking around the nursing units at the facility and was not wearing her ted hose. R149 was wearing bedroom slippers.
On 9/11/24 at 10:44 a.m. an observation was made of R149. R149 was observed walking around the facility hallways with flip flops on and her ted hose were not being worn.
On 09/12/24 at 8:25 a.m. an interview was conducted with a licensed practical nurse, LPN # 2 (LPN2). LPN2 stated, the resident can put the ted hose on independently and she typically likes things a certain way. LPN2 walked with the surveyor to R149's room and there was no ted hose in R149's room.
On 9/12/24 at 8:25 a.m. an interview was conducted with R149 concerning her ted hose. R149 stated that she could put the ted hose on by herself, but sometimes she needed help. R149 stated that she only had the black socks that the supply clerk gave her because she was unable to find ted hose at the store, so the supply clerk bought these socks.
On 9/12/24 at 8:45 a.m. an interview was conducted with the supply clerk. The supply clerk stated that she did not have the correct size for R149, so she went to the store and bought the black socks and was not aware the socks were not ted hose. The supply clerk stated she has had R149's size in the ted hose for 2 weeks and will give the ted hose to R149 today.
On 9/12/24 a clinical record review was conducted. R149 had a physician's order dated 7/29/24 to apply ted hose in the am and remove in the pm written by the nurse practitioner.
On 9/12/24 a review of a facility policy was conducted. The facility's policy titled, Physician's Orders, read in part, .admission Physician's orders must be provided for every patient at the time of admission to activate a medical plan of care. Other orders indicated by patient's condition with specific directions.
On 9/12/24 at 10:25 a.m. the administrator and regional nurse consultant was made aware of the above concerns.
No new information was provided.
5. For resident #92 (R92), the facility staff failed to obtain a valproic acid level lab in accordance with the physicians orders.
On 9/10/24, a clinical record review was conducted. This review revealed that according to the diagnosis tab of the chart, R92 had a diagnosis of epilipsy. R92's medications included Depakote delayed release, which was indicated as being for siezure disorder. According to a physician order dated 8/9/24, it read, Valproic acid level one time only for labs until 08/10/2024.
A review of R92's results tab of the chart revealed that on 8/10/24, a uric acid level lab had been obtained.
On 9/11/24, during an end of day meeting, the facility administrator, director of nursing and coproate staff were made aware of the above findings.
On 9/12/24, the survey team was provided a copy of the lab slip which was completed by a nurse at the facility, and they stated, the wrong test was noted on the lab sheet.
Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to follow physician orders for five of thirty-three residents in the survey sample (Residents #66, #159, #99, #149, and #92).
The findings include:
1. Resident #66's heel protectors (bunny boots) were not applied as ordered.
The findings include:
Diagnoses for R66 included; Dementia, diabetes, osteoarthritis, and failure to thrive on hospice. The most current MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of 8/8/24. R66 was assessed with a cognitive score of 00 indicating severe cognitive impairment.
Review of R66's clinical record evidenced a physicians order dated 8/8/24 for Bunny boots bilaterally while in bed. The order indicated no documentation was needed.
On 9/10/24 multiple observations were made between 8:30 a.m. and 10:30 a.m. of R66 lying in bed without bunny boots in place. The bunny boots were observed on the bed-side dresser.
On 9/10/24 at 10:39 a.m. license practical nurse (LPN #1) was asked to observe R66's heels while R66 was still in bed. LPN #1 observed R66 without heel protectors and when asked LPN #1 verbalized unawareness of the heel protector order. When it was explained to LPN #1 the possible reason for not knowing about the order was because the order did not indicate documentation was needed (on the TAR, Treatment Administration Record) to ensure the bunny boots were in place, LPN #1 agreed. R66's heels were assessed at this time and showed dry, peeling skin to the right heel with a finger-tip size dark area. The left heel showed dry skin.
On 9/10/24 at approximately 2:00 p.m. review of R66's orders indicated the bunny boot order had been updated and entered in a way that the order transferred to the TAR, requiring documentation.
On 9/10/24 at 5:06 p.m., the above finding was presented to the administrator, DON, and nurse consultant.
No other information was presented prior to exit conference on 9/12/24.
2. Resident #159's feeding tube was not anchored as ordered.
The Findings Include:
Diagnoses for R159 included; Displacement of esophageal anti-reflux device (tracheostomy), chronic obstructive pulmonary disease, esophageal obstruction, cellulitis of abdominal wall, feeding tube. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 7/2/24, which assessed R159 with a cognitive score of 15 out of 15, indicating intact cognition.
Review of R159's clinical record evidenced a physicians order, dated 6/21/24, to Anchor feeding tube every shift.
On 9/10/24 at 2:30 p.m., R159 was interviewed regarding an anchor being applied to the feeding tube. R159 verbalized that an anchor was not being used and showed that the feeding tube was not anchored.
On 9/10/24 at 2:45 p.m., registered nurse (RN #1, assistant director of nursing) joined the surveyor to observe R159's feeding tube, that was without a feeding tube anchor. RN #1 said that she thinks the anchor is the balloon that holds the tube in.
On 9/10/24 at 5:05 p.m., RN #1 reported that she had found the anchors for the feeding tubes and verbalized being unaware that the facility had them.
On 9/10/24 at 5:06 p.m., the above finding was presented to the administrator, DON, and nurse consultant.
3. Resident #99 was administered two tablets of acetaminophen ER (extended release) 650 mg (milligrams) when the physician's order required two tablets of acetaminophen 325 mg.
A medication pass observations was conducted on 9/10/24 at 7:51 a.m. with licensed practical nurse (LPN) #4 administering medications to Resident #99 (R99). Among the medications administered were two tablets of acetaminophen ER 650 mg.
R99's clinical record documented a physician's order dated 8/2/24 for acetaminophen 325 mg with instructions to give two tablets every 4 hours as needed for pain/headache.
On 9/10/24 at 8:45 a.m., LPN #4 was interviewed about the incorrect dose of acetaminophen administered to R99. LPN #4 stated she was nervous and pulled the wrong bottle of Tylenol (acetaminophen). LPN #4 stated she was not used to being watched.
This finding was reviewed with the administrator, director of nursing and regional nurse consultants during a meeting on 9/10/24 at 5:15 p.m. with no further information presented prior to the end of the survey.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected multiple residents
Based on observation, staff interviews, resident interviews, clinical record reviews, and facility documentations the facility staff failed to provide trauma informed care for six residents, (Resident...
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Based on observation, staff interviews, resident interviews, clinical record reviews, and facility documentations the facility staff failed to provide trauma informed care for six residents, (Resident #30-R30, Resident #39-R39, Resident #105-R105, Resident #134-R134, Resident #149-R149 and Resident #367-R367) out of a survey sample of 33 residents.
The findings included:
1. The facility staff failed to identify triggers related to trauma and did not provide interventions to address trauma-informed care on the care plans for R39, R105, R134 and R149.
1a. According to the clinical record R39 had diagnosis of psychotic disturbance, mood disturbance, and anxiety disorder.
On 9/11/24 at 8:29 a.m. an interview was conducted with R39. R39 stated that she has increased anxiety with the way some staff speak to her at times. R39 stated, When the staff are rude with me or raise their voice, I become anxious.
On 9/11/24, a clinical record review was conducted for R39. R39 had a trauma screen that was completed on 10/27/23, which identified trauma areas of physical abuse, homicide attempt, and domestic violence. The trauma screen documented that R39's ex-boyfriend tried to kill her by smashing her head. The care plan documented that R39 had reported trauma during their trauma screening related to past relationships and abuse. Care plan interventions were listed as referred to psych services as indicated and trauma screen as indicated. No triggers were identified on the care plan for staff to be aware of/to avoid and there were no interventions for staff related to trauma and/or trauma-informed care were noted.
1b. According to R134's clinical record, they had a diagnosis of anxiety disorder, borderline personality disorder, and major depressive disorder.
On 9/11/24 at 9:24 a.m., an interview was conducted with R134. R134 stated that their triggers included, mean people and things upset me.
On 9/11/24 a clinical record review was conducted for R134. R134 had a trauma screen that was completed on 7/16/24, which identified trauma areas of physical abuse, domestic violence, and a traumatic divorce. The care plan documented that R134 reported trauma during their trauma screening related to having an alcoholic father, a traumatic divorce, and a violent car accident. Care plan interventions were listed as referred to psych services as indicated and trauma screen as indicated. No triggers were identified on the care plan for staff to be aware of/ to avoid and there were no interventions for staff related to trauma-informed care.
1c. R149's clinical record noted diagnoses of anxiety disorder, borderline personality disorder and psychoactive substance abuse.
On 9/11/24 at 10:44 a.m. an interview with R149 was conducted. R149 stated that,Loud noises and violence on television are the things that bother me.
On 9/11/24 a clinical record review was conducted for R149. R149 had a trauma screen that was completed on 7/24/24, which identified trauma areas of physical abuse, gun violence, stalking, and abuse of drugs. The trauma screen documented that R149 had been shot with a gun. The care plan documented that R149 reported trauma during their trauma screening related to being physically, sexually, and mentally abused. Care plan interventions were listed as to have familiar staff to take care of R149, to refer to psych services as indicated, and trauma screen as indicated. No triggers were identified on the care plan for staff to be aware of/to avoid and there were no interventions for staff related to trauma trauma-informed care.
1d. According to R367's record, their diagnoses included anxiety disorder and major depressive disorder.
On 9/11/24 at 9:08 a.m. an interview was conducted with R367. R367 stated, Medical procedures and being held down is a trigger.
On 9/11/24 a clinical record review was conducted for R367. R67 had a trauma screen that was completed on 9/6/24, which identified trauma areas of physical abuse, homicide attempt, suicide attempt, and domestic violence. R367's care plan had no reference to the trauma screening. No triggers were identified on the care plan for staff to be aware of/to avoid and there were no interventions for staff related to trauma-informed care.
On 9/11/24 at 9:34 a.m., an interview was conducted with the regional social work and discharge planning specialist (RSWDCP). The RSWDCP stated, We give [residents] the option to talk about their trauma and we try to be sensitive I agree, it should be more on the trauma screening and more options should be addressed on the care plan. The RSWDCP stated, I was not aware that the diagnosis of post-traumatic stress disorder had to be addressed on the care plan, with goals and triggers, for staff to know what triggers the patient.
2. The facility staff failed to identify triggers related to post traumatic stress disorder and failed to provide trauma-specific interventions on the care plan.
According to the clinical record, R105 had diagnosis to include major depressive disorder, bipolar disorder, and post-traumatic stress disorder.
On 9/11/24 at 8:33 a.m. an interview was conducted with R105. R105 stated, I have very bad anxiety at times. The way staff speaks and the way they act will make me escalate with my anxiety and I have nightmares at times. Just some things make me more anxious than others.
On 9/11/24 at 9:34 a.m., an interview was conducted with the regional social work and discharge planning specialist (RSWDCP). The RSWDCP stated, We give [residents] the option to talk about their trauma and we try to be sensitive I agree, it should be more on the trauma screening and more options should be addressed on the care plan. The RSWDCP stated, I was not aware that the diagnosis of post-traumatic stress disorder had to be addressed on the care plan, with goals and triggers, for staff to know what triggers the patient.
On 9/11/24, a clinical record review was conducted for R105. R105 had a trauma screen that was completed on 9/21/23, which identified trauma areas of physical and emotional abuse. Care plan interventions for R105 included psychiatry referral, familiar staff, and trauma screening as indicated. No triggers were identified on the care plan related to her post traumatic stress disorder for staff to be aware of or to avoid and there were no trauma-informed care interventions for staff.
On 9/11/24 at 4:35 p.m. an end of day meeting was conducted with the administrator, regional director of clinical services, the director of nursing, and the vice president of operations. The above findings were discussed, and the regional director of clinical services stated that an 100% audit of the trauma screening, post-traumatic stress disorder management, and care plans has been initiated.
No new information was provided.
3. For resident #30 (R30) who had a history of trauma, the facility staff failed to provide trauma-informed care.
On 9/9/24 and 9/10/24, R30 was visited in their room, but appeared to be asleep and did not actively engage in conversation with the surveyor.
On 9/10/24 a clinical record review was conducted. According to hospital records dated 4/10/24, that were under the documents tab of the chart, R30 was hospitalized with suicidal ideation prior to admission to this facility.
According to a trauma screen completed 4/22/24, R30 had suffered sexual assault. According to the form it indicated, resident was sexually assaulted by father at a young age. The trauma screen also indicated that R30 .feels fears and anxieties stemming from the sexual abuse committed against her .
According to the clinical record, R30 had only been seen by psychiatric services three times since her admission to the facility in April. The visits occurred on 5/21/24, 7/31/24 and 8/14/24. Each of the notes revealed the only mention of the prior suicidal ideation was in the past medical history and read, suicidal behavior onset 1/24/24, with attempted self-injury . The prior sexual assault trauma was not noted. The focus of the visit was to address, .concern of intermittent refusal of care. The note did indicate that R30 denied suicidal and/or homicidal ideations at that time. Diagnosis included bipolar disorder, dementia with behavioral disturbance, major depressive disorder- recurrent- moderate, and insomnia. Recommendations included, but were not limited to: . maintain a quiet stress-free environment, encourage participation in planned activities and social gatherings, gentle redirection and reassurance, identify, address and eliminate underlying causes for distress, and approach the patient in a way that doesn't escalate distress or result in behavioral dysregulation .
According to R30's care plan, trauma was addressed with interventions, which read as, refer to psych services as indicated and trauma screen as indicated. There was no indication that the facility staff had talked with the resident to identify triggers that increase the resident's fears or anxiety, nor steps the facility staff were to take to minimize re-traumatization. The care plan did not address the prior suicidal ideation.
On 9/11/24 at approximately 3:30 p.m., R30 was interviewed by the surveyor. R30 did acknowledge that she had been sexually abused previously but was not willing to discuss it with the surveyor. R30 only acknowledged the abuse had not occurred in the facility.
On 9/12/24 at 9 a.m., an interview was conducted with the registered nurse (RN #5), who was a care plan coordinator for the facility. RN #5 reported that the care plan is developed by assessment, talking with the resident, family and staff to get the best plan of care for the residents. It helps staff know task involved and serves as a guide.
Review of the facility policy titled; Trauma Informed Care was conducted. The policy read in part, . 2. Through available medical records review and by interviewing the patient, indicate any diagnosis of PTSD or any history of trauma on the Trauma Informed Screen Assessment. 3. If a patient is diagnosed with PTSD, or indicates a history of trauma, encourage the patient to disclose known systems, triggers, and coping mechanisms so that the center can best accommodate those needs in a way that makes the patient feel safe and respected. a. Symptoms may include but are not limited to agitation, anxiety, nightmares, isolation, decreased interest in activities. b. Triggers may include but are not limited to sounds, lights, smells. c. Coping mechanisms may include but are not limited to attending group meetings, deep breathing, mindfulness, physical activity. Immediately update the care plan to reflect information about trauma gathered from the patient and alert the IDT of identified symptoms, triggers, and coping mechanisms.
On 9/12/24, the above concerns were discussed with the facility administration and corporate staff. No other information was provided prior to exit.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0808
(Tag F0808)
Could have caused harm · This affected multiple residents
Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide a therapeutic diet as ordered by the physician for four residents...
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Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide a therapeutic diet as ordered by the physician for four residents (Resident #139, #55, #9, and #30), in a survey sample of 33 residents.
The findings included:
1. For Residents #139, 55, and 9, all who had therapeutic diets ordered, the facility kitchen failed to provide the appropriate diet.
On 9/9/24 at 12:58 p.m., the lunch meal was observed in the restorative room on the west unit. It was noted that R139's meal ticket indicated she was to receive chopped meats. R139's meal tray included a whole/intact pork chop, which nursing staff had to cut up into bite size pieces, which was not a chopped consistency. R139 was observed to not eat the pork chop and verbalized several times, it's too tough. R24 and R9's meal ticket indicated they were to receive pureed foods. The meat on the tray was not a smooth consistency and appeared more like ground meat. Several staff members, to include LPN #6, LPN #3 and CNA #4 all agreed the pureed meat was not a pureed consistency. LPN #6 took R9's tray back to the kitchen to get a replacement. CNA #4 was assisting to feed R55, confirmed the resident was not only to receive pureed foods but was to receive double portions and none of his meal items were double portions.
On 9/9/24 at approximately 1:05 p.m., the unit manager, LPN #3 was asked to accompany the surveyor into the restorative room where residents were eating. LPN #3 was shown each of the resident's trays, R139, 55 and 9. LPN #3 confirmed the above findings. LPN #3 went on to stay she had spoken to the kitchen previously for the same concerns with regards to portion sizes and therapeutic diets not being served.
On 9/9/24, clinical record reviews were conducted for each of the residents named above. The records revealed the following:
R9's diet order dated 7/17/24, read, Regular diet Dysphagia Pureed texture, Thin Liquids consistency, magic cup with lunch, large portions of dessert.
R55's diet order dated 7/17/24 read, Regular diet Dysphagia Pureed texture, Thin Liquids consistency, Large portions.
R139's diet order from the physician dated 7/17/24, read, Regular diet Regular texture, Thin Liquids consistency, Chopped meats.
2. For Resident #30 (R30), who had experienced weight loss, the facility staff failed to provide nutritional supplements as ordered.
On 9/11/24, R30's breakfast meal was observed. According to the meal ticket, R30 was to receive a health shake with breakfast. The shake was not on the tray. When asked, R30 said she likes the strawberry shakes, not the chocolate, but doesn't get them often.
On 9/11/24, other employee #13 (OE13), who conducted daily rounds on R30's room was asked to step into the room. OE13 confirmed that R30's meal ticket indicated she was to receive a health shake at breakfast, but it was not present.
On 9/11/24 at approximately 9 a.m., the unit manager, LPN #3 was shown the above, that R30 did not receive the health shake. LPN #3 and the surveyor went to the kitchen and LPN #3 notified the kitchen staff R30 did not get her shake. The kitchen staff immediately provided LPN #3 with a health shake that she then took to R30.
The dietary manager was asked why R30 wasn't provided the health shake on the tray as ordered, and she didn't have an answer.
According to R30's physician order dated 7/30/24, it read, Regular diet Regular texture, Thin Liquids consistency, large portions at lunch and dinner, health shake at breakfast for to prevent malnutrition/promote wt. [weight] maintenance.
The facility provided the survey team with the requested facility policy titled, Therapeutic Diets. The policy read in part, .3. Diets will be offered as ordered by the physician or designee .
On 9/11/24, all the above findings were reviewed with the facility administrator, director of nursing and corporate staff.
No additional information was provided.
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, the facility staff failed to store, prepare and serve food in a sanitary manner from the main kitchen and on one of three units (We...
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Based on observation, staff interview, and facility document review, the facility staff failed to store, prepare and serve food in a sanitary manner from the main kitchen and on one of three units (West unit).
The findings include:
a) The walk-in refrigerator and freezer in the main kitchen had out-of-date and/or unsealed food items. Stainless prep pans were stored nested and wet. The bench mounted can opener was dirty with accumulated debris. Flies were observed in the kitchen during meal prep near the exit door beside the handwashing sink.
On 9/9/24 at 10:41 a.m., accompanied by the dietary manager (other staff #2), the main kitchen was inspected during the initial tour of the facility. Stored in the walk-in refrigerator was a package of sliced turkey labeled with a use by date of 9/5/24. There was an opened 46-ounce carton of thickened cranberry cocktail with no label indicating when opened. A package of slice turkey, with no manufacturer's label was stored and available for use. There was no identification on the packaged turkey indicating a use by or expiration date. A box with 18 pasteurized eggs was stored with a use by date of 7/11/24. In the walk-in freezer was stored an unsealed bag of frozen sausage patties and an unsealed bag of frozen French fries. Seven stainless quarter-sized pans were observed stored nested and wet. The bench mounted manual can opener near the 3-compartment sink was dirty with accumulated black/brown debris on the blade and bracket.
The dietary manager (other staff #2) was interviewed at the time of the observations about the out-of-date and unsealed food items stored in the refrigerator and freezer. The dietary manager stated all food items were supposed to be labeled with a date opened and a discard date. The dietary manager stated foods were supposed to be stored in sealed containers. The dietary manager stated the package of slice turkey with no identification should not have been removed from the original box/packaging. The dietary manager stated the prep pans were supposed to air dry on a rack prior to nesting. The dietary manager stated the can opener needed to be soaked and cleaned.
On 9/9/24 at 11:32 a.m., lunch preparation was observed. Flies were observed in the kitchen near the handwashing sink located beside an exit door. Several flies were observed near the convection ovens. Kitchen staff members were observed exiting and re-entering the through the exit door, multiple times during meal preparation/service. An air curtain positioned over the exit door did not activate when the door was opened. The dietary manager was interviewed at this time about the flies and the non-functioning air curtain. The dietary manager stated the air curtain at the exit door did not come on automatically when the door was opened. The dietary manager stated she had to turn the air curtain on at the breaker box. The dietary manager stated she usually turned the air curtain on when the door stayed open for deliveries. The dietary manager stated she did not routinely run the air curtain during meal prep.
On 9/9/24 at 11:55 a.m., a warming oven in use was inspected. The front of the unit was dirty with drips, fingerprints, and smudges on the glass door. The bottom of the unit had accumulated crumbs, spills, and debris. The control panel near the floor was dirty with crumbs and debris.
b) On 9/10/24 at 2:53 p.m., accompanied by licensed practical nurse (LPN) #4, the [NAME] unit nutrition/snack refrigerator was inspected. Stored in the refrigerator was an opened 32-ounce carton of Med Pass supplement. There was no date or label indicating when the Med Pass was opened. LPN #4 was interviewed at this time. LPN #4 stated she was not sure how long the Med Pass had been opened because there was no label indicating the date opened. LPN #4 stated nurses were supposed to label supplements when opened.
The facility's policy titled Food Storage: Cold (Oct. 2019) documented, .It is the center policy to insure all Time/Temperature Control for Safety (TCS), frozen and refrigerated food items, will be appropriately stored in accordance with guidelines of the FDA Food Code .The Dining Services Director/Cook(s) insures that all food items are stored properly in covered containers, labeled and dated and arranged in a manner to prevent cross contamination . The facility's food storage chart (referencing Food Code 2017) documented that ready-to-eat foods and leftovers may be stored for up to 7 days after preparation or opening.
The facility's policy titled Ware Washing (policy 22) documented, .It is the center policy that all dishware and service ware will be cleaned and sanitized after each use . The Dining Services Director ensures that all dishware is air dried and properly stored .
The facility's policy titled Equipment (policy 27) documented, .It is the center policy that all food service equipment is clean, sanitary, and in proper working order .The Dining Services Director will ensure that all equipment is routinely cleaned and maintained in accordance to manufacturer directions and training materials .The Dining Service Director will ensure that all food contact equipment is cleaned and sanitized .The Dining Services Director will submit requests for maintenance or repair to the Administrator and/or Maintenance Director as needed .
This finding was reviewed with the administrator, director of nursing and regional nurse consultants during a meeting on 9/10/24 at 5:15 p.m. with no further information presented prior to the end of the survey.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
Based on observation, staff interview, and facility document review, the facility staff failed to maintain effective pest control.
The findings include:
Flies were observed during the survey on the ...
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Based on observation, staff interview, and facility document review, the facility staff failed to maintain effective pest control.
The findings include:
Flies were observed during the survey on the [NAME] unit dining/day room and in the main kitchen during food preparation.
On 9/9/24 at 11:32 a.m., lunch preparation was observed in the main kitchen. Flies were observed in the kitchen near the handwashing sink located beside an exit door. Several flies were observed near the convection ovens. Kitchen staff members were observed exiting and re-entering through the exit door multiple times during meal preparation/service. An air curtain positioned over the exit door did not activate when the door was opened. The dietary manager was interviewed at this time about the flies and air curtain. The dietary manager stated the air curtain at the exit door did not come on automatically when the door was opened. The dietary manager stated she had to turn on the air curtain at the breaker box. The dietary manager stated she usually turned the air curtain on when the door stayed open for deliveries. The dietary manager stated she did not routinely run the air curtain during meal prep.
On 9/9/24 at approximately 12:00 p.m., residents on the [NAME] unit were observed eating lunch in the day room. Multiple flies were observed in the day room while residents were eating and/or being fed lunch. On 9/9/24 at 4:26 p.m., Resident #55 (R55) was observed seated in a wheelchair in the [NAME] unit day room. Several flies were observed on and/or around the resident. Flies were observed flying/landing on the resident's shirt, the resident's head/forehead, and on R55's hands/forearms.
On 9/11/24 at 10:23 a.m., the assistance maintenance director (other staff #1) was interviewed about the observed flies and the facility's pest control. The assistant maintenance director stated that a pest control vendor came each month and treated the facility for pests including flies. The assistant maintenance director stated he was not aware that flies were in the [NAME] unit day/dining room. The assistant maintenance director stated the air curtain in the main kitchen was not working properly. The assistant maintenance director stated he did not know what was wrong with the air curtain and that the air curtain was supposed to come on automatically when the door was opened to prevent flying insects from entering.
The assistant maintenance director presented monthly reports from a contracted pest control vendor. The most recent report dated 8/28/24 documented treatment for ants, glue boards for flies and treatment for fruit flies in the kitchen. The report made no mention of the non-functional air curtain in the kitchen or of any targeted treatment for flies in the kitchen and/or [NAME] unit dining room.
This finding was reviewed with the administrator, director of nursing and regional nurse consultants during a meeting on 9/11/24 at 4:40 p.m. with no further information provided prior to the end of the survey.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0909
(Tag F0909)
Could have caused harm · This affected most or all residents
Based on staff interview and facility documentation review, the facility staff failed to implement a bed safety program for the entire facility affecting all residents residing on 3 of 3 units.
The f...
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Based on staff interview and facility documentation review, the facility staff failed to implement a bed safety program for the entire facility affecting all residents residing on 3 of 3 units.
The findings included:
On 9/11/24, in the afternoon an interview was conducted with the facility's maintenance director. When asked about the bedrails on Resident #49's (R49) bed, the maintenance director stated that he had put the railings on the bed not long after he started working at the facility, approximately two months ago. The maintenance director was asked to provide a copy of the maintenance work order where that was done.
On 9/11/24, the facility staff was asked to provide any evidence of an inspection being conducted on R49's bed and bedrails.
On 9/12/24, the regional director of clinical services (RDCS) reported to the survey team that they were not able to locate the maintenance work order regarding the application of bedrails for R49. The RDCS also showed the survey team a 3-ring binder that was the bed safety program and said, I'm not going to even open it, indicating it was not complete.
On 9/12/24 at approximately 11 a.m., the surveyor reviewed the bed management binder and there was what appeared to be a bed inventory listing dated April 2023, that listed bed frame model numbers. There was no indication of an actual inspection being conducted. When the surveyor asked the corporate team who was in the office, the RDCS confirmed that was accurate, there was no indication of any inspections being performed.
Review of the facility policy titled; Bed System Audits was conducted. This policy read in part, 1. Maintenance will identify each center bed by number and will conduct a full bed audit on each bed a minimum of annually. The audit will include the frame, the deck, the headboard, the footboard, the mattress, and any installed bed rails and/or assistive devices . 4. Annual and intermittent bed audits will reference the FDA's Seven Zones of Entrapment, the dimensional criteria as established by the HBSW (Hospital Bed Safety Workgroup) guidelines, and other areas of potential safety risk within the bed system .
No additional information was provided.
Apr 2024
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure resident identifiable information was not released to the public for 41 of 42 reside...
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Based on staff interview, clinical record review, and facility document review, the facility staff failed to ensure resident identifiable information was not released to the public for 41 of 42 residents in the survey sample, Residents 1- 41.
The findings included:
Residents 1 through 41 had personal health information given to the Registrar's office by facility staff that revealed their cognitive status.
On 4/15/24 at 4:39 PM, during an interview with the facility administrator it was revealed that the facility had violated the Federal Standards for Privacy of Individually Identifiable Health Information. The administrator stated that on 1/10/24 the U.S. Department of Health and Human Services (HHS), Office for Civil Rights (OCR), had emailed her stating that they had received an allegation on 11/3/23 that the facility had violated the Federal Standards for Privacy of Individually Identifiable Health Information (45 C.F.R. Parts 160 and 164, Subparts A, C and E, (the Privacy and Security Rules), indicating that the facility provided a list of residents to the local Registrar's office that included information that they were recommended by a physician to be adjudicated mentally incompetent.
The administrator provided documentation that had been received from the HHS, OCR, on 4/15/24, indicating that the review of the allegation had been completed. According to the letter on 1/10/24, the OCR notified the facility of the breach allegation. The letter documented the outcome of the investigation as follows: The administrator explained that their social service assistant engaged in discussions with the Registrar's Office to seek guidance on facilitating voter registration for both short-term and long-term patients. The necessity for this initiative arose from the fact that numerous patients have undergone address changes due to health-related requirements and they wanted to identify the patients who were eligible for voting and those who would require voting assistance. The letter also documented that the facility had stated that .to ensure impartiality in the registration process for facility residents, the Registrar's office suggested the implementation of a competency evaluation, conducted by a physician, to identify those who required assistance and proposed that the total census of the facility be categorized into two distinct lists: one comprising eligible residents and the other non-eligible residents. The letter also indicated that the facility .believed that the Registrar's office required proof of inability to participate in the election process to prevent voter fraud.
Also, per the letter from the HHS, OCR, the OCR spoke to the General Registrar and Director of Elections, regarding the request for the above information, and he declined that his staff would request a list of ineligible residents.
The letter also stated that on 3/19/24, to resolve the breach of information, the facility provided OCR with assurance that it took various steps to ensure that this type of disclosure does not occur in the future. They apologized for the error, reviewed policies and procedures to protect patient information, educated responsible staff, filed a breach report with HHS, and sent appropriate breach notifications to the affected individuals. OCR closed the complaint based on the facility's voluntary compliance.
The facility's documented plan of correction included:
1. a review of the facilities policies and procedures for HIPPA, no revisions were made to the policy
2. the employee involved in the incident was educated on the HIPPA policy manual, documented on 2/22/24
3. breach report filed on 2/29/24
4. letters sent to the affected residents 2/22/24
5. On 3/7/24 Quality Assurance Plan included a Process Improvement guide for HIPPA Compliance/Voting Protocol with a goal of compliance with encrypted information for protected health information
Compliance date verified to be 3/7/24.
The facility provided the Standards of Practice HIPPA Policy effective date 1/11/24 that stated, The Privacy/Security Policy of this organization is implemented for the purpose of complying with the privacy/security regulations promulgated under the Health Insurance Portability and Accountability Act of 1996 (HIPPA or the Privacy/Security Rule). It is the policy of the company to protect the confidentiality of Protected Health Information (PHI) of its patients. Per the policy, . sensitive information should never be discussed with others, if they do not have a direct involvement with the patient's care.
On 4/16/24 at 2:20 PM, during the end of the day meeting the administrator and the regional nurse consultant were made aware of the above findings.
No additional information was provided.
The plan of correction was deemed acceptable with interventions implemented as listed. There were no deficiencies identified since the correction date of 3/7/24, regarding unauthorized release of resident-identifiable information.
This deficiency was cited as past non-compliance.
Dec 2022
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and complaint investigation, the facility staff failed to follow professional s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and complaint investigation, the facility staff failed to follow professional standards of practice for two of nine residents in the survey sample, Residents #3 and #4. These were closed record reviews.
The findings include:
The nurse assigned to Resident #3 and #4 was unable to locate the DNR (Do Not Resuscitate) status during a medical emergency.
1. Diagnoses for Resident #3 included; Cerebral Palsy, Malnutrition, sepsis, intellectual disabilities, seizures and depression. The most current MDS (minimum data set) was a significant change assessment with an ARD (assessment reference date) of [DATE]. Resident #3 was assessed as having short and long-term memory problems and severely cognitively impaired.
Review of the resident #3's clinical record on [DATE] documented a physician's order dated [DATE] that read Code status DNR.
A nursing note dated [DATE] 2:00 AM indicated that a CNA (certified nursing assistant) found Resident #3 on the floor beside his bed and alerted the assigned nurse to assess Resident #3. The nurse (license practical nurse, LPN #2, person writing the nursing note) assessed Resident #3 and was unable to obtain vital signs and documented that Resident #3 had rapid breathing. A call was placed to the nurse practitioner, giving an order to call 911 and send to the emergency department.
Another nursing note dated [DATE]/ at 3:10 AM Documented EMT [emergency medical technician] arrived at facility observed resident with no response when touched [ .] CPR begun by EMT's and was stated 'had a pulse' and EMT's transferred to [name of hospital].
On [DATE] at 2:50 PM the complainant (EMT on scene) was interviewed. The complainant verbalized upon arrival to the facility Resident #3 was sitting in a wheelchair and was unresponsive. Complainant stated that Resident was pulled to the floor and CPR was started, adding that during this time a nurse came by and said to stop CPR as Resident #3 was a DNR. The complainant asked the nurse to present documentation regarding a DNR status for Resident #3, but the nurse was unable to present a DNR order. The complainant then said that the nurse opened up Resident #3's chart and typed DNR on Resident #3's face sheet. The complaint responded to the nurse that that was not legal and needed a physician's order. During this time Resident #3 was revived and sent to the hospital.
On [DATE] at 3:25 PM LPN #2 was interviewed regarding the concern involving Resident #3's DNR status. LPN #2 verbalized that she could not remember the incident that well, but did say that she was unable to find Resident #3's DNR status and thought it was on the profile sheet. When asked since the incident does she know where a nurse would be able to find the DNR status, LPN #2 verbalized that she thought it was in a book, but didn't know for sure, adding that the book is locked up in the office.
On [DATE] starting at 4:05 PM interviews were conducted with three LPN's working on different units. All three LPN's interviewed were able to explain where to find the DNR status of residents in the facility and demonstrated the DNR status on the computer for randomly picked resident's.
On [DATE] at 9:15 AM the above information was presented to the director of nursing (DON) and nurse consultant. The DON verbalized that after taking the position she realized a few things were not being done the way they should be done based on the previous DON, but things have been put into place and education has been a priority.
The DON and nurse consultant were asked if there were any procedures that the nurses should be doing to check for DNR status prior to beginning CPR. The nurse consultant verbalized that it is hard for her to believe that LPN #2 did not know where to look in the chart to retrieve a DNR status and went on to say it is a nursing standard of practice and something that is taught to all nurses that a DNR has to have an physician's order, adding that LPN #2 should have reviewed the orders.
This a complaint deficiency.
No other information was presented prior to exit conference on [DATE].
2. The findings include:
Diagnoses for Resident #4 included; Dementia, dysphagia, epilepsy, and chronic kidney disease. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of [DATE]. Resident #4 was assessed as having short and long-term memory problems and severely cognitively impaired.
Review of the resident #4's clinical record on [DATE] documented a physician's order dated [DATE] that read Code status DNR.
A nursing note dated [DATE] 5:30 AM documented: Observed resident laying in bed unresponsive. Vitals unable to obtain. CPR started and 911 was telephone to facility until second gave order that resident was a DNR (SIC), CPR stopped per writer and two nurses. 0545 eMT's arrived cpr started and called the resident deceased . (SIC)
On [DATE] at 2:50 PM the complainant (EMT on scene) was interviewed regarding Resident #4. The complainant verbalized that a call came in reporting a resident was in cardiac arrest and CPR was being performed by nursing staff. Upon arrival to the facility, the resident was found on the floor with no one attending to the resident and was informed that resident #4 was a DNR, but they [the facility] didn't have the paperwork to confirm a DNR status. So CPR was started by EMS medic, until code status was confirmed. The complainant verbalized that another medic was able to reach out to a physician that gave direction to stop CPR, based on wife request for Resident #4 to be a DNR.
On [DATE] at 3:25 PM, LPN #2 (nurse that was assigned to Resident #4 at the time of the incident) was interviewed regarding the concern involving Resident #4's DNR status. LPN #2 verbalized that she could not remember the incident that well, but did say that she was unable to find Resident #4's DNR status and thought it was on the profile sheet. When asked since the incident, does she know where a nurse would be able to find the DNR status, LPN #2 verbalized that she thought it was in a book, but didn't know for sure, adding that the book is locked up in the office.
On [DATE] starting at 4:05 PM interviews were conducted with three LPN's working on different units. All three LPN's interviewed were able to explain where to find the DNR status of residents in the facility and demonstrated the DNR status on the computer for randomly picked resident's.
On [DATE] at 9:15 AM the above information was presented to the director of nursing (DON) and nurse consultant. The DON verbalized that after taking the position, she realized a few things were not being done the way they should be done based on the previous DON, but things have been put into place and education has been a priority.
The DON and nurse consultant were asked if there were any procedures that the nurses should be doing to check for DNR status prior to beginning CPR. The nurse consultant verbalized that it is hard for her to believe that LPN #2 did not know where to look in the chart to retrieve a DNR status and went on to say it is a nursing standard of practice and something that is taught to all nurses that a DNR has to have an physician's order, adding that LPN #2 should have reviewed the orders.
This a complaint deficiency.
No other information was presented prior to exit conference on [DATE].
Jul 2021
12 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Quality of Care
(Tag F0684)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9. Resident #32 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included schizoaf...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9. Resident #32 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included schizoaffective disorder, hypertension, colon cancer, muscle weakness, unspecified psychosis, major depression disorder, anemia, dysphasia, unspecified severe protein-calorie malnutrition, and Parkinson's disease. The most recent minimum data set (MDS) dated [DATE] was the admission assessment and assessed Resident #32 as moderately impaired for daily decision making with a score of 9 out of 15.
On [DATE], Resident #32's clinical record was reviewed. Observed on the physician's order summary was the following order: obtain weekly weight. Order Status: Active. Order Date: [DATE]
Observed on the care plans was the following: Nutrition risk r/t (related to) colon cancer/tx (treatment), hx (history) overweight. Does not wear bottom dentures during meals by how choice, limited chewing. Hx (history) mech (mechanical) altered diet d/t (due to dysphasia. Hx (history) weight fluctuations - currently loss. Created on: [DATE]. Revision on: [DATE]. Goal: Resident will avoid significant weight change through next review Revision on [DATE]. Target date [DATE]. Interventions: . Weights per protocol Created on: [DATE] .
Observed within the clinical record were the following weights:
[DATE] 164.9 (Standing) - readmission
[DATE] 166.8
[DATE] 166.5 (Standing)
[DATE] 168 lbs
[DATE] 178.3 lbs (Standing)
[DATE] 179.9 lbs.
On [DATE] at 6:01 p.m., the unit manager (LPN #4) was interviewed regarding how weight orders were communicated to staff. LPN #4 stated the weight orders are communicated in daily meetings and is also posted on the unit bulletin board by the Dietitian. LPN #4 was asked if she had a copy of she sheet that was provided by the dietitian. LPN #4 stated she did not have a hard copy of the notice from the dietitian and was not sure how the order for the weekly weights was missed for Resident #32. LPN #4 was asked who was responsible for weighing the residents. LPN #4 stated mostly the certified nursing assistants (CNAs) completed the weights. LPN #4 was asked how were the weight orders communicated to the CNAs. LPN #4 stated the CNAs could view the information on the unit bulletin board and were given a weight sheet. LPN #4 was asked Resident #32 refused weights. LPN #4 stated, no, not that I am aware of.
On [DATE] at 6:15 p.m., the registered dietitian (OS #1) was interviewed regarding how weight orders were communicated to staff. OS #1 stated the information was shared in the facility weight meetings and nursing was able to print the orders and communicate it to the CNAs to obtain the weights. OS #1 stated Resident #32 had lost weight while he was in the hospital and when he was readmitted to the facility the order for weekly weights was placed. OS #1 stated since Resident #32 readmitted , he had noted some increased intake and was eating better.
The above findings were reviewed with the administrator, director of nursing and corporate consultant during a meeting on [DATE] at 1:10 p.m.
Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to ensure glucose-monitoring devices were calibrated and accurate on three of three units. A total of twelve glucose monitoring devices were located on nine medication carts and available for use on all three units. Review of the calibration logs for the devices revealed calibration had not been completed on a nightly basis per facility policy. All twelve devices were calibrated for accuracy by facility staff, and nine devices were out of range. Staff observed conducting the calibration of the devices did not follow manufacturer instructions for correctly performing the calibrations, and control solutions for the testing of high and low values were expired. Thirty-two (32) residents were identified as requiring insulin and blood sugar monitoring. Thirteen (13) of those residents (Residents # 27, 95, 113, 108, 249, 384, 42, 97, 69, 84, 88, 236, and 247) were included in the survey sample and the extended survey sample. Four of the thirteen residents (#27, 108, 249, and 69) were identified as having concerns related to glucose monitoring. Staff were performing blood sugar tests and administering insulin based on blood sugar readings obtained on equipment that had not been calibrated.
This was identified as Immediate Jeopardy (IJ) in the area of Quality of Care [DATE] at 4:55 p.m., with resulting SQC (substandard quality of care). The Immediate Jeopardy was abated on [DATE] at 1:10 p.m., and the Scope and Severity was lowered to Level II, pattern.
The facility staff also failed to follow physician orders for four of 38 residents in the survey sample: Residents #56, #71, #42 and #32. Resident #56 was not provided support hose as ordered by the physician. Resident #71 was not started on antibiotics as ordered by the physician until four days after admission. Residents #32 and #42 did not have physician ordered weights obtained by staff.
Findings include:
1. On [DATE] at 9:45 a.m., accompanied by the licensed practical nurse (LPN #6), the medication carts were inspected on the East unit. The January, February, and [DATE] blood glucose monitoring calibration sheets for the East unit glucometers were blank with no entries or control checks completed on the unit's three medication carts. There were no blood glucose monitoring calibration sheets for the glucometers for April, May, or [DATE].
On [DATE] at 10:15 a.m., accompanied by the East unit manager (LPN #6), three blood glucose monitors were checked with the manufacturer's control solution. The acceptable high range was labeled as 204-255 and the acceptable low range was 82-101.
Cart #1 included two glucometers. The first glucometer had a high reading of 233 and a low reading of 96 with both readings within range. The second glucometer had a high reading of 243 and a low of 94 with both readings within range.
Cart #2 included two glucometers. There was no test solution for Cart #2. LPN #6 stated she would use the solution from cart #3. One of the glucometers from Cart #2 had a high reading of 258 and a low reading of 88, with the high reading out of range. The second glucometer on Cart #2, had a high reading of 237 and a low reading of 94, both readings were within range.
Cart #3 included two glucometers. One of the glucometers from Cart #3 had a high reading of 359 and a low reading of 79, both readings were out of range. The second glucometer on Cart #3 had a high reading of 223 and a low reading of 91, both readings were within range. LPN #6 stated at the time of the cart inspections that there was no documentation of which glucometer was used with which resident.
2. On [DATE] at 10:18 AM, medication storage and labeling was observed on the South wing. Medication cart B was observed. This cart had one glucometer; the glucometer was labeled with a permanent marker, Cart B #1.' LPN (Licensed Practical Nurse) # 3 stated that the device is cleaned before and after each use, and provided the cleaning protocol with demonstration. LPN #3 was asked if the glucometer had been calibrated. LPN #3 stated, I'll have to get an answer for that and stated, I don't do it. LPN #3 had a new bottle of test strips dated [DATE]. There was no control solution on this medication cart to do a calibration test.
At 10:28 AM, LPN #3 asked LPN #2 about the glucometers being calibrated. LPN #2 stated that they should be calibrated every night on 3rd shift. LPN #2 stated that the 3rd shift nurse has a checklist with things to do and that is one of them. LPN #2 was asked how many glucometers were on the South unit. LPN #2 stated that Cart A has two glucometers, Cart B has one glucometer and Cart C has one glucometer, for a total of four glucometers on the South unit.
The glucometers were labeled as Cart A #1 and #2, Cart B #1, and Cart C #1.
At approximately 10:30 AM, LPN #3 asked LPN #1 where the calibration/control solution to test the glucometers was located. LPN #1 stated that they do the calibration test to see if the glucometers are operating correctly and then document in the book. LPN #1 stated that this is done every night on the glucometers. LPN #1 was asked to perform a control test. LPN #1 and LPN #3 both stated that they did not have any control solution on their carts [Cart B and Cart C]. LPN #1 was then asked to review the book with quality control tests.
LPN #1 went to the nurse's station and pulled a binder book with glucometer control testing results. Inside the book were sheets titled, blood glucose monitoring meter checks quality control record. LPN #1 stated that there is a sheet for each glucometer on the unit. Each sheet had 13 columns, each column labeled as follows: the date, station/shift, operator initials, meter cleaned, check strip result, test strip lot #, expiration date, code #, Level 1 control range , Level 1 control result, Level 2 control range, Level 2 control result, and Corrective Action column [last]. The glucometers were counted on the South wing unit by staff and verified that four glucometers were on the South wing [2 glucometers on Cart A, 1 on Cart B, and 1 Cart C].
The quality control logs located in the book were reviewed for the last three months, [DATE] through present [[DATE]], the following was revealed:
Cart A glucometer #1 only had one log sheet for June. The dates tested were [DATE]th, 25th, 28th, and 29th. It was documented that this glucometer was in range on those dates.
There was no log for Cart A glucometer #2, although there were two glucometers on Cart A. There was no documentation for Cart A #1 or #2 glucometers for the months of April and May to evidence any testing.
Cart B glucometer #1 log sheet for June documented testing dates were [DATE]th, 25th, 28th, and 29th. There was no documentation for April or [DATE] to evidence any testing.
Cart C glucometer #1 log sheet for June documented testing dates were [DATE]th, 25th, 28th, and 29th. There was no documentation for April or May to evidence any testing.
At approximately 10:40 AM, LPN #2 stated that she had control solution on her cart, Cart A.
At 10:42 AM, LPN #2 and LPN #3 gathered their assigned glucometers and supplies to perform the control tests, which included Cart A glucometers #1 and #2, and Cart B glucometer #1. All the supplies gathered [test strips, control solution] were verified by lot number, not expired, and not past an open date.
Cart A glucometer #1 was tested and did not pass the control test for the level 2 test. The level 2 test range was listed on the bottle as 204-254. The actual result for glucometer #1 was 345.
Cart A glucometer #2 was tested and did not pass the control test for the level 2 test. The level 2 test range was listed on the bottle as 204-254. The actual result for glucometer #2 was 349.
Cart B glucometer #1 was tested and did not pass the control test for level 2 test. The level 2 test range was listed on the bottle as 204-254. The actual result for glucometer #1 was 362.
According to the control logs, all four glucometers were last tested on [DATE] and all four passed the control test [level 1 and level 2].
At 11:05 AM, LPN#1 was asked to test Cart C glucometer #1. LPN #1 stated, I don't have any controls [solution] on my cart because it expired and the facility doesn't have anymore. LPN #1 stated that she had thrown them away this morning. LPN #1 stated that she only had one glucometer on her cart. The control solution was borrowed from Cart A to perform the control test.
Cart C glucometer #1 was tested and did not pass the control for the level 2 test. The level 2 test range was listed on the bottle as 204-254. The actual result for glucometer #1 was 348.
All four glucometers on the South wing were found out of calibration and none of the glucometers were removed from service.
At approximately 11:45 AM, LPN #2 performed a blood glucose check on Resident #108 with glucometer #2 from Cart A. This glucometer was checked at approximately 10:45 AM and was found out of calibration [failed the level 2 test]. The resident's blood glucose result on this glucometer was 259.
Resident #108 was admitted to the facility on [DATE]. Diagnoses for Resident #108 included, but were not limited to: type 2 diabetes with hyperglycemia [insulin dependent], muscle weakness, chronic kidney disease stage 3, and vascular dementia without behaviors.
The most current MDS (minimum data set) for Resident #108 was a five day admission assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 13. Resident #108 was assessed in Section N. [Medications] as receiving 3 injections of insulin in the last three days [with one order for insulin].
Resident #108's physician's orders were reviewed and documented orders for, but not limited to: Accuchecks AC [before meals] and HS [bedtime] as needed for DM [diabetes mellitus] Notify MD [medical doctor] for BS [blood sugar] less than 60 or greater than 400 .Accuchecks AC and HS before meals and at bedtime for for DM Notify MD for BS less than 60 or greater than 400 .Hold meal insulin for blood sugars less than 100 .Insulin Glargine .inject 50 units subcutaneously in the morning .Insulin Lispro .inject 15 units subcutaneously with meals for Diabetes Hold meal time insulin for blood sugars less than 100 .
Resident #108's care plan was reviewed and documented, .has Diabetes Mellitus .medication as ordered by doctor. Monitor/document for side effects .dietary consult .educate regarding medications .compliance .podiatry consult as needed .
Resident #108's MARS [medication administration records] were then reviewed. According to the resident's MARS the resident was given 15 units of Lispro by LPN#2 on [DATE] at noon. The resident was also given Lispro 15 units at 5:00 PM, the blood glucose reading was 173.
3. On [DATE] at 4:13 PM, glucometer calibration tests were performed on the west wing by registered nurse, (RN) #4. Test solution and test strips were not expired. The results were as follows:
Glucometer labeled west C cart was tested. The bottle of test strips indicated the range for low side (Level 1) should be 83-103. The bottle also indicated the range for high side (level 2) should be 206-257. The test was run for low side with the results being 79 (indicating out of parameter). The test was completed for the high side with the results being 355 (indicating out of parameter).
B cart glucometer was tested. The bottle of test strips indicated the range for low side should be 83-104. The bottle also indicated the range for high side should be 209-261. The test was run for low side with the results being 90 (indicating within parameter). The test was completed for the high side with the results being 357 (indicating out of parameter).
A cart glucometer was tested. The bottle of test strips indicated the range for low side should be 82-102. The bottle also indicated the range for high side should be 204-254. The test was run for low side with the results being 83 (indicating within parameter). The test was completed for the high side with the results being 350 (indicating out of parameter).
RN #4 stated that she would take the glucometers out of service and get a new one.
Glucometer calibration logs were then reviewed with the unit manager (license practical nurse, LPN #4). Documentation showed each cart glucometers (A, B, and C) were last tested on [DATE] with only one test done prior on [DATE]. LPN #4 stated that tests on the glucometers are supposed to be run on every night shift.
Resident #27 was admitted to the facility on [DATE]. Diagnoses for Resident #27 included: Type 2 diabetes, cognitive deficit, coagulation defect, and muscle weakness. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of [DATE]. Resident #27 was assessed with a cognitive score of 9 indicating moderately cognitively impaired.
On [DATE] Resident #27's medical record was reviewed. A progress noted dated [DATE] documented a call from the facility contracted lab indicating Resident #27 had a critical glucose result of 24 from a lab that was taken earlier in the morning. The lab report dated [DATE] documented that the lab test was taken at 5:38 AM on [DATE] and also documented the glucose lab was confirmed by a repeat analysis.
Resident #27's blood sugar test flow sheet was then reviewed and documented a blood sugar test had been obtained on [DATE] at 5:51 AM with results being 83 (13 minutes after the lab had drawn blood).
4. Resident #69 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: end stage renal disease, dementia, hypertension, schizoeffective disorder, and diabetes mellitus.
The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of [DATE]. Resident #69 was assessed as cognitively intact with a summary score of 12.
The clinical record was reviewed on [DATE] at approximately 4:00 p.m. The following progress notes were observed:
[DATE] 23:37 [11:37 p.m.] Resident blood sugar at 2154 [9:54 p.m.] was 67. Resident was alert and stated he did not feel like his blood sugar was low. Went and got a coke and snacks from vending machine for resident. Resident was eating snacks and drinking his coke when leaving room. Went to recheck bs [blood sugar] at 2230 [10:30 p.m.] and resident was in the floor between the two beds, Resident was laying on his left side. Resident had spilled his coke and was laying in the coke on the floor. Resident would open his eyes but was unresponsive. Resident was breathing and had a pulse. Call for nursing assistants and called 911 from the room. Attempted several times to get a BS and got reading all over the place. One read HI, one read 85, one read 247, last one read 54. Gave resident glucose since he was being [beginning] to be a little more alert. However, resident would just cough and not swallow glucose. 3 emts [emergency medical technicians] arrived and assisted resident to stretcher .
[DATE] 01:55 [a.m.] Received report from [Name] in ER [emergency room] who states when resident got to hospital he was alert and answering correctly. She noted he had urinated on himself and she walked him to the bathroom and cleaned him. His BS was 226. His white blood cells are up @ 21.8 she states. He was DX [diagnosed] with UTI [urinary tract infection .States he is returning back to the facility via car and wife.
The following note was a late entry created [DATE] at 2:36 a.m.: [DATE] 02:09 During report, evening shift nurse stated resident had had a low BS at bedtime. She asked to stop report and recheck up on him. This nurse was the third nurse in to see resident. He was laying in the floor. He was on his left side with a small amount of white froth noted at the corners of his mouth. He barely had his eyes open but they weren't focused. He could not answer or response to stimuli by nurses. His skin was very cold and clammy. He had his coke spilled all over him. He was making the snoring noises diabetics make when they are trying to slip into a coma. All nurses were called to the room and crash cart brought in. No code performed r/t [related to] he has a heart beat and he is breathing at this time. 911 was called. Evening nurse unable to obtain an accurate blood sugar r/t [related to] spilled coke on his hands. Staff stayed at bedside until EMTs arrived and took him to the ambulance around 2348 [11:48] pm. Ambulance remained in the lot for 20 minutes before leaving for the hospital.
[DATE] 15:20 [3:20 p.m.] MEDICAL NOTE: ProMedical Progress Note
CC: Okay .S: Patient is being evaluated today for hospital follow-up. On [DATE], patient had an episode of hypoglycemia. Nursing staff found the patient laying on the floor on his left side with a small amount of white frothy at the corners of his mouth. Patient barely can keep his eyes open and focus. He cannot answer or respond to stimuli by nurses. Patient was very cold and clammy. Patient was sent to the emergency department for further evaluation. CT scan of the head and neck were unremarkable. There was concern for UTI and patient was started on Keflex. On [DATE], patient was evaluated for hypoglycemia. Patient's blood sugars were 64 and 87 and insulin was held. At the time he was thought this could have been an isolated incident. An A1c was checked. On [DATE], patient was evaluated to follow-up on diabetes to follow-up on the results of the A1c. A1c was 9.9 on [DATE]. Patient was currently taking Humalog 8 units with meals, glargine insulin 50 units daily and a sliding scale as needed for blood sugars greater than 200. Glargine was increased from 50 units to 55 units daily. Lispro was increased to 10 units with meals. Since [DATE], blood sugar ranges have been between 95 and 472. Patient states that he is eating all of his meals. He denies any changes in his diet. He is on a diabetic diet .A: This is a [AGE] year-old male with a history of diabetes being evaluated for a fall that occurred on [DATE] and an episode of hypoglycemia resulting in a hospital follow-up. P: Consulted for mechanical ground-level fall with no significant injuries. There was questionable loss of consciousness due to hypoglycemia. Medications were evaluated and no changes are indicated at this time. We will follow-up with patient in 2 weeks.
The hospital records from the emergency room documented the following:
Basic information Chief complaint: Pt (patient) sent for suspected syncopal episode from [name of facility] d/t [due to] hypoglycemia. Pt stated, I don't know what I was doing but I was lightheaded and then it all went blank. Pt was hypoglycemic upon EMS arrival, blood sugar rose w/ [with] D10 . History of Present Illness: 58- year-old male with history of end stage renal disease now status post kidney transplant .type 2 diabetes with brittle blood sugars presents with concern for hypoglycemia and subsequent syncopal episode. Patient reports he ate a full dinner of a cheeseburger, fries, tea, and coffee. He then went back to his room and his blood sugar was checked and found to be in the 50s. Staff immediately brought him things to eat. He does remember drinking a coke but then had a syncopal episode and fell from the bed .daughter reports that he has very labile blood sugars and has had syncopal episodes from hypoglycemia in the past .states this event appears very similar to past events.
Laboratory data from the emergency room showed a Glucometer POCT [point of contact testing] reading on [DATE] at 23:58 [11:58 p.m.] of 226. A routine Chemistry lab test dated [DATE] and resulted at 00:57 [12:57 a.m.] showed a blood glucose level of 254.
Concerns were voiced to the DON, administrator, the corporate nurse consultant on [DATE] at approximately 4:50 p.m., that the blood glucose monitors in the facility were not calibrated per facility policy and when tested with the control solution were testing out of range. Documentation in Resident #69's record indicated that blood sugar readings were all over the place.
5. Resident #249 had scheduled insulin and insulin administered before meals and at bedtime each day with dosages determined by blood sugar readings (sliding scale). These readings were obtained with glucometers that either had not been calibrated, were calibrated with out of date solution or were found out of calibration (not meeting manufacturer's specifications for calibration).
Resident #249 was admitted to the facility on [DATE] with diagnoses that included status post orthopedic surgical amputation, diabetes, hypothyroidism, hypertension, gout, history of breast cancer, asthma and gastroesophageal reflux disease. The admission nursing assessment dated [DATE] assessed Resident #249 as cognitively intact.
Resident #249's clinical record documented the following physician orders dated [DATE] for insulin to manage diabetes.
Insulin Lispro100 units/milliliter (ml), inject per sliding scale subcutaneously before meals and at bedtime. Sliding scale listed: blood sugar 200 to 299 give 5 units, 300 to 399 give 10 units, 400 to 401 give 15 units, above 400 call physician.
NPH Isophane & regular suspension insulin pen (70-30) 100 units/ml, inject 20 units subcutaneously each evening and 30 units each morning.
Accuchecks (blood sugar) before meals and at bedtime each day.
The record documented a physician's order dated [DATE] for Glucagen Hypokit solution (Glucagon HCL (rDNA)) 1 milligram with instructions to inject one application intramuscularly as needed for low blood sugar
Resident #249's clinical record documented the insulin was administered as ordered. Blood sugar checks were documented before meals and at bedtime each day, with insulin administered per sliding scale.
A nursing note dated [DATE] at 1:17 p.m. documented, .rsd [resident's] BS [blood sugar] was 61 @ [at] 1230 pm gave rsd. teddy grams and graham crackers. rsd. alert and verbal at this this time stated she felt okay and didn't feel like her BS was low. recheck BS at 1245 pm it was 59 gave rsd 1 IM [intramuscular] glucagon rechecked BS at 105 pm bs 149 . (Sic)
On [DATE] at 2:15 p.m., the director of nursing (DON) was interviewed about calibration of the facility's glucometers. The DON stated the night shift (11:00 p.m. to 7:00 a.m.) nurses were responsible for calibrating the glucometers each night. The DON stated any glucometers found out of calibration were supposed to be taken out of service and replaced with a meters meeting control checks. The DON stated any problems with glucometer calibrations were supposed to be reported to her or the unit managers. The DON stated she had not been made aware of any issues with glucometers out of calibration in the facility.
The facility was determined to be in immediate jeopardy on [DATE] at 4:55 p.m. regarding a system failure with glucometers on all nursing units found without recent calibrations, found out of calibration or had been calibrated with out of date solution. There was no system to track which glucometers were used with which residents and glucometers were found without accurate date setup for historical reference of blood sugar readings.
The facility staff presented the following plan of correction that was accepted by the survey team on [DATE] at 6:37 p.m.:
1) New blood glucose meters will be purchased immediately, calibrated per manufacturer's guidelines and documented on the Blood Glucose Monitoring Control Log.
2) An audit will be conducted to identify all residents with current blood glucose monitoring orders. All identified residents will have their blood glucose level checked immediately with a one-time order. We will use the new glucometers post calibration to obtain blood glucose levels.
3) All licensed staff will be educated by the Director of Nursing or designee on the manufacturer's guidelines for calibrating blood glucose monitors and appropriate documentation. Calibration and documentation will be completed once a shift. By tomorrow 7/1 at 1200 will educate remaining nursing staff before their shift is scheduled.
4) Blood Glucose Monitoring Control Log will be audited daily for 4 weeks and weekly thereafter.
5) Step 1 will be completed by [DATE] at 1900. Step 2 will be completed by [DATE] at 2100. Step 3 will be completed by [DATE] at 1200.
On [DATE] at 6:40 PM, LPN #2 was interviewed and was asked if glucometer #1 and glucometer #2 for Cart A had been taken out of service and if the information regarding the failed control tests for both of these glucometers had been reported. LPN #1 stated that they had not been taken out of service and the information had not been reported to anyone. LPN #2 was then asked if Resident #108 received any insulin after the glucose reading. LPN #1 stated that she did administer the resident 15 units of Lispro [with lunch per order] based on the blood glucose reading from the glucometer that failed the control test.
On [DATE] at 6:50 PM, LPN #3 was interviewed and was asked if glucometer #1 for Cart B had been taken out of service and if the information regarding the failed control test the glucometer had been reported. LPN #3, No, you took the book. LPN #3 was asked again, if the failed test had been reported to anyone. LPN #3 stated, No.
On [DATE] at 8:22 a.m., the licensed practical nurse (LPN #2) that administered the Glucagon to Resident #249 on [DATE] was interviewed. LPN #2 stated the unit glucometers were used for blood sugar checks and administration of scheduled and sliding scale insulin. LPN #2 stated she did not think Resident #249 was checked with an out of range glucometer but there was no record of which glucometers were used with the resident.
On [DATE] at 8:57 AM, Resident #27 was interviewed regarding the hypoglycemic event on [DATE]. Resident #27 said he has been a diabetic most of his adult life and knows when his blood sugar is getting low. Resident #27 stated he could not remember what day the lab technician drew labs but had not been feeling that his blood sugars had been low lately. Resident #27 said he did not remember eating anything after the labs test were taken but did eat breakfast.
On [DATE] at approximately 9:00 AM, the glucometer control solution test information was reviewed for the [name of glucometer] that were being used by the facility.
The glucometer manual, [Name of glucometer] blood glucose monitoring system .Compare the result to the range printed on the test strip bottle. Make sure the result is within the acceptable range. If the result falls within the range, the meter and test strip are working correctly. Do not use system if control solution is out of range. Healthcare professionals: Record result in quality logbook .
On [DATE] at 10:00 AM, the DON (director of nursing), the administrator and nurse consultant were again made aware of the serious concerns regarding staff not performing glucometer control checks and using glucometers after failing the control tests and administering insulin based on a test result from a glucometer that had failed control tests. The DON stated that they did not have a policy, but stated that the glucometer control tests are done every night by night shift and that the glucometer manual is the policy and stated that is what we go by.
On [DATE] at 11:30 a.m., in-service education records were presented by the facility documenting staff education regarding: blood glucose meter control logs; completion of the calibration logs; blood glucose meter calibration protocol per manufacturer's guidelines; visual, verbal and return demonstrations of performing calibration; use of control solutions; and logging results in calibration test book. All current nursing staff were educated and a system was in place to educate any unavailable staff prior to their next scheduled shift. Glucometer checks were documented on all residents with current orders for blood sugar checks (30 residents) using newly purchased and successfully calibrated glucometers.
On [DATE] at 12:08 p.m., the survey team inspected all glucometers in use on the three nursing units. All glucometers in use had been calibrated and were documented as meeting manufacturer's calibration requirements. Nurses on each unit demonstrated to surveyors the calibration pro[TRUNCATED]
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to ensure an acc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview and clinical record review, the facility staff failed to ensure an accurate minimum data set (MDS) for one of 38 residents in the survey sample. An admission MDS for Resident #56 had an inaccurate assessment of the resident's dental issues.
The findings include:
Resident #56 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, atherosclerotic heart disease, hypertension, heart failure, benign prostatic hyperplasia, inguinal hernia, gastroesophageal reflux disease and localized edema. The MDS dated [DATE] assessed the resident with moderately impaired cognitive skills.
On 6/29/21 at 2:52 p.m., Resident #56 was interviewed about quality of care in the facility. The resident was observed when talking with missing front teeth. Other visible teeth were broken, dark in color with several teeth black and decayed next to the gum tissue. The resident was interviewed about the condition of his teeth at this time. Resident #56 stated his teeth were in bad shape and he had not been to a dentist in over two years. The resident stated he only had six teeth with a fragment of a tooth near the front. Resident #56 stated, Sometimes it's hard to chew.
Section L of Resident #56's admission MDS assessment dated [DATE] documented the resident had no dental issues. Form sections to indicate tooth fragments, obvious/likely cavities, broken teeth and difficulty with chewing were blank. The form was marked, None of the above [tooth fragments, obvious/likely cavities, broken teeth, difficulty chewing] were present.
On 6/30/21 at 5:30 p.m., the registered nurse (RN #2) responsible for MDS assessments was interviewed about Resident #56's dental assessment. RN #2 stated her assessment included interviews with the resident and a review of the clinical record. RN #2 stated she did not have an explanation for the inaccurate assessment of the resident's dental condition.
This finding was reviewed with the administrator and director of nursing during a meeting on 7/1/21 at 1:10 p.m.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, complaint investigation, clinical record review, and staff interview, the facility staff failed for three...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, complaint investigation, clinical record review, and staff interview, the facility staff failed for three of 38 residents in the survey sample (Residents # 80, 88 and 127), to provide routine foot care. Residents # 80, 88 and 127 had elongated toenails with clearly visible debris under the great toes on their left and right feet.
The findings include:
1. Resident # 88 was admitted to the facility on [DATE], and most recently readmitted on [DATE] with diagnoses that included malignant neoplasm of endometrium, anemia, hypertension, renal insufficiency, diabetes mellitus, depression, generalized muscle weakness, difficulty walking, dysphagia, pulmonary hypertension, cerebral atherosclerosis, and gastroesophageal reflux disease.
According to a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/21/2021, Resident # 88 was assessed under Section C (Cognitive Patterns) as being moderately cognitively impaired, with a Summary Score of 09 out of 15. Under Section G (Functional Status), the resident was assessed as needing limited assistance with one person physical assist for personal hygiene.
At approximately 9:00 a.m. on 6/30/2021, an observation of Resident # 88's fingernails and toenails was conducted. Resident # 88's toenails were elongated and in need of trimming. There was debris clearly visible under the nails on the great toes of her right and left feet. LPN # 7 (Licensed Practical Nurse) was present for the observation.
2. Resident # 127 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of the left breast, hypertension, diabetes mellitus, arthritis, history of falling, right hip pain, difficulty walking, generalized muscle weakness, and hypercalcemia.
According to an admission MDS with an ARD of 5/27/2021, Resident # 127 was assessed under Section C (Cognitive Patterns) as being moderately cognitively impaired, with a Summary Score of 11 out of 15. Under Section G (Functional Status), the resident was assessed as needing extensive assistance with one person physical assist for personal hygiene.
At approximately 9:20 a.m. on 6/30/2021, an observation of Resident # 127's fingernails and toenails was conducted. Resident # 127's toenails were elongated and in need of trimming. There was debris clearly visible under the nails on the great toes of her right and left feet. LPN # 7 was present for the observation.
During the observation, Resident # 127 was asked who trims her toenails and when was the last time they were trimmed. The resident said she did not know (who trimmed them), but thought it was several months since they were trimmed.
At approximately 9:50 a.m. on 6/30/2021, SW # 2 (Social Worker), who was identified as the person who schedules podiatry visits, was interviewed. Asked how he decides who sees the Podiatrist, SW # 2 said, I start with the farthest out (meaning the resident with the longest time since a podiatry visit) and put them on the list. SW # 2 went on to say, The Podiatrist comes once a month and sees 20 residents. In six months he will have seen everyone. When asked what happens if nursing identifies a resident that needs to be seen by the Podiatrist, SW # 2 said, If nursing tells me about someone, I will put their name on the list.
SW # 2 was asked for, and provided, a list of facility residents that included the date each was last seen by the Podiatrist, as well as a list of residents scheduled for the next podiatry visit. According to the facility list, Resident # 88 was last seen by the Podiatrist on 3/31/2021. Resident # 127 was on the facility list, but there was no last seen date. Resident # 127 was on the podiatry schedule for 7/7/2021.
3. Resident # 80 was admitted to the facility on [DATE], and most recently readmitted on [DATE], with diagnoses that included pneumonia, anemia, atrial fibrillation, depression, gastroesophageal reflux disease, acute respiratory failure with hypoxia, ventral hernia with obstruction, generalized muscle weakness, difficulty walking, overactive bladder, morbid obesity, and polyneuropathy.
According to an admission MDS with an ARD of 5/19/2021, Resident # 80 was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 13 out of 15. Under Section G (Functional Status), the resident was assessed as needing extensive assistance with one person physical assist for personal hygiene.
At approximately 10:20 a.m. on 6/30/2021, an observation of Resident # 80's fingernails and toenails was conducted. Resident # 127's toenails were elongated and in need of trimming. There was debris clearly visible under the nails on the great toes of her right and left feet. CNA # 3 (Certified Nursing Assistant) was present for the observation.
Resident # 80's name appeared on the facility podiatry list provided by SW # 2, but there was no date indicating when she was last seen. Resident # 80's name was listed on the on the podiatry schedule for 7/7/2021.
A review of the Progress Notes (Nurses Notes) in Resident # 80's electronic health record revealed
the following entry, dated 2/9/2021, made by Discharge Planning (SW # 2), Resident was seen by the podiatrist, Dr. (name) on this date
At approximately 1:15 p.m. on 7/1/2021, during a meeting that included the Administrator, Director of Nursing, and the survey team, the findings regarding Residents # 88, 127 and 80 were discussed.
COMPLAINT DEFICIENCY
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and clinical record review, the facility staff failed to ensure one of ten residents was ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and clinical record review, the facility staff failed to ensure one of ten residents was administered oxygen as ordered by the physician, Resident #106.
Findings were:
Resident #106 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: COPD (chronic obstructive pulmonary disease), malignant neoplasm of the endometrium, vascular dementia and hypertension.
The most recent MDS (minimum data set) was a quarterly review with an ARD (assessment reference date) of 06/23/2021. Resident #106 was assessed as moderately impaired with a cognitive summary score of 10.
During initial tour of the facility on 08/10/2021 at approximately 9:15 a.m., Resident #106 was observed lying in bed. She was wearing a nasal cannula with oxygen running at 2 liters/minute.
The clinical record was reviewed at approximately 11:00 a.m. The physician orders included: Oxygen therapy-Oxygen at 1 liters per minute via nasal cannula every shift for SOB [shortness of breath].
At 12:15 p.m., Resident #106's oxygen was again observed at 2 liters via nasal cannula. The unit manager was asked to go check the oxygen concentrator. She was asked at what level the oxygen was being delivered. She looked at the settings and stated, She is getting two liters. She was asked what was ordered. The unit manager went to the nurse's station and looked at the orders. She stated, It says oxygen at one liter, I'm not sure why she is on two I will ask her nurse.
At 12:20 p.m., the unit manager stated, I am just [NAME] to put it back on one liter, I don't know why it got turned up. She was asked who checked the oxygen settings to ensure the appropriate amount was being delivered. She stated, I look at it if I'm taking care of the resident .the nurses should. She was asked who was caring for Resident #106. She stated, The nurse who was here this morning, left around 11:30 (a.m.), and another nurse took over (Name of licensed practical nurse [LPN] #4) has her now.
LPN # 4 was interviewed about Resident #106. She was asked if she had been in to see her yet. She stated, Yes, that's the first room I went in. She was asked if she had checked her oxygen. She stated, No. She was asked who normally checked that. She stated, I only check it if it is on the TAR (Treatment Administration Record) or if they are having difficulty breathing.
The TAR was reviewed at approximately 12:30 p.m. The following entry was observed: Oxygen therapy: Oxygen at 1 liters per minute via nasal cannula for SOB. The entry was not initialed indicating that it had been checked/verified for day shift. When the copies of the TAR were received from the facility at approximately 1:00 p.m., the entry had been initialed by LPN #4.
The above information was reviewed during an end of the day meeting on 08/10/2021 at approximately 3:30 p.m., with the DON, ADON (assistant director of nursing), administrator, and corporate nurse consultant.
No further information was obtained prior to the exit conference on 08/10/2021.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, document review, and staff interview, the facility staff failed to ensure expired vaccine was not availabl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, document review, and staff interview, the facility staff failed to ensure expired vaccine was not available for administration on one of 3 units: East unit. A bag containing seven expired vials of Afluria, an influenza vaccine, was in a thermal container in the medication room refrigerator.
Findings include:
On [DATE] at approximately 10:15 a.m. an inspection of the medication room on the East unit was conducted with LPN (licensed practical nurse) # 6. A silver thermal bag was located in the bottom of the refrigerator and contained seven multi-dose boxes of Afluria. The boxes were marked with an expiration date of [DATE]. LPN # 6 stated I had no idea those were even in there.
The package insert for the Afluria vaccine under 16.2 Storage and Handling directs Do not use AFLURIA QUADRIVALENT (sic) beyond the expiration date .
The administrator, DON, and nurse consultant were made aware of the findings [DATE] at 1:15 p.m. during a meeting with facility staff.
No further information was provided prior to the exit conference.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0800
(Tag F0800)
Could have caused harm · This affected 1 resident
Based on observation, resident interview, and staff interview the facility staff failed to honor food preferences for one of 38 residents in the survey sample: Resident # 18.
Findings include:
Residen...
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Based on observation, resident interview, and staff interview the facility staff failed to honor food preferences for one of 38 residents in the survey sample: Resident # 18.
Findings include:
Resident # 18 was admitted to the facility 1/26/21 with diagnoses to include, but were not limited to: osteoporosis, muscle weakness, COPD, and Vitamin D deficiency.
The most MDS (minimum data set) was a quarterly review dated 4/6/21 and had Resident # 18 assessed 13 out of 15 for cognition, indicating cognitively intact.
On 6/30/21 at approximately 8:25 a.m. Residenty # 18 was observed with her breakfast tray on the overbed table. Resident # 18 was asked about her breakfast. She stated Not too good. I have scrambled eggs and oatmeal I am not going to eat, and look here: I have a biscuit but no butter or jelly or anything to put on it! Some of that sausage gravy would be nice to have to put on it . (Resident # 18's roommate had sausage gravy on her biscuit). The meal ticket for Resident # 18 was reviewed and revealed the resident should have also received a banana and bacon on her meal tray. Also included on the ticket was a note written in bold print Note: No Meat. (Can have eggs, Sausage, Bacon, and Sausage Gravy).
On 6/30/21 at 8:45 a.m. the regional certified dietary manager, identified as Other Staff (OS) # 7, and the RD (registered dietitian) were interviewed about the meal ticket. OS # 1 and the RD were asked why the resident wasn't given sausage gravy for her biscuit as indicated she could have on the meal ticket. They were also asked about the lack of condiments on the meal tray. OS # 1 stated Well, that's my fault; I was afraid I'd get a tag if I served her meat .I didn't read past the 'No Meat' to see she could have had sausage gravy. I will send a new tray down right now. The RD then stated As far as butter, jelly, etc., there are condiment carts on the units so all the resident has to do is ask for that.
The administrator, DON, and nurse consultant were made aware of the findings 7/1/21 at 1:15 p.m. during a meeting with facility staff.
No further information was provided prior to the exit conference.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility staff failed to ensure a complete and accurate clinical record...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility staff failed to ensure a complete and accurate clinical record for two of 38 residents (Resident #285 and Resident #71). Resident #285's clinical record contained another resident's Covid-19 vaccination record, and Resident #71 had an incomplete treatment record for pressure ulcer dressing changes.
Findings include:
1. Resident #285 was admitted to the facility on [DATE]. Diagnoses for this resident included, but were not limited to: cerebral infarct (stroke/sub-[NAME] hematoma), dysphagia, pneumonitis, muscle weakness, high blood pressure, peg tube placement, acute hypoxia and respiratory failure.
The most current MDS (minimum data set) was an admission assessment (still in progress). This MDS was not complete. Resident #285 was assessed as alert and oriented to person and place on the nursing admission assessment dated [DATE].
On 06/29/21 at 2:59 PM, Resident #285's clinical records were reviewed. Another resident's [identified as Resident #286] Covid-19 vaccination record was located in Resident #285's chart. Resident #285's own Covid-19 vaccination record was also observed in the record.
On 07/01/21 at 8:50 AM, the SW (social worker) was interviewed regarding the above information. The SW stated that when a new admission comes in she will see the residents and gather the information/documentation and then scan it all in. The SW stated that she didn't think anyone goes behind her to check that what she has scanned is accurate for each resident, but stated while scanning she will check and double check to ensure the records are accurate. The SW stated that she wasn't aware that the records were commingled, and stated that if other staff happen to see that scanned items are incorrect they will tell her that it has been scanned in error. The SW stated that she wasn't aware of the error and that it had not been reported to her.
The DON and administrator were made aware on 07/01/21 at 1:30 PM. No further information and/or documentation was presented prior to the exit conference. 2. Resident #71 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #71 included enterocolitis due to clostridium difficile (C-diff), neuropathic bladder, history of urinary tract infections, hypertension, chronic kidney disease, autistic disorder and anemia. The minimum data set (MDS) dated [DATE] assessed Resident #71 with moderately impaired cognitive skills.
Resident #71's clinical record documented the resident was re-admitted from the hospital on 6/17/21 with multiple pressure ulcers on his buttocks. A weekly skin evaluation sheet dated 6/17/21 documented the following pressure ulcer assessment for Resident #71:
Left buttock - stage 2 pressure ulcer measuring 0.5 x 0.5 x 0 (length by width by depth in centimeters)
Right buttock - two stage 2 pressure ulcers measuring 4.0 x 1.0 x 0 cm and 2.0 x 1.0 x 0 cm
The clinical record documented a physician's order dated 6/18/21 to cleanse and apply zinc ointment with a dry dressing to the right and left buttock ulcers until healed.
Resident #71's treatment administration record (TAR) documented no daily dressing changes/treatments for the pressure ulcers from 6/18/21 through 6/24/21 and on 6/26/21. Spaces for nurses' initials signing off completion of the treatments were blank. There were no attached notes or explanation of why the TAR was incomplete.
Nursing notes from 6/18/21 through 6/26/21 documented treatments and dressing changes to the resident's pressure ulcers.
On 7/1/21 at 8:25 a.m., the licensed practical nurse (LPN #2) routinely caring for Resident #71 was interviewed about the incomplete TAR. LPN #2 stated the treatments and dressing changes were done on the day shift as ordered. LPN #2 stated she did not know why the TAR was not signed off or completed.
On 7/1/21 at 9:00 a.m., the director of nursing (DON) was interviewed about Resident #71's incomplete TAR. The DON stated skilled nursing notes made mention of the intact dressings on the resident. The DON stated the treatments should have been signed off on the TAR to document implementation of the physician's order.
This finding was reviewed with the administrator and DON during a meeting on 7/1/21 at 1:10 p.m.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, facility policy review and clinical record review, the facility staff failed to follow infection control practices during meal tray distribution on one of three ...
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Based on observation, staff interview, facility policy review and clinical record review, the facility staff failed to follow infection control practices during meal tray distribution on one of three nursing units. Staff members on the South wing failed to don gowns and gloves when serving meal trays to residents on droplet precautions.
The findings include:
On 6/29/21 at 12:20 p.m., meal tray service on the South unit was observed. On 6/29/21 at 12:36 p.m., certified nurses' aide (CNA) #2 with a mask on and no other personal protective equipment (PPE), entered room (number), positioned the over-bed table and placed the meal tray for A-bed resident. CNA #1, without gown or gloves, also entered this room and set up the meal tray for B-bed resident. CNA #1 and #2 exited the room and applied hand sanitizer to their hands. On 6/29/21 at 12:38 p.m., CNA #2 entered room (number), moved the over-bed table and setup the meal tray for the B-bed resident. CNA #2 had no gown or gloves on when entering the room and providing meal setup.
All residents in this section of the South wing including rooms the CNAs entered, were identified and posted with signs for droplet precautions. Signs posted documented masks, gowns and gloves were required prior to entering rooms. Clinical record review for the residents in rooms above, documented they were new admissions and were on droplet precautions as part of the facility's COVID-19 prevention protocols.
On 6/29/21 at 12:43 p.m., CNA #2 was interviewed about entering rooms without a gown or gloves. CNA #2 stated staff were supposed to wear masks, gowns and gloves when entering rooms on droplet precautions. CNA #2 stated the residents in the rooms observed were on droplet precautions like all the residents on the unit.
On 6/29/21 at 2:37 p.m., CNA #1 was interviewed about not donning gowns and gloves during the meal observation. CNA #1 stated she thought the gowns and gloves were only required when performing direct care. CNA #1 stated she was not aware the gowns and gloves were required for meal tray delivery. CNA #1 stated the rooms observed were part of the quarantine unit due to COVID-19 and all rooms behind the designated red line required full PPE (gowns, gloves, masks).
On 7/1/21 at 11:20 a.m., the director of nursing (DON) was interviewed about the PPE requirement when entering rooms with droplet precautions for meal service. The DON stated anytime staff entered rooms on droplet precautions, a gown, gloves and masks were to be worn.
On 7/1/21 at 11:48 a.m., the infection preventionist (other staff #5) was interviewed about the meal observation on 6/29/21. The infection preventionist stated staff were required to wear gowns, gloves and masks anytime they entered rooms on droplet precautions.
The facility's policy titled Transmission Based Precautions - General Practice (effective 2/6/20) documented, The Center initiates transmission-based precautions (TBPs) to protect other patients, employees and visitors from the spread of a confirmed or suspected infection or contagious disease .Transmission based precautions are used in addition to standard precautions .Meal tray delivery to the room .Use gown, gloves, and/or mask if indicated by the type of isolation precautions being used for the patient .If gown, gloves, and/or mask were used, remove and dispose of properly .Perform hand hygiene .
This finding was reviewed with the administrator and director of nursing during a meeting on 7/1/21 at 1:10 p.m.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to notify the physician in a timely manner of med...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to notify the physician in a timely manner of medication (Hydrocodone) not given per order, for one of thirteen residents, Resident #201.
Findings were:
Resident #201 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: COPD (chronic obstructive pulmonary disease), malignant neoplasm of the endometrium, vascular dementia and hypertension.
The most recent MDS (minimum data set) was a quarterly review with an ARD (assessment reference date) of 06/23/2021. Resident #201 was assessed as moderately impaired with a cognitive summary score of 10.
On 09/21/2021 the clinical record was reviewed. The physician order section contained the following: HYDROcodone-Acetaminophen Tablet 5-325 MG Give 1 tablet by mouth three times a day for Pain.
The progress note section included the following documentation:
09/11/2021 20:44 [8:44 p.m.] HYDROcodone-Acetaminophen Tablet 5-325 MG Give 1 tablet by mouth three times a day for Pain Medication on Order.
09/13/2021 12:06 [p.m.] Medication not available, notified pharmacy.
09/13/2021 13:51 [1:51 p.m.] Not available ordered from pharmacy.
09/14/2021 07:17 [a.m.] HYDROcodone-Acetaminophen Tablet 5-325 MG Give 1 tablet by mouth three times a day for Pain Awaiting medications from pharmacy.
09/14/2021 14:42 [2:42 p.m.] HYDROcodone-Acetaminophen Tablet 5-325 MG Give 1 tablet by mouth three times a day for Pain Script faxed pharmacy. NP [nurse practitioner] aware.
09/15/2021 07:27 [a.m.] HYDROcodone-Acetaminophen Tablet 5-325 MG Give 1 tablet by mouth three times a day for Pain Awaiting medication from pharmacy. Script sent to pharmacy. NP aware.
09/15/2021 13:16 [1:16 p.m.] HYDROcodone-Acetaminophen Tablet 5-325 MG Give 1 tablet by mouth three times a day for Pain Script sent to pharmacy. NP aware.
09/15/2021 20:54 [8:54 p.m.] HYDROcodone-Acetaminophen Tablet 5-325 MG Give 1 tablet by mouth three times a day for Pain On order
09/16/2021 09:18 [a.m.] Lortab 5-35 mg [Same as HYDROcodone-Acetaminophen 5-325- the 35 is a typo] not available in cart for administration at this time. New script printed and forwarded to [name] NP for signature. Order faced to [name of pharmacy] and should arrive with evening delivery per [name of pharmacy representative]. NP and resident made aware.
09/17/2021 12:14 [p.m.] HYDROcodone-Acetaminophen Tablet 5-325 MG Give 1 tablet by mouth three times a day for Pain hold until arrive from pharmacy NP [name] aware medication script has been faxed.
Additional progress notes regarding the hydrocodone were written until 09/20/2021. The MAR (Medication administration record was reviewed. Resident #201's last dose of physician ordered Hydrocodone was administered on 09/11/2021 at 2:00 p.m. The nurse practitioner was not notified until 09/14/2021 (after eight missed doses) that Resident #201 was not receiving her medications. A new prescription was sent to the pharmacy on 09/16/2021. The medication was still not available for administration during the survey on 09/21/2021. There was no documentation that the nurse practitioner or the physician were notified after 09/17/2021 that the medication was still not available.
A meeting was held with the administrator, the DON (director of nursing) and the two corporate nurse consultants on 09/21/2021 at approximately 4:00 p.m. Concerns were voiced that Resident #201 had not received her pain medication as ordered and neither the physician nor nurse practitioner were notified for three days. The question was asked as to what should have happened. The corporate nurse consultant stated, If the medications are not here, the nurse needs to call the pharmacy and see where they are, every time .not say someone else called, they need to continue calling and notify the physician that the medicine isn't being given as ordered .every time it is scheduled .and they need to write a descriptive progress note .each nurse is responsible for medication administration on her shift. The note from 09/17/2021 was discussed. There was no order on the POS to hold the Hydrocodone. The corporate nurse consultant was asked if there was some place else that the order might be written. He stated, No, if there was an order that is where it would be.
No further information was received prior to the exit conference on 09/21/2021.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4a. Resident #86 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hospice, ac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4a. Resident #86 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hospice, acute kidney failure, hypertension, mood disorder, dementia, anxiety, anemia, depression, and hyperlipidemia. The most recent minimum data set (MDS) dated [DATE] was a significant change and assessed Resident #86 as severely cognitively impaired for daily decision making with a score of 7 out of 15.
On 06/29/2021 at 10:51 a.m. during the initial tour, Resident #86 was observed sitting near the nurse's station on the [NAME] Unit wearing geri-sleeves on both of his arms.
On 06/30/2021 at 8:23 a.m. Resident #86 was observed sitting near the nurse's station on the [NAME] Unit, he was not wearing geri-sleeves at this time.
On 06/30/2021 at 10:50 a.m., Resident #86 was observed sitting near the [NAME] Unit nurse's station wearing geri-sleeves on both of his arms.
On 06/30/21 8:23 a.m., Resident #86 was observed sitting near the [NAME] Unit nurse's station, he was not wearing geri-sleeves at this time.
On 06/30/21 at 10:50 a.m., Resident #86 was observed being transported in his wheelchair on the [NAME] Unit by the certified nursing assistant (CNA #3) who routinely provides care for him. Resident #86 was observed attempting to removing his geri-sleeves. CNA #3 was interviewed regarding the use and application of the geri-sleeves for Resident #86 at the time of the transport. CNA #3 stated at times Resident #86 becomes upset and will remove his geri-sleeves at other times he will not allow staff to place them on him at all. CNA #3 was asked if they documented Resident #86's refusal to wear the geri-sleeves. CNA #3 stated yes she notifies the charge nurse each time Resident #86 refuses care.
On 6/30/2021 Resident #86's clinical record was reviewed. Observed on the physician's order summary was the following order: Geri Sleeves bilateral Arms every shift for prevention Order Status: Active. Order Date: 04/13/2021. Start Date 04/13/2021
Resident #86's care plan did not document the use of the geri-sleeves as a preventive measure.
On 06/30/2021 at 12:30 p.m. and 6:30 p.m., Resident #86 was observed on the [NAME] Unit wearing geri-sleeves on both of his arms. On 06/30/2021 at 6:30 p.m., the unit manager (LPN #4) was interviewed regarding the use and application of the geri-sleeves for Resident #86. LPN #4 stated Resident #86 would often remove his geri-sleeves and slipper socks and she had educated staff on the importance of documenting his refusals and removals. LPN #4 was asked if the geri-sleeves should be included on the treatment orders and the care plans. LPN #4 stated yes this would be a way to document Resident #86's refusal to wear and/or removal of the geri-sleeves. LPN #4 was asked who was responsible for updating the care plans and treatment orders. LPN #4 stated both nursing and the MDS coordinators updated care plans and treatment orders.
On 07/01/2021 at 9:10 a.m., the MDS Coordinator (RN #1) was interviewed regarding the geri-sleeves and updating the care plan. RN #1 stated the geri-sleeves should have been added to the care plan. The corporate consultant was present at the time of the interview and stated he spoke with the nursing staff on the [NAME] Unit and there was some confusion whether or not to include the geri-sleeves on the treatment record and the care plans because Resident #86 would remove the geri-sleeves. The corporate consultant was asked what was the expectation and he stated the geri-sleeves should have been placed on both the treatment record and the care plans as an intervention.
4b. Resident #86's clinical record was reviewed on 06/30/21. Observed on the physician's order summary was the following order: .ADMIT to Hospice [agency name and number]. Order Status: Active. Order Date: 05/13/2021 Observed within the clinical record was a progress note dated 05/13/2021 which documented, He (Resident #86) was admitted to Hospice [agency name] effective today 5/13/2021 Son [Name] has been updated, staff will continue to monitor for changes Resident #86's hospice binder was reviewed. Observed within the binder was weekly hospice documentation regarding Resident #86's care. Resident #86's care plan did not include the hospice admission.
On 06/30/21 at 6:15 p.m. the unit manager, LPN #4 was interviewed regarding if the hospice admission should have been included on Resident #86's care plan. LPN #4 stated yes that the MDS nurses should have included it when the significant change was completed.
On 07/01/21 at 9:10 a.m., the MDS coordinator (RN #1) was interviewed regarding if the hospice admission should be included on the care plan. RN #1 stated she normally reviewed and revised the care plans during the comprehensive assessments for any triggered CAAs (care area assessments) and the hospice admission should have been added to the care plan during the recent significant change assessment on 05/18/2021.
The above findings was shared with the administrator, director of nursing and corporate consultant during a meeting on 07/01/2021 at 1:10 p.m. Based on clinical record review, staff interview, and facility document review, the facility staff failed to review and revise the comprehensive care plan for 5 of 38 Residents, (Resident #10, #23, #133, and #71). Resident #10's care plan was not reviewed and revised regarding hospice services, enhanced droplet precautions, and diabetes mellitus. Resident #23's care plan was not reviewed and revised regarding the resolution of pressure ulcers. Resident #133's care plan did not include hospice services. Resident #86's care plan was not reviewed and revised to include hospice admission and the use of geri-sleeves. Resident #71's care plan was not revised with problems, goals and interventions regarding pressure ulcers.
Findings were:
1. Resident #10 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: COPD (chronic obstructive pulmonary disease), malignant neoplasm of the endometrium, vascular dementia and hypertension.
The most recent MDS (minimum data set) was a quarterly review with an ARD (assessment reference date) of 06/23/2021. Resident #10 was assessed as moderately impaired with a cognitive summary score of 10.
On 06/29/2021 at approximately 11:00 a.m., during initial tour of the facility, Resident #10 was interviewed regarding life at the facility. During the interview, Resident #10 stated, I just had a birthday last week .I was 90 .my sister and I ate a whole chocolate cake to celebrate. Resident #10 was asked if she was a diabetic. She stated, Heck no!
The clinical record was reviewed at approximately 2:00 p.m. An order was observed for Hospice Services. The care plan was reviewed. There were no interventions on the care plan for hospice services or any mention that hospice services were in place. Also observed on the care plan was a problem area, Enhanced Droplet Precautions with interventions in place. Resident #10 was not on enhanced droplet precautions. A problem area Diabetes Mellitus with interventions was also on the care plan. Resident #10 did not have a diagnosis of diabetes on her clinical record.
On 06/30/2021 at approximately 3:30 p.m. the DON (director of nursing) was interviewed regarding the review and revision of care plans. She stated, It's a combination between nursing and MDS. The problems identified with Resident #10's care plan were discussed. The corporate nurse consultant stated, The nurses should be reviewing the care plans and updating them. He and the DON were asked how often care plans should be reviewed. The DON stated, MDS makes changes at the quarterly and annual meetings .anything else should be updated and changed as it happens, usually within 24 hours. They were asked who should have made the changes to Resident #10's care plan. The DON stated, The charge nurse but (name of LPN-licensed practical nurse #6) just took that position back over, (Name of LPN #5) was doing it before .I will look at it though and update it.
On 07/01/2021 at approximately 9:00 a.m., LPN #6 was interviewed regarding care plan revision. She stated, I try to review them, but I just came back .(Name of LPN #5) would have done that. LPN #5 was then interviewed. She stated, (Name of LPN #6) should do that.
The facility policy Care Planning was obtained and reviewed. The following was observed: Computerized care plans will be updated by each discipline on an ongoing basis as changes in the patient occur, and reviewed quarterly.
The above information was discussed with the administrator, the DON, the unit manager, and the corporate nurse consultant, during an end of the day meeting on 07/01/2021 at approximately 1:30 p.m. The DON was asked if there was an additional policy regarding reviewing and revising care plans that discussed the frequency of care plan revision. The corporate nurse consultant stated, It is nursing .it's taught in school and it carries over to their job .they should have done it. The DON stated, What you have is the only policy we have .there isn't one about revising.
No further information was obtained prior to the exit conference on 07/01/2021.
2. Resident #23 was admitted to the facility on [DATE]. Her admitting diagnoses included but were not limited to: Ulcerative colitis, hypertension, adult failure to thrive and major depressive disorder. An admission MDS (minimum data set) with an ARD (assessment reference date) of 04/13/2021, assessed Resident #23 as moderately impaired with a cognitive summary score of 08.
During the initial tour of the facility on 06/29/2021, at approximately 11:15 a.m., Resident #23 was interviewed. She was asked if she had any wounds, or sores on her body that the facility was treating. She stated, No, I had some, but they done healed them all up. I'm good now.
On 06/29/2021 at approximately 1:30 p.m., the unit manager, LPN (Licensed Practical Nurse) #6 was asked if Resident #23 had any current skin issues. She stated, No, she had some pressure areas at one time, but they are healed now.
The clinical record was reviewed on 06/30/2021 at approximately 8:30 a.m. The care plan was reviewed. Observed were problem areas listed for: .has DTI [deep tissue injury] to left heel .Unstageable pressure ulcer to right heel .has stage 3 pressure ulcer sacrum . with interventions to Administer treatments as ordered and monitor for effectiveness for all three areas.
On 06/30/2021 at approximately 10:00 a.m., Resident #23's care plan was discussed with the DON. She stated that the nurses should have updated the care plan when the pressure areas resolved.
On 07/01/2021 at approximately 9:00 a.m., LPN #5, who was the former unit manager was interviewed regarding Resident #23's care plan for pressure areas and deep tissue injury. She stated, I thought I had resolved that off the care plan .I am sure I did. LPN #5 was told the problem areas were still showing as current. She stated, I don't know what happened.
The above information was discussed with the administrator, the DON, the unit manager, and the corporate nurse consultant, during an end of the day meeting on 07/01/2021 at approximately 1:30 p.m.
No further information was obtained prior to the exit conference on 07/01/2021.
3. Resident # 133 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: Dysphagia, vascular dementia, and adult failure to thrive. The admission MDS (minimum data set) with an ARD (assessment reference date) of 05/30/2021, assessed her as severely cognitively impaired with a summary score of 06.
The clinical record was reviewed on 06/30/2021 at approximately 1:00 p.m. A physician order for Hospice services was observed. The hospice records were reviewed indicating Resident #133 was admitted to hospice services on 06/18/2021. The facility care plan was reviewed. There were no interventions or indications on the care plan that Resident #133 was receiving hospice services.
On 06/30/2021 at approximately 1:30 p.m., Resident #133's care plan for hospice was discussed with the DON. She stated, That resident is a recent admission to hospice, but the care plan should have been updated within 24 hours by the nursing staff to include that.
The above information was discussed with the administrator, the DON, the unit manager, and the corporate nurse consultant, during an end of the day meeting on 07/01/2021 at approximately 1:30 p.m.
No further information was obtained prior to the exit conference on 07/01/2021.5. Resident #71 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #71 included enterocolitis due to clostridium difficile (C-diff), neuropathic bladder, history of urinary tract infections, hypertension, chronic kidney disease, autistic disorder and anemia. The minimum data set (MDS) dated [DATE] assessed Resident #71 with moderately impaired cognitive skills.
Resident #71's clinical record documented the resident was re-admitted from the hospital on 6/17/21 with multiple pressure ulcers on his buttocks. A weekly skin evaluation sheet dated 6/17/21 documented the following pressure ulcer assessment for Resident #71:
Left buttock - stage 2 pressure ulcer measuring 0.5 x 0.5 x 0 (length by width by depth in centimeters)
Right buttock - two stage 2 pressure ulcers measuring 4.0 x 1.0 x 0 cm and 2.0 x 1.0 x 0 cm
The clinical record documented a physician's order dated 6/18/21 to cleanse and apply zinc ointment with a dry dressing to the right and left buttock ulcers until healed. Nursing notes documented dressing changes and treatments were implemented as ordered.
Resident #71's current plan of care (print date 6/30/21) was not revised with problems, goals and/or interventions regarding the pressure ulcers. The plan of care created on 5/17/21 listed the resident had potential for skin impairment but made no mention the resident currently had pressure ulcers with ongoing treatments.
On 7/1/21 at 9:00 a.m., the registered nurse (RN #1) responsible for MDS and care plans was interviewed about Resident #71. RN #1 stated she and the nurses were responsible for updating care plans as needed. Concerning Resident #71's care plan, RN #1 stated if the pressure ulcers were not on the plan then it had not been updated.
This finding was reviewed with the administrator and director of nursing during a meeting on 7/1/21 at 1:10 p.m.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to ensure medications were available for two of 1...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to ensure medications were available for two of 13 residents, Resident # 201 and Resident # 210. Resident #201 did not receive Hydrocodone three times per day as ordered by the physician because it was not available for administration. Resident # 210 was not administered Ofloxacin three times a day as ordered, and once a day as ordered.
The findings were:
1. Resident #201 was admitted to the facility on [DATE] with the following diagnoses, including but not limited to: COPD (chronic obstructive pulmonary disease), malignant neoplasm of the endometrium, vascular dementia and hypertension.
The most recent MDS (minimum data set) was a quarterly review with an ARD (assessment reference date) of 06/23/2021. Resident #201 was assessed as moderately impaired with a cognitive summary score of 10.
On 09/21/2021 the clinical record was reviewed. The physician order section contained the following: HYDROcodone-Acetaminophen Tablet 5-325 MG Give 1 tablet by mouth three times a day for Pain.
The progress note section was reviewed. From 09/11/2021 through 09/20/2021, the nursesb documented that the medication Hydrocodone-Acetaminophen 5-325 mg was not available for administration. Entries in the nurses notes regarding the medication included: Medication on order; not available ordered from pharmacy; On order; Awaiting medications from pharmacy, script sent to pharmacy.
The MAR (Medication administration record was reviewed. Resident #201's last dose of physician ordered Hydrocodone was administered on 09/11/2021 at 2:00 p.m. At the time of the survey on 09/21/2021 she had missed a total of 30 doses of Hydrocodone.
On 09/21/2021 at approximately 2:00 p.m., LPN (licensed practical nurse) #2 was interviewed. She was assigned to give medications to Resident #201 her medicine and was asked if all of Resident #201's medication had been given as ordered. She stated, She doesn't have any of her pain medicine here, it's supposed to be coming. She was asked if she had called the pharmacy. She stated, No, they said it's coming.
A meeting was held with the administrator, the DON (director of nursing) and the two corporate nurse consultants on 09/21/2021 at approximately 4:00 p.m. Concerns were voiced that Resident #201 had not received her pain medication as ordered. The question was asked as to what should have happened when the nurses saw the medication was not on the medication cart. The corporate nurse consultant stated, If the medications are not here and the nurse needs to call the pharmacy and see where they are, every time .not say someone else called, they need to continue calling and notify the physician that the medicine isn't being given as ordered and they need to write a descriptive progress note .each nurse is responsible for medication administration on her shift. He was asked why the medication had not been delivered. He stated, I don't know, I need to follow up with the pharmacy. During then meeting the survey team was told that the whole company had switched to a new pharmacy on 09/01/2021 and that medications for the residents were being delivered from North Carolina three times per day. He was asked if the nurses knew how to contact the pharmacy. He stated, There are numbers for the new pharmacy at the nurses stations. The telephone number for the pharmacy was requested and received.
At approximately 4:30 p.m., the pharmacist, OS (other staff) #5 was contacted at the pharmacy. He was asked why Resident #201's Hydrocodone had not been delivered. He looked up the information and stated, We got a new prescription on September 16th. It was filled and sent out that evening. Let me check with my driver. He returned to the phone and stated, The medication was delivered on 09/17/2021 and signed for by [Name of RN #2] at 3:02 a.m. He was asked how much hydrocodone had been delivered. He stated, Thirty tablets. He was asked how he knew they were delivered on that date at that time. He stated, We keep a history of the medications. The medication was placed in Tote #14189 .I also have the delivery receipt that the driver just sent to me. It shows the time and date the tote was delivered and the signature of the person who received it at the facility. He was asked when prior to 09/17/2021 the medication Hydrocodone had been delivered for Resident #201. He stated, That was the first time. We just took over on September 1st. They probably had medicine there from the previous pharmacy that carried them over until then. That's why we needed a new prescription in order to fill it.
No further information was received prior to the exit conference on 09/21/2021.
2. Resident # 210 was admitted to the facility on [DATE], and most recently readmitted on [DATE]. Resident # 210's diagnoses at readmission included cerebral vascular disease, anemia, hypertension, renal insufficiency, pneumonia, diabetes mellitus, hyperlipidemia, aphasia, non-Alzheimer's dementia, depression, dysphagia, and polyneuropathy.
According to the most recent Quarterly Minimum Data Set with an Assessment Reference Date of 9/1/2021, the resident was assessed under Section C (Cognitive Patterns) as being moderately cognitively impaired, with a Summary Score of 10 out of 15.
Resident # 210 had the following physician's order, dated 9/10/2021: Ofloxacin Solution 0.3% - Instill 2 drop in right eye three times a day for conjunctivitis for 7 days.
Review of the Progress Notes in the resident's Electronic Health Record revealed the following entry:
9/14/2021 - 12:56 p.m. - Mr. (name of resident) missed a dose of her (sic) medication for conjunctivitis on 9/10 1400 (2:00 p.m.), 2100 (9:00 p.m.), and 9/11 1400 dose. Education provided to nursing in what to do if meds (medications) had not arrived from the pharmacy or could not be located
Review of the Medication Administration Record in the resident's Electronic Health Record verified the Ofloxacin was not administered as ordered twice on 9/10/2021, and once on 9/11/2021. The order written on 9/10/2021 was discontinued on 9/14/2021.
On 9/14/2021, the following new order for the ophthalmic solution was written: Ofloxacin Solution 0.3% - Instill 2 drop in right eye one time only for conjunctivitis for 4 days.
According to the Medication Administration Record in the resident's Electronic Health Record, the medication was administered as ordered on 9/14/2021, but was not administered on 9/15, 9/16, or 9/17/2021.
There was no documentation to indicate why the medication ordered on 9/14/2021 was not administered for three of four days.
The findings were discussed during a meeting at 4:15 p.m. on 9/21/2021 that included the Administrator, Interim Director of Nursing, Executive Nurse, Nurse Consultant, and the survey team. No explanation was offered at that time as to why the medication was not available for administration as ordered for either the order of 9/10/2021 or the order of 9/14/2021.
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, the facility staff failed to store and prepare food in a sanitary manner in the main kitchen.
The findings include:
On 6/29/21 at 10...
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Based on observation, staff interview and facility document review, the facility staff failed to store and prepare food in a sanitary manner in the main kitchen.
The findings include:
On 6/29/21 at 10:48 a.m., accompanied by the dietary manager (other staff #2), the kitchen and food storage areas were inspected. Stored in the walk-in refrigerator was a plastic container of potato salad. The potato salad was labeled with a prep date of 6/12/21 and use by date of 6/19/21. A plastic container of applesauce was also stored and labeled with prep date of 6/17/21 and use by date of 6/28/21. The dietary manager was interviewed at the time of the observation. The dietary manager stated the potato salad and applesauce should have been discarded prior to today.
On 6/29/21 at 11:04 a.m., accompanied by the dietary manager, meal preparation was observed in the kitchen. A scoop was observed stored in bulk container of raw sugar, with the handle touching the sugar. The dietary manager stated at the time of the observation that the scoop was supposed to be stored separately and not positioned in the food product.
The facility's policy titled Leftovers (effective 9/14/18) documented, Leftovers shall be stored in a manner which maintains the food so that it is safe to eat, and retains optimal nutrient content and aesthetic quality .All leftovers shall be stored in sealed or air-tight containers .All leftovers containers shall be labeled, indicating the name of the product and the use-by-date .Storage of leftovers is a maximum of (7) seven days from date prepared .
These findings were reviewed with the administrator and director of nursing during a meeting on 7/1/21 at 1:10 p.m.
Sept 2019
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation and staff interview, the facility staff failed to ensure a dignified dining experience on one of three dining areas. During breakfast in the East unit restorative dining room, fac...
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Based on observation and staff interview, the facility staff failed to ensure a dignified dining experience on one of three dining areas. During breakfast in the East unit restorative dining room, facility staff stood over residents while feeding them and fed them without initiating any conversation.
The findings include:
On 9/16/19 from 7:50 a.m.to 8:15 a.m., breakfast service was observed in the East unit restorative dining room. On 9/16/19 at 7:50 a.m., certified nurses' aide (CNA) #3 offered Resident #34 a banana. CNA #3 handed a peeled banana to the resident. Resident #34 took one bite of the banana and placed it on a napkin on the table. The resident had no plate or dish in front of her.
During this meal observation, certified nurses' aide (CNA) #1 was observed feeding Residents #9, #33 and #87 seated at the same table. CNA #1 was standing and went from resident to resident feeding them the breakfast food items/drink from their trays. CNA #1 gave Resident #33 a bite of food, then went to Resident #87 and fed him several bites. CNA #1 then went to Resident #9 and fed her several bites of food. CNA #1 proceeded to go from resident to resident feeding each resident several bites before moving to the next resident.
On 9/16/19 at 8:06 a.m., CNA #7 entered the dining room and started feeding Resident #9. CNA #7 stopped feeding Resident #9 after a few minutes, cleaned off dirty plates/cups/napkins from another table, then returned to feed Resident #9. CNA #1 continued to feed Residents #33 and #87, going back and forth between the residents. Both CNAs stood while feeding the three residents and had no conversation with any of the residents during the observation. On 9/16/19 at 8:14 a.m., CNA #1 sat beside Resident #33 and continued feeding her but shortly got up to feed Resident #87.
On 9/16/19 at 9:18 a.m., CNA #1 was interviewed about standing and feeding multiple residents at the same time during breakfast. CNA #1 stated, We have more feeders now. CNA #1 stated she was trying to get everyone fed so that was why she was feeding all three residents. CNA #1 stated CNA #7 came in to help during the meal and they probably should have been seated while feeding them.
On 9/16/19 at 9:21 a.m., the licensed practical nurse unit manager (LPN #4) was interviewed about the breakfast observation. LPN #4 stated the aides normally sit with the residents and were supposed to feed one resident at a time. LPN #4 stated there usually were two aides in the dining room to feed those needing assistance. LPN #4 stated the aides usually sit and engage residents while feeding them.
This finding was reviewed with the administrator and director of nursing during a meeting on 9/16/19 at 5:40 p.m.
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 resident interview, staff interview and clinical record review the facility staff failed to implement the care plan (CP) for Resident # 86 for restorative services, and failed to develop a co...
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Based on resident interview, staff interview and clinical record review the facility staff failed to implement the care plan (CP) for Resident # 86 for restorative services, and failed to develop a comprehensive plan of care (CCP) for Resident # 408's fluid restriction.
Findings include:
1. Resident # 86 was admitted to the facility 8/3/17 with diagnoses to include, but not limited to: spinal stenosis, chronic pain, and chronic kidney disease.
The most recent MDS (minimum data set) was a quarterly review dated 9/5/19 and had Resident # 86 with moderate impairment in cognition with a total summary score of 10 out of 15.
On 9/15/19 at 2:00 p.m. Resident # 86 was observed in her room sitting in a wheel chair. Resident # 86 was observed with splint boots to each foot. The boot on the left foot was not applied securely, and the right boot was sideways on the resident's foot. Resident # 86 stated Yes, they are quite a sight, aren't they? She went on to state the CNA (certified nursing assistant) applied the boots in the mornings after getting her out of bed. CNA # 3 was in the hallway across from the resident's room, and was asked to come and assist the resident to adjust the boots. CNA # 3 was asked when the boots were put on the resident and she stated, They get put on in the morning and taken off at bedtime.
The clinical record was reviewed 9/16/19 at approximately 7:45 a.m. The order for the boots was not located on the current POS (physician order summary). The care plan was then reviewed, and included the following:
Focus: The resident has limited physical mobility related to muscle weakness, difficulty walking, spinal stenosis. Created on: 7/19/17. Revision on: 4/23/19 . Goals included, The resident will remain free of complications related to immobility .through the next review date. Created on: 8/8/17. Revision on: 7/9/19. Interventions included, NURSING REHAB/RESTORATIVE: PASSIVE ROM (range of motion) Program # 1: Pt (patient) has excessive tone in legs but with very slow long stretch can reach full knee extension on L (left) lower extremity and full flexion on R (right) lower extremity for 15 minutes twice daily. The revision date for the intervention was 4/23/19. NURSING REHAB/RESTORATIVE: ACTIVE ROM: Program # 2: Resident will maintain present muscle strength and endurance without evidence of contractures through next review. Need ROM to bilateral lower extremities in sitting working on straightening the left lower extremity and bending the right lower extremity in chair. Place pt. neuro multipodus boots on for 2 hours in chair with left leg straightened and elevated and right leg bent with leg rest lowered. Created on :9/5/19. The frequency was noted as PRN (as needed).
On 9/16/19 at 9:15 a.m. the DON (director of nursing) was asked if an order was needed for the multipodus boots in use by Resident #86, and was also asked for the documentation of the restorative services provided. The DON reviewed the clinical record, then stated There is no documentation for the restorative services or an order for the boots. When there is a referral for restorative serves the unit manager should have put in definitive times for the services to be provided and notified the doctor; that wasn't done. It was entered as 'prn' so it did not trigger over to the CNA to know the resident should be picked up for restorative, so there is no documentation. The DON was advised that the resident had been observed with the boots on since the survey team entered the facility 9/15/19 at 1:00 p.m. The DON stated I will make sure the physician is notified about the order and the specific times for the boots to be applied.
On 9/16/19 at 9:25 a.m.,. CNA # 1, who was assigned to restorative services on Resident # 86's hall, was asked if she was aware Resident # 86 was to be receiving restorative services. CNA # 1 stated No. It is not on my ADL (activities of daily living) sheet; she is? I certainly did not know that .I think (name of CNA # 3) might work with her some too, you may want to ask her . CNA # 3, who was present during the interview was then asked about the restorative services for the resident. CNA # 3 stated she was aware, and further stated When she got the boots we had an inservice with therapy about it. CNA # 3 was asked if she was in the inservice, and she stated she was. She was then asked about the time frame for the boots as she stated the day before that Resident #86 wore the boots from morning until bedtime. CNA # 3 was also asked for her documentation of the restorative exercises. CNA # 3 stated It's not documented in the ADL's; I thought the boots were to be on all day .
On 9/16/19 at 9:30 a.m. the unit manager, identified as LPN (licensed practical nurse) # 4 was interviewed about the restorative referral. LPN # 3 stated I was not aware to put it in with times or to notify the doctor .
The administrator, DON (director of nursing), and regional nurse consultant were informed of the above findings during a meeting with facility staff 9/16/19 beginning at 5:40 p.m.
No further information was provided prior to the exit conference.
2. Resident # 408 was admitted to the facility 9/3/19 with diagnoses to include, but were not limited to: left femur fracture, muscle weakness, diabetes, and congestive heart failure.
The most recent MDS (minimum data set) was the admission assessment. Resident # 408 was assessed as cognitively intact with a total summary score of 14 out of 15.
The clinical record was reviewed 9/15/19 at approximately 3:00 p.m. The current POS (physician order summary) included an order dated 9/13/19 for Fluid restriction 2,000 ml daily.
The MAR (medication administration record) and TAR (treatment administration record) were then reviewed, but no information about the fluid restriction could be located. A review of the care plan revealed no documentation for the fluid restriction.
The administrator, DON (director of nursing), and regional nurse consultant were informed of the above findings during a meeting with facility staff 9/16/19 beginning at 5:40 p.m. The DON was asked if a care plan should be developed for the fluid restriction. She stated Yes.
No further information was provided prior to the exit conference.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #69 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, left and right hand cont...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #69 was admitted to the facility on [DATE] with diagnoses that included multiple sclerosis, left and right hand contractures, depression, chronic pain, neuromuscular bladder, anxiety and type 2 diabetes. The most recent minimum data set (MDS) dated [DATE] was a quarterly assessment and assessed Resident #69 as cognitively intact with a score of 14 for daily decision making.
Resident #69's clinical record was reviewed on 09/15/19 at 5:06 p.m. A progress note documented the following: 09/06/19 11:40 Skin/Wound Note. Observed residents R (right) buttocks, pressure ulcer healed at this time. No drainage, or odor observed. No s/s (signs/symptoms) of infection observed. No open areas observed Notified resident's dad of wound healing .
A review of Resident #69's care plan documented the following: The resident has a stage 3 to R buttocks r/t (related to) immobility The care plan included goals and interventions for pressure ulcer treatment and healing. Resident #69's care plan had not been reviewed and revised to to reflect the pressure ulcer had healed.
On 09/16/19 at 3:00 p.m. the unit manager (LPN #1) who was responsible updating the care plan was interviewed. LPN #1 was asked if the stage 3 pressure ulcer on Resident #69's right buttock had healed. LPN #1 stated yes the pressure ulcer had healed. LPN #1 was asked to review the care plan. LPN #1 reviewed the care plan and stated she simply overlooked updating the care plan.
These findings were shared with the administrator, director of nursing and corporate nurse during a meeting on 09/16/19 at 5:00 p.m.
No additional information was received prior to the exit conference on 09/17/19 at 1:00 p.m.
Based on observation, staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan for two of 39 residents in the survey sample. Resident #112's care plan was not revised to include use of fall mats and an air mattress. Resident #69's care plan was not revised regarding a healed pressure ulcer.
The findings include:
1. Resident #112 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #112 included respiratory failure, seizures, cerebrovascular disease, diabetes, COPD (chronic obstructive pulmonary disease), dysphagia, cognitive communication deficit, schizophrenia, glaucoma, mood disorder and high blood pressure. The minimum data set (MDS) dated [DATE] assessed Resident #112 with short and long-term memory problems and moderately impaired cognitive skills.
On 9/15/19 at 5:20 p.m., Resident #112 was observed in bed. The resident's right foot was hanging off the side of the bed. The resident was on an air mattress with no floor mats in place. Resident #112 was observed again on 9/16/19 at 7:47 a.m., 10:13 a.m. and 2:15 p.m. in bed with no floor mats in place on either side of the bed.
Resident #112's clinical record documented the resident had an unwitnessed fall from the bed on 8/8/19. A nursing note dated 8/8/19 at 11:37 p.m. documented, Resident was found by CNA [certified nurses' aide] with his head and upper torso on the floor and lower extremities on the bed. Un-witnessed .No acute distress noted. No injury . The clinical record documented a post-fall assessment dated [DATE] listing immediate action taken to prevent further falls/injury was, Fall mats.
Resident #112's plan of care (revised 9/5/19) listed the resident was at risk of falls. Interventions listed anticipate and meet the resident's needs, use assistive devices, call light within reach, fall education, appropriate footwear and trip-free environment. The plan of care was not updated to indicate use of the protective fall mats and made no mention of the alternating air mattress.
On 9/16/19 at 2:20 p.m., the licensed practical nurse (LPN #3) caring for Resident #112 was interviewed about the protective floor mats. LPN #3 stated she was not sure if the resident required floor mats. LPN #3 reviewed the resident's plan of care and stated she did not see the floor mats listed. LPN #3 stated, Normally, I don't care for him [Resident #112].
On 9/16/19 at 2:25 p.m., the unit manager (LPN #4) was interviewed about floor mats indicated on the post-fall assessment for Resident #112 and the air mattress in use. LPN #4 stated she remembered implementing the floor mats after the resident's fall on 8/8/19. LPN #4 reviewed the plan of care and stated she did not see the mats listed. LPN #4 stated she thought she added the mats to the care plan but did not see them listed.
On 9/16/19 at 3:30 p.m., the director of nursing (DON) and corporate nursing consultant were interviewed about Resident #112's post-fall assessment indicating the use of protective fall mats and the air mattress. The DON stated the resident was supposed to have fall mats in place for injury prevention. The DON stated the mats were initiated following the resident's fall from the bed on 8/8/19. The DON stated the unit manager was responsible for updating the care plan. The corporate consultant stated the air mattress was provided by hospice and was listed on the hospice plan.
This finding was reviewed with the administrator and director of nursing during a meeting on 9/16/19 at 5:40 p.m.
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** 2. Resident # 114 was admitted tot he facility 8/13/19 with diagnoses to include, but were not limited to: history of falls, acu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident # 114 was admitted tot he facility 8/13/19 with diagnoses to include, but were not limited to: history of falls, acute respiratory failure, and COPD (choronic obstructive pulmonary disease).
The most recent MDS (minimum data set) was the admission assessment dated [DATE]. Resident # 114 was coded with moderate impairment in cognition with a total summary score of 10 out of 15.
The clinical record was reviewed 9/16/19 at 9:00 a.m. The current POS (physician order summary) included an order dated 8/14/19 for Oxygen Therapy- Oxygen at (1) liters per minute via nasal cannula every shift for shortness of breath.
On 9/16/19 at 10:45 a.m. Resident # 114 was observed in bed with his oxygen being administered at 3 lpm (liters per minute). LPN (licensed practical nurse) # 2, who was at the nurses' station, was asked about the oxygen for Resident # 114. LPN # 2 looked at the order and confirmed it was to be administered at 1 lpm. Resident #114's oxygen was observed with LPN # 2 who confirmed the oxygen was being administered at 3 lpm. She adjusted the oxygen back to 1 lpm, and stated I don't know how that happened; there are people in and out of here all the time. Therapy comes in and works with him, and he complains a lot of feeling like he can't breathe so they may have turned it up . LPN # 2 was asked if it was acceptable for anyone coming in the room to adjust the oxygen. LPN # 2 stated I'm not saying that .
On 9/16/19 at 4:30 p.m. the physical therapy assistant (PTA) who worked with Resident # 114 was interviewed about what would happen if a resident complained of feeling unable to breathe during a session. The PTA stated Well, I would check with nursing about what to do.
The administrator, DON (director of nursing), and regional nurse consultant were informed of the above observations during a meeting with facility staff 9/16/19 beginning at 5:40 p.m.
No further information was provided prior to the exit conference.
Based on observation, staff interview, and resident record review, the facility staff failed to follow physician orders for oxygen administration for 2 of 39 resdients in the survey sample, Residents #46 and #114.
The Findings Include:
1. Resident #46 was admitted to the facility on [DATE]. Diagnoses for Resident #46 included: Congestive heart failure, diabetes, chronic obstructive pulmonary disease, and sleep apnea. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 7/17/19. Resident #46 was assessed as being cognitively intact.
On 09/16/19 at 9:12 AM, Resident # 46 was interviewed. During the interview Resident #46 was asked if staff change out oxygen tubing and asked to observed oxygen concentrator. Resident #46 stated that staff do change the oxygen tubing. The oxygen concentrator was then observed and the rate of oxygen was set at 4 LPM (liters per minute).
On 09/16/19 Resident #46's record was reviewed and included an active physician's order dated dated 5/16/19 which documented Oxygen Therapy-Oxygen at 2 liters per minute via nasal cannula every shift.
On 09/16/19 at 10:15 AM, Resident #46's oxygen was again observed with a rate at 4 LPM.
On 09/16/19 at 10:35 AM, license practical nurse (LPN) #9, who was assigned to Resident #46, was interviewed regarding the oxygen rate. LPN #9 reviewed Resident #46's oxygen order and then observed Resident #46's oxygen rate at 4 LPM. LPN #9 turned down the oxygen and said that's on me.
On 09/16/19 at 5:39 PM, the administrator and director of nursing were informed of the above information.
No other information was provided prior to exit conference.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to assess ...
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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 assess one of 39 residents (Resident #112) for entrapment risks prior to use of bed rails with a specialty mattress.
The findings include:
Resident #112 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #112 included respiratory failure, seizures, cerebrovascular disease, diabetes, COPD (chronic obstructive pulmonary disease), dysphagia, cognitive communication deficit, schizophrenia, glaucoma, mood disorder and high blood pressure. The minimum data set (MDS) dated [DATE] assessed Resident #112 with short and long-term memory problems and moderately impaired cognitive skills. The MDS listed the resident had highly impaired vision and required the extensive assistance of two people for bed mobility.
On 9/15/19 at 5:20 p.m., Resident #112 was observed in bed. The resident's right foot was hanging off the side of the bed. The resident was on an alternating air mattress with short bed rails raised on both sides of the bed. The rails were near the head of the bed. Resident #112 was observed again on 9/16/19 at 7:47 a.m., 10:13 a.m. and 2:15 p.m. in bed with both bed rails in the up position. No floor mats were in place by the bed.
Resident #112's clinical record documented the resident had an unwitnessed fall from the bed on 8/8/19. A nursing note dated 8/8/19 at 11:37 p.m. documented, Resident was found by CNA [certified nurses' aide] with his head and upper torso on the floor and lower extremities on the bed. Un-witnessed .No acute distress noted. No injury .
Resident #112's clinical record documented a Device Assessment dated 8/6/19 listing the resident used side rails and a low bed with mats. The purpose of the side rails and concave mattress was documented as safety. This assessment listed the responsible party was notified and the care plan was updated to include use of the side rails.
The clinical record and device assessment listed no prior attempted alternatives to the bed rails, no informed consent from the resident's representative regarding bed rail use and no indication of the medical need addressed by the rails. There was no additional bed rail safety assessment performed after the resident's unwitnessed fall on 8/8/19 and no assessment regarding the resident's bed rail use with the alternating air mattress currently on the bed.
Resident #112's plan of care (revised 9/5/19) documented the resident was at risk of falls, had left sided weakness, a seizure disorder, impaired cognitive function and impaired vision. Interventions listed included anticipate and meet the needs, use assistive devices that included assist bars, call light within reach, fall education, appropriate footwear and trip-free environment. There was no mention the resident had assist bars in use with an alternating air mattress.
On 9/16/19 at 2:30 p.m., the licensed practical nurse unit manager (LPN #4) was interviewed about Resident #112's bed rail use with the air mattress. LPN #4 stated residents were assessed upon admission for use of side rails. LPN #4 stated Resident #112 could hold the grab rails during care but he did not independently use the rails to turn or move about in bed. LPN #4 stated the resident required the assistance of two people for bed mobility. LPN #4 stated there was no re-assessment of the bed rails after the resident fell on 8/8/19. LPN #4 stated she did not know of an assessment regarding rail use with the air mattress.
On 9/16/19 at 2:40 p.m., a certified nurses' aide (CNA #3) that routinely cared for Resident #112 was interviewed. CNA #3 stated Resident #112 was total assist and did not use the bed rails on his own.
On 9/16/19 at 3:18 p.m., the maintenance director (other staff #6) was interviewed about any assessment or review of Resident #112's bed rails. The maintenance director stated his department annually reviewed beds, mattresses and bed rails for entrapment risks and safety using FDA guidelines. After reviewing his records, the maintenance director stated Resident #112's bed was last inspected for safety on 9/18/18. The maintenance director stated hospice placed the current alternating air mattress on Resident #112's bed. The maintenance director stated he had not reviewed and/or assessed Resident #112's bed or rails with the current air mattress because he was not aware the specialty mattress was in use.
On 9/16/19 at 3:30 p.m., the director of nursing (DON) and corporate nursing consultant were interviewed about Resident #112's bed rail use without an assessment for safety. The DON stated that the resident should have been re-assessed regarding bed rail use after the fall on 8/8/19. The DON stated the assessment completed on 8/6/19 was not accurate as the resident had assist bars and not side rails. The corporate consultant stated he did not think assist bars were considered bed rails. The DON stated she had no information about any attempted alternatives to the bed rails. The DON stated she did not realize the entrapment risk requirements applied to assist bars.
The facility's policy titled Bed Systems Audit (effective 1/1/19) documented, .Maintenance will also conduct an intermittent audit immediately upon notification by nursing of any individual change of a bed frame, an assistive device, a mattress, or a bed rail. Maintenance and nursing will collaborate in order to identify gaps, ensure a tight fit of mattress to the bed system and, if appropriate, to inspect for mattress compressibility .Any bed rail and/or mattress changes implemented and/or newly purchased separately from the bed frame system, will be assessed collaboratively for compatibility in width and length and with adherence to the manufacturer's recommendation and specifications .
This finding was reviewed with the administrator and director of nursing during a meeting on 9/16/19 at 5:40 p.m.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, staff interview and facility document review, the facility staff failed to perform hand hygiene during meal assistance in one of three dining rooms (East unit restorative).
The ...
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Based on observation, staff interview and facility document review, the facility staff failed to perform hand hygiene during meal assistance in one of three dining rooms (East unit restorative).
The findings include:
On 9/16/19, breakfast was observed in the East unit restorative dining room from 7:50 a.m. until 8:15 a.m. On 9/16/19 at 7:50 a.m., certified nurses' aide (CNA) #3 offered Resident #34 a banana. Without use of gloves, CNA #3 completely peeled the banana and directly touched the food with her bare hands before handing the banana to the resident. The resident took one bite of the banana and placed it on a napkin on the table. Certified nurses' aide (CNA) #1 was observed feeding Residents #9, #33 and #87, who were seated at the same table. CNA #1 was standing and went from resident to resident feeding them the breakfast food items/drink from their trays. CNA #1 gave Resident #33 a bite of food, then went to Resident #87 and fed him several bites. CNA #1 then went to Resident #9 and fed her several bites of food. CNA #1 proceeded to go from resident to resident feeding each resident several bites before moving to the next resident. CNA touched the residents' utensils, drink cups, milk cartons, wheelchair backs and patted one resident on the shoulder during the meal assistance. CNA #1 performed no hand hygiene between any of the residents while assisting and feeding them.
On 9/16/19 at 8:06 a.m., CNA #7 entered the dining room and started feeding Resident #9. CNA #7 stopped feeding Resident #9 after a few minutes, cleaned off dirty plates/cups/napkins from another table. Without performing hand hygiene, CNA #7 then returned to feeding Resident #9. CNA #1 continued to feed Residents #33 and #87, going back and forth between the residents. There was no hand hygiene performed by either CNA during the meal observation.
On 9/16/19 at 9:18 a.m., CNA #1 was interviewed about hand hygiene during the breakfast observation. CNA #1 stated hand sanitizer was available. CNA #1 stated hand sanitizer was used when passing out meal trays. When asked about hand hygiene between residents, CNA #1 had no response.
On 9/16/19 at 9:21 a.m., the licensed practical nurse unit manager (LPN #4) was interviewed about the breakfast observation. LPN #4 stated staff members were supposed to use hand sanitizer between contacts with residents or their items.
The facility's policy titled Handwashing Requirements (effective 12/26/17) documented, .Employees will wash hands at appropriate times to reduce the risk of transmission and acquisition of infections .Hand hygiene can consist of handwashing with soap and water or use of an alcohol based hand rub .The following is a list of some situations that require hand hygiene .Before and after eating or handling food (hand washing with soap and water) .Before and after assisting a patient with meals (hand washing with soap and water) .
This finding was reviewed with the administrator and director of nursing during a meeting on 9/16/19 at 5:40 p.m.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview, and clinical record review, the facility staff failed to follow physi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview, and clinical record review, the facility staff failed to follow physician orders for 4 of 39 residents in the survey sample. A physician ordered knee brace for Resident # 86 was not applied per order; fluid restriction for Resident # 408 was not implemented as ordered; TED hose (compression stockings) were not applied as ordered for Resident # 143; and medications were not administered per physician's orders for Resident #355.
Findings include:
1. Resident # 86 was admitted to the facility 8/3/17 with diagnoses to include, but not limited to: spinal stenosis, chronic pain, and chronic kidney disease.
The most recent MDS (minimum data set) was a quarterly review dated 9/5/19 and had Resident # 86 with moderate impairment in cognition with a total summary score of 10 out of 15.
On 9/15/19 at 2:00 p.m. Resident # 86 was observed in her room sitting in a wheel chair with splint boots on each foot. Resident #86 stated I also have another brace I usually have on my knee; I think it's over there behind the door. There was not any device behind the resident's door. Resident #86 was observed randomly throughout 9/15/19, without a brace on either knee.
The clinical record was reviewed 9/16/19 at approximately 7:45 a.m. The current POS (physician order summary) included an order carried forward from 4/23/19 for Left Knee Brace to Left Knee every shift .
On 9/16/19 at 9:00 a.m. Resident # 86 was observed without the knee brace to the left knee. The regional nurse consultant was in the hallway, and came in the resident's room to inquire if assistance was needed. He was informed of the order, and the observations that the knee brace had not been observed on Resident #86 since 9/15/19 at 2:00 p.m. The nurse consultant then asked LPN (licensed practical nurse) # 3 about the brace. At that time, LPN # 3 and the nurse consultant searched the resident's room, but were unable to locate the brace. LPN # 3 asked Resident #86 if the brace was in the laundry, and the resident responded she did not know. The regional nurse consultant stated he would go look in laundry to see if it was there.
On 9/16/19 at 5:40 p.m. during an end of the day meeting with facility staff the nurse consultant and DON (director of nursing) were asked if the knee brace had been located. The DON stated No; it was discontinued today.
No further information was provided prior to the exit conference.
2. Resident # 408 was admitted to the facility 9/3/19 with diagnoses to include, but were not limited to: left femur fracture, muscle weakness, diabetes, and congestive heart failure.
The most recent MDS (minimum data set) was the admission assessment. Resident # 408 was assessed as cognitively intact with a total summary score of 14 out of 15.
The clinical record was reviewed 9/15/19 at approximately 3:00 p.m. The current POS (physician order summary) included an order dated 9/13/19 for Fluid restriction 2,000 ml daily.
The MAR (medication administration record) and TAR (treatment administration record) were then reviewed, but no information about the fluid restriction could be located.
On 9/16/19 at 10:30 a.m. the DON (director of nursing) was asked for assistance in locating the fluid restriction documentation. The DON stated It should be documented on the MAR. The DON then reviewed the MAR and the physician order and stated The order was not entered correctly, so it didn't trigger on the MAR. The DON then stated the name of LPN (licensed practical nurse) # 2 as the nurse who entered the order.
On 9/16/19 at 10:35 a.m. LPN # 2 was asked where Resident # 408's fluid restriction was being documented. LPN # 2 stated Let me look in my computer; it should be on the MAR. LPN # 2 then reviewed the MAR then stated It's not on here; she's on fluid restriction? LPN # 2 then pulled up the orders and stated I didn't even have this resident Friday, but my name is on there as entering the order. I have no idea how that happened but I have fixed it now .
The administrator, DON (director of nursing), and regional nurse consultant were informed of the above findings during a meeting with facility staff 9/16/19 beginning at 5:40 p.m.
No further information was provided prior to the exit conference.3. Resident #143 was admitted to the facility on [DATE]. Diagnoses for Resident #143 included; Sepsis, bladder cancer, chronic AFIB, emphysema, and chronic kidney disease. The most current MDS (minimum data set) was a 14 day assessment with an ARD (assessment reference date) of 9/5/19. Resident #143 was assessed as having moderately impaired cognitive skills.
On 9/16/19 resident #143's clinical chart was reviewed. A physician's order dated 9/4/19 documented, Apply TED hose [compression hose] to Bilateral lower extremities in am [sic] and remove @ (at) bedtime two times a day for swelling.
On 09/16/19 at 9:15 AM, Resident #143 was observed sitting up on side of the bed without TED hose in place and both legs were edematous. When asked about the TED hose, Resident #143 stated they haven't put them on. Resident #143 was observed again at 9:45 AM sitting on the side of bed without TED hose.
On 09/16/19 at 10:02 AM, certified nursing assistant (CNA #2, assigned to Resident #143) was interviewed and also observed Resident #143 without TED hose. When asked about the TED hose, CNA #2 stated that she was aware that Resident #143 had an order for TED hose but hadn't got to him yet and said she had been very busy because another CNA had called off work.
09/16/19 05:39 PM the above information was presented to the administrator and director of nursing.
No other information was presented prior to exit conference on 9/17/19.4. Resident #355 was admitted to the facility on [DATE] and discharged on 02/15/19. Admitting diagnoses for this resident included, but were not limited to: hip fracture (right femur), Parkinson's disease, muscle weakness, history of falls, encephalopathy, vitamin d deficiency, and constipation.
The most current full MDS (minimum data set) was an admission assessment dated [DATE] Resident #355 was assessed as receiving 4 injections on this MDS (not insulin).
The clinical record was reviewed and documented the resident was admitted to the facility at approximately 10:30 AM on 01/27/19. The resident was ordered medications that included, but were not limited to: Sinemet (Parkinson's medication) three times daily, celebrex (scheduled pain medication) twice daily, lovenox (anticoagulant) once daily, Lortab (as needed pain medication) every 6 hours, ramelteon (insomnia medication) every night, and senna (laxative medication) every day.
The resident's January 2019 MARs (medication administration records) were reviewed and revealed that the resident only received as needed pain medications on the date of admission [DATE]) and one dose of the Sinemet (Parkinson's disease) on the day of admission (1 PM dose). All other medications were not administered as ordered by the physician. Several of the resident's medications for 01/27/19 and 01/28/19 had a code of '5' and a code of '9' documented on the MARs. The 5 indicated that the medication was not administered and documented, Hold/See progress notes. The 9, indicated that the medication was not administered and documented, Other/See Progress Notes.
The physician's orders and progress/nursing notes were reviewed from admission to discharge and no information was found regarding the why the resident did not have medications for administration.
The DON (director of nursing) was interviewed on 09/17/19 at 7:34 AM regarding Resident #355 and the above information. The DON stated that for a new admission, they activate the orders put in the queue, once the resident is at the facility they will confirm and then the medications are brought from pharmacy on the next run, or from the back up pharmacy. The DON stated that there is a cut off and stated that if the resident is admitted and the medications are put in before 5:00 PM, the pharmacy will deliver them by 7:00 PM. The DON was asked for any information as to why this resident did not receive her medications from the pharmacy as ordered. The DON stated that they have had problems with the pharmacy as far as getting medications. The DON stated that the pharmacy is open Monday through Friday, but they are available 24 hours a day from the backup pharmacy. The DON stated off hours for backup pharmacy would be after 7:00 PM and on the weekends.
A policy was presented, titled Providing pharmacy products and services. The policy stated, .will provide facility with the facility specific information sheet, which details how facility staff can contact pharmacy 24 hours a day, seven days a week .normal business hours set forth in the facility specific information sheet, facility staff may contact by phone .fax .by mail or hand delivery .if orders for medications are received from physician .when pharmacy is closed .contact emergency number .
The facility specific information sheet documented, that the pharmacy hours of operation were Monday through Friday 9 AM to 9 PM and Saturday, Sunday and Holidays: 9 AM to 5 PM. This did not match what the DON stated in her interview.
On 09/18/19 at approximately 9:45 AM, the GM (General Manager) from the local pharmacy was interviewed. The GM stated that the local pharmacy closes at 7:00 PM (Monday through Friday) and closes at 5:00 PM on Saturday, the pharmacy is closed Sunday. The GM stated those hours have been in effect since early 2018 and the facility should be aware of that. The GM further stated that the facility will have to call the back up pharmacy to get medications during off hours and that the medications are typically delivered within 4 hours; there is not cut-off on that and that if the facility put that information in the computer that medications will not be delivered within the 4 hours, a phone call actually has to be made. The GM stated that he was not sure where the breakdown happened, but stated that if there were extenuating circumstances that information would have been documented and there was no information indicating that.
The DON and administrator were made aware that the information presented did not match the interviews. The DON was asked where the breakdown occurred with Resident #355. The DON stated that she could not look the information up in the computer to see if the medications were ordered and could not determine what happened.
No further information and/or documentation was presented prior to the exit conference on 09/17/19 at 1:00 PM to evidence that the facility staff ordered the physician prescribed medications for Resident #355 to ensure the medications were available upon admission to the facility for administration, without interruption.
This is a complaint deficiency.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review, the facility staff failed to implement interventions for the p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review, the facility staff failed to implement interventions for the prevention of pressure ulcers for one of 39 residents in the survey sample. Resident #121, with a recent history of pressure ulcers on both heels, did not have dressings, topical treatment and protective booties applied for 10 consecutive days as required by physician orders and the care plan for pressure ulcer prevention.
The findings include:
Resident #121 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #121 included bladder cancer, peptic ulcer, hypertension, adult failure to thrive, depression, congestive heart failure, dementia and diabetes. The minimum data set (MDS) dated [DATE] assessed Resident #121 with moderately impaired cognitive skills.
Resident #121's clinical record documented the resident was assessed with pressure ulcers on both heels on 5/25/19. Skin assessment sheets documented the pressure ulcers as healed on 8/30/19. The clinical record documented a physician's order dated 9/6/19 to apply skin prep treatment and an Allevyn dressing to both heels every day for pressure ulcer prevention. The resident's plan of care (revised 9/4/19) listed the resident was at risk of skin breakdown. Interventions for pressure ulcer prevention included use of bunny boots, a heels-up cushion and an air mattress.
On 9/16/19 at 11:10 p.m., accompanied by licensed practical nurse (LPN) #3 and LPN #10, Resident #121's feet/heels were observed. Resident #121 was in bed with his heels positioned directly on the bed sheets. The resident's heels had no Allevyn dressings, no booties and no elevation of his feet/heels. The left heel had a scarred area with dry skin. The right heel was dry, with an area of peeling thick skin. LPN #3 was interviewed at this time about the Allevyn dressing and booties. LPN #3 stated the resident had a physician's order for the Allevyn dressing to be on each heel and the resident's heels were supposed to be elevated. LPN #3 stated she did not know why the dressings were not in place. LPN #3 looked and found the bunny boots in the resident's closet.
Further review of Resident #121's clinical record on 9/16/19 documented no evidence the Allevyn dressings or skin prep had been applied since ordered on 9/6/19. There was no evidence indicating application of the protective booties as required on the care plan. The Allevyn, skin prep and bunny boots were not listed on the resident's treatment administration record or medication administration record.
On 9/16/19 at 3:40 p.m., the director of nursing (DON) was interviewed about Resident #121 in bed without physician ordered dressings, booties or heel elevation. The DON reviewed the resident's current treatment record and stated she did not see the Allevyn, skin prep or booties listed. The DON stated the nurse entering the orders was supposed to mark the items to show on the treatment and/or medication record to ensure the interventions were implemented. The DON reviewed Resident #121's record and stated the orders for the Allevyn and skin prep were not marked properly in the computer and therefore were not listed on the treatment record. The DON stated the Allevyn was a padded dressing used to protect the resident's heels from further breakdown.
This finding was reviewed with the administrator and director of nursing during a meeting on 9/16/19 at 5:40 p.m.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected multiple residents
Based on observation, staff interview, and clinical record review the facility staff failed to provide restorative nursing services for one of 39 residents in the survey sample, Resident # 86.
Finding...
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Based on observation, staff interview, and clinical record review the facility staff failed to provide restorative nursing services for one of 39 residents in the survey sample, Resident # 86.
Findings include:
Resident # 86 was admitted to the facility 8/3/17 with diagnoses to include, but not limited to: spinal stenosis, chronic pain, and chronic kidney disease.
The most recent MDS (minimum data set) was a quarterly review dated 9/5/19 and had Resident # 86 with moderate impairment in cognition with a total summary score of 10 out of 15.
On 9/15/19 at 2:00 p.m. Resident # 86 was observed in her room sitting in a wheel chair. Resident # 86 was observed with splint boots to each foot. The boot on the left foot was not applied securely, and the right boot was sideways on the resident's foot. Resident # 86 stated Yes, they are quite a sight, aren't they? She went on to state the CNA (certified nursing assistant) applied the boots in the mornings after getting her out of bed. CNA # 3 was in the hallway across from the resident's room, and was asked to come and assist the resident to adjust the boots. CNA # 3 was asked when the boots were put on the resident and she stated They get put on in the morning and taken off at bedtime.
The clinical record was reviewed 9/16/19 at approximately 7:45 a.m. The order for the boots was not located on the current POS (physician order summary). The care plan was then reviewed, and included the following:
Focus: The resident has limited physical mobility related to muscle weakness, difficulty walking, spinal stenosis. Created on: 7/19/17. Revision on: 4/23/19 . Goals included, The resident will remain free of complications related to immobility .through the next review date. Created on: 8/8/17. Revision on: 7/9/19. Interventions included, NURSING REHAB/RESTORATIVE: PASSIVE ROM (range of motion) Program # 1: Pt (patient) has excessive tone in legs but with very slow long stretch can reach full knee extension on L (left) lower extremity and full flexion on R (right) lower extremity for 15 minutes twice daily. The revision date for the intervention was 4/23/19. NURSING REHAB/RESTORATIVE: ACTIVE ROM: Program # 2: Resident will maintain present muscle strength and endurance without evidence of contractures through next review. Need ROM to bilateral lower extremities in sitting working on straightening the left lower extremity and bending the right lower extremity in chair. Place pt. neuro multipodus boots on for 2 hours in chair with left leg straightened and elevated and right leg bent with leg rest lowered. Created on :9/5/19. The frequency was noted as PRN (as needed).
On 9/16/19 at 9:15 a.m. the DON (director of nursing) was asked if an order was needed for the multipodus boots in use by the resident, and also for the documentation of the restorative services provided. The DON reviewed the clinical record, then stated There is no documentation for the restorative services or an order for the boots. When there is a referral for restorative services the unit manager should have put in definitive times for the services to be provided and notified the doctor; that wasn't done. It was entered as 'prn' so it did not trigger over to the CNA to know the resident should be picked up for restorative, so there is no documentation. The DON was advised at that time the resident had been observed with the boots on since 9/15/19 at 1:00 p.m. The DON stated I will make sure the physician is notified about the order and the specific times for the boots to be applied.
On 9/16/19 at 9:25 a.m., CNA # 1, who was assigned to restorative services on Resident # 86's hall, was asked if she was aware Resident # 86 was to be receiving restorative services. CNA # 1 stated No. It is not on my ADL (activities of daily living) sheet; she is? I certainly did not know that .I think (name of CNA # 3) might work with her some too, you may want to ask her . CNA # 3, who was present during the interview was then asked about the restorative services for the resident. CNA # 3 stated she was aware, and further stated When she got the boots we had an inservice with therapy about it. CNA # 3 was asked if she was in the inservice, and she stated she was. She was then asked about the time frame for the boots as she had stated the day before the resident wore the boots from morning until bedtime. CNA # 3 was also asked for her documentation of the restorative exercises. CNA # 3 stated It's not documented in the ADL's. I thought the boots were to be on all day .
On 9/16/19 at 9:30 a.m. the unit manager, identified as LPN (licensed practical nurse) # 4 was interviewed about the restorative referral. LPN # 3 stated I was not aware to put it in with times or to notify the doctor .
The administrator, DON (director of nursing), and regional nurse consultant were informed of the above findings during a meeting with facility staff 9/16/19 beginning at 5:40 p.m.
No further information was provided prior to the exit conference.
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** Based on observation, staff interview and clinical record review, the facility staff failed to implement interventions for fall ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review, the facility staff failed to implement interventions for fall and injury prevention for one of 39 residents in the survey sample. Resident #112's fall mats were not implemented for over a month following an unwitnessed fall from his bed.
The findings include:
Resident #112 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #112 included respiratory failure, seizures, cerebrovascular disease, diabetes, COPD (chronic obstructive pulmonary disease), dysphagia, cognitive communication deficit, schizophrenia, glaucoma, mood disorder and high blood pressure. The minimum data set (MDS) dated [DATE] assessed Resident #112 with short and long-term memory problems and moderately impaired cognitive skills. The MDS listed the resident had highly impaired vision and required the extensive assistance of two people for bed mobility.
On 9/15/19 at 5:20 p.m., Resident #112 was observed in bed. The resident's right foot was hanging off the side of the bed. The resident was on an air mattress with no floor mats in place. Resident #112 was observed again on 9/16/19 at 7:47 a.m., 10:13 a.m. and 2:15 p.m. in bed with no floor mats in place on either side of the bed.
Resident #112's clinical record documented the resident had an unwitnessed fall from the bed on 8/8/19. A nursing note dated 8/8/19 at 11:37 p.m. documented, Resident was found by CNA [certified nurses' aide] with his head and upper torso on the floor and lower extremities on the bed. Un-witnessed .No acute distress noted. No injury . The clinical record documented a post-fall assessment dated [DATE] listing immediate action taken to prevent further falls/injury was, Fall mats.
On 9/16/19 at 2:20 p.m., the licensed practical nurse (LPN #3) caring for Resident #112 was interviewed about the protective floor mats. LPN #3 stated she was not sure if the resident required floor mats. LPN #3 reviewed the resident's plan of care and stated she did not see the floor mats listed. LPN #3 stated, Normally, I don't care for him [Resident #112].
On 9/16/19 at 2:25 p.m., the unit manager (LPN #4) was interviewed about the floor mats indicated on Resident #112's post-fall assessment. LPN #4 stated she remembered implementing the floor mats after the resident's fall on 8/8/19. LPN #4 reviewed the plan of care and stated she did not see the mats listed. LPN #4 stated she thought she added the mats to the care plan but did not see them listed. LPN #4 stated she did not know why the mats had not been implemented.
On 9/16/19 at 2:40 p.m., the certified nurses' aide (CNA #3) that routinely cared for Resident #112 was interviewed. CNA #3 stated she was not aware of any floor mats used with Resident #112.
On 9/16/19 at 2:53 p.m., CNA #7 caring for Resident #112 was interviewed. CNA #7 stated, To my knowledge, he [Resident #112] does not have mats. CNA #7 stated she had worked with Resident #112 since 8/12/19 and she had not been instructed to use mats for Resident #112.
On 9/16/19 at 3:30 p.m., the director of nursing (DON) was interviewed about Resident #112's post-fall assessment indicating the use of protective fall mats. The DON stated the resident was supposed to have fall mats in place for injury prevention. The DON stated the mats were initiated following the resident's fall from the bed on 8/8/19. The DON stated the unit manager was responsible for adding the mats to the care plan and communicating the need for the mats to the direct-care staff.
Resident #112's plan of care (revised 9/5/19) listed the resident was at risk of falls. Interventions listed were anticipate and meet needs, use assistive devices, call light within reach, fall education, appropriate footwear and trip-free environment. The plan of care was not updated to indicate use of the protective fall mats.
This finding was reviewed with the administrator and director of nursing during a meeting on 9/16/19 at 5:40 p.m.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "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.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s). Review inspection reports carefully.
- • 57 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • Grade F (28/100). Below average facility with significant concerns.
Bottom line: Trust Score of 28/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Lynchburg Health & Rehabilitation Center's CMS Rating?
CMS assigns LYNCHBURG HEALTH & REHABILITATION CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Virginia, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Lynchburg Health & Rehabilitation Center Staffed?
CMS rates LYNCHBURG HEALTH & REHABILITATION CENTER's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 52%, compared to the Virginia average of 46%. RN turnover specifically is 58%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Lynchburg Health & Rehabilitation Center?
State health inspectors documented 57 deficiencies at LYNCHBURG HEALTH & REHABILITATION CENTER during 2019 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 56 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Lynchburg Health & Rehabilitation Center?
LYNCHBURG HEALTH & 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 LIFEWORKS REHAB, a chain that manages multiple nursing homes. With 180 certified beds and approximately 159 residents (about 88% occupancy), it is a mid-sized facility located in LYNCHBURG, Virginia.
How Does Lynchburg Health & Rehabilitation Center Compare to Other Virginia Nursing Homes?
Compared to the 100 nursing homes in Virginia, LYNCHBURG HEALTH & REHABILITATION CENTER's overall rating (1 stars) is below the state average of 3.0, staff turnover (52%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Lynchburg Health & Rehabilitation Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.
Is Lynchburg Health & Rehabilitation Center Safe?
Based on CMS inspection data, LYNCHBURG HEALTH & REHABILITATION CENTER has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Virginia. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Lynchburg Health & Rehabilitation Center Stick Around?
LYNCHBURG HEALTH & REHABILITATION CENTER has a staff turnover rate of 52%, which is 6 percentage points above the Virginia average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Lynchburg Health & Rehabilitation Center Ever Fined?
LYNCHBURG HEALTH & 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 Lynchburg Health & Rehabilitation Center on Any Federal Watch List?
LYNCHBURG HEALTH & 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.