BAYSIDE OF POQUOSON HEALTH AND REHAB
For profit - Corporation
60 Beds
TRIO HEALTHCARE
Data: November 2025
Trust Grade
25/100
#237 of 285 in VA
Last Inspection: August 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Bayside of Poquoson Health and Rehab has a Trust Grade of F, indicating significant concerns about the quality of care, which places it in the lowest category. It ranks #237 out of 285 facilities in Virginia, meaning it is in the bottom half, and is the only option in Poquoson County. While the facility is showing an improving trend, with issues decreasing from 12 in 2024 to 10 in 2025, its staffing situation is alarming, with a turnover rate of 96%, much higher than the state average of 48%, and an overall staffing rating of 1 out of 5 stars. On the positive side, there have been no fines issued, which is a good sign, and the facility does maintain average RN coverage, which can help identify issues that CNAs might miss. However, there are serious concerns: staff failed to prevent pressure ulcers in multiple residents, and CNAs have not completed required training on vital topics such as dementia care and abuse prevention.
- Trust Score
- F
- In Virginia
- #237/285
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 96% turnover. Very high, 48 points above average. Constant new faces learning your loved one's needs.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Virginia facilities.
- Skilled Nurses ○ Average
- Each resident gets 34 minutes of Registered Nurse (RN) attention daily — about average for Virginia. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 71 deficiencies on record. Higher than average. Multiple issues found across inspections.
25/100
Bottom 17%
Needs review
12 → 10 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 12 issues
2025: 10 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: 96%
49pts above Virginia avg (46%)
Frequent staff changes - ask about care continuity
Chain: TRIO HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is very high (96%)
48 points above Virginia average of 48%
The Ugly 71 deficiencies on record
1 actual harm
Mar 2025
10 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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, staff interview, clinical record review, and review of facility documents, the facility's staff faile...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to assess and monitor a surgical wound on a resident's right breast after a breast biopsy was completed; which contributed to the resident becoming septic and hospitalized for 1 of 12 residents (Resident #1), in the survey sample.
The findings included:
Resident #1 was initially admitted to the facility on [DATE] and discharged on 11/11/24. The resident did not return to the nursing facility. The current diagnoses included major depressive disorder.
The admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 04/21/24, coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of 15.
The care plan dated 4/27/24 read Resident #1 had open areas related to dermatitis of the right buttock and perineum. The goal for Resident #1 is open areas will be free of infection and healing state through the next care plan review on 05/01/2024. The interventions for Resident #1 were: Encourage proper nutrition. If a resident refuses a meal, offer an alternative and provide medication/treatment as ordered by the physician, observe for effectiveness, and use pressure-reducing seats/mattresses as necessary.
A general note read: A physician visit was conducted by the facility Physician's Assistant (PA) on 11/11/24, the day of transfer from the nursing facility to the hospital admission. The chief complaint was sepsis. The resident had an elevated temperature and was hypotensive (90/60). Fluids and resuscitation were ordered. Although the provider doubted her sacral ulcer as the cause of her fever. No other source was identified at this time. A wound care consult was ordered. And local wound care was continued.
According to medical records and Family Member #1, the resident had a biopsy of her right breast on 10/22/24.
A review of a general progress note on 11/11/24 at 9:00 AM., read: Resident alert/verbal/responsive with difficulty understanding mumbling of words, eyes dazed in bed, head of bed up no signs and symptoms (s/s) of aspiration, skin clammy, hot/warm to touch, observed not eating breakfast vital signs (v/s) Temperature=100.7, blood pressure (bp)= 93/46, Pulse =93, Respiration =18, Oxygen 02= 83% with return 1min 94% 02 applied as ordered blood sugar (b/s) 86, lung sounds slightly diminished on left, right side clear, cap refill less than 3 seconds, and within normal limits with active bowel sounds large bowel movement.
The progress note dated 11/11/24 at 9:10 AM read: PA in the facility and updated orders given, unable to do Intravenous (IV). At 9:15 AM, the company called, spoke to staff, and requested midline stat confirmation number given at 9:25 AM., Responsible Party (RP) updated per his request wants resident sent to the Emergency Room/ ER/Treatment 9:30 AM., Message left via PA answering machine along with phone number waiting call back. 09:30 AM., 911 called 9:45 AM., Resident left via stretcher going to the hospital. Resident remains alert/verbal/responsive prior to departure, all peri care done Assistant Director of Nursing (ADON)/Unit Manager (UM) updated, at 11:30 AM., RP updated of departure.
A review of the hospital records dated 11/11/24 at approximately 2:08 PM., read that the patient expressed concern that she was not getting adequate care and was not feeling safe at the facility. According to the History and Physical (H&P) the patient was diagnosed with Sepsis (mostly due to draining of the right breast).
On 3/25/25 at approximately 2:15 PM, an interview was conducted with family member (FM) #1 concerning his loved one. FM #1 said that when his mom came into the hospital, she smelled bad from the infections. He also said that she had had a breast biopsy a few weeks before coming here.
On 3/26/25 at approximately 2:50 PM, an interview was conducted with Certified Nursing Assistant (CNA) #1. CNA #1 said that on 11/10/24, before the staff called 911, the resident was seen sleeping a lot. The resident started feeling bad after eating her breakfast. She was nauseated and refused her lunch. CAN#1 said, The next mornings she didn't look herself, she would open her eyes and not speak, she didn't eat breakfast that morning (11/11/24). LPN #3 helped me turn the resident in because she had a foley catheter. While giving her a bath I noticed a small area on her butt cheek. We put a protective cream on it. She would always have a bowel movement when receiving activities of daily living (ADL) care. Other CNAs said she had a milky substance coming from her breast.
On 3/27/25 at approximately 3:45 PM, an interview was conducted with the Physician Assistant (PA). The PA said that the right breast drainage had been ongoing for some time. The PA also said that he was not informed the resident had a breast procedure done requiring steri strips.
An interview was conducted on 3/27/25 at approximately 4:00 PM with Corporate Staff #2, the DON, and the facility Administrator. The administrator said that Resident #1 had a work-up for a breast mass, intermittent discharge, and an inverted nipple at the diagnostic center on 10/22/24. The Administrator said, We saw no progress notes. We should monitor for s/s of infections. The PA and the Medical Director were contacted via telephone during this interview. The DON said, If they came back with no orders (The Diagnostic Breast Center), you would call the hospital. Corporate Staff #2 asked the PA, Did you see anything? The PA said he wasn't aware at all that the resident had a biopsy until the resident went out to another facility (after hospital admission, the resident was discharged to another facility). The PA was asked what the facility was doing to monitor and care for the resident's right breast. The PA said, That was outpatient. I was not aware of a discharge at that time.
On 3/27/25 at approximately 4:25 PM, a document was presented by Corporate Staff #2. Corporate staff #2 said that the document could not be found in the Medical Records under Point Click Care (PCC) a cloud-based electronic health records (EHR) system; it could only be found under Point Click Care Connect (Optimize care collaboration by connecting to a national-level health data network with hospitals, active resident and patient records, to exchange timely clinical data). The PA and staff present said they were not aware of this system until now. Corporate Staff #2 said that the staff would be educated on Point Click Care Connect because they can access it. The surveyors were not able to retrieve any notes or documents as they were not informed of this system until 3/27/25. The retrieved document from Point Click Care Connect was presented to the surveyors by Corporate Staff #2, dated 10/29/24 at 9:45 AM, that read: Called patient and gave negative biopsy results. Patient very happy with the results, patient has no signs of infection around the biopsy site. Steri strips on and precautions reviewed per protocol. Post operative Biopsy results-Unspecified lump in right breast, subareolar. Pathology from right breast twelve o'clock radius subareolar margin demonstrates benign squamous epithelium with focal acute and chronic inflammation, including giant cells, suggestive of ruptured cyst. Findings are benign. At minimum suggest a 3 month follow-up.
On 3/27/25, at approximately 4:50 PM, Licensed Practical Nurse (LPN) #3 was interviewed. LPN #3 said that she noticed the discharge coming from the resident's right breast and notified the doctor.
The above findings were shared with the Administrator, Corporate Consultant, and Regional [NAME] President of Operations on 3/27/25 at approximately 7:45 p.m. The facility's staff was offered an opportunity to present additional information, but no additional information was provided.
Steri-Strips (Butterfly Bandage)
Steri-Strips and butterfly bandages are thin, sticky bandages that cover small cuts and some surgical incisions. You apply them across your cut (running in the opposite direction) to help the two sides of your skin stay tightly closed. This helps prevent bacteria from getting in. Seek medical care immediately at the first sign of a wound infection. https://my.clevelandclinic.org/health/treatments/steri-strip-butterfly-bandage
Incision & Surgical Wound Care
An incision is an opening of your skin after surgery. Your surgeon will close this surgical wound with stitches (sutures), staples or adhesives (Steri-Strips). A dressing goes over the closed incision. You'll need to keep your incision clean to prevent infection. Your healthcare provider will give you instructions to take care of your wound.
What is incision and surgical wound care?
Incision and surgical wound care are instructions that you follow to prevent infections and help your body heal. You get these instructions after a surgery or procedure where a surgeon or healthcare provider made an incision (entry point) to access the inside of your body. You'll need to clean and protect your incision site until it heals completely. If you notice any pain, swelling, warmth around the site, or fluid oozing out of your wound, visit a healthcare provider, as you may have an infection.
Adhesives: Adhesives include special tapes and glues that use their stickiness to hold your skin together. A healthcare provider may choose adhesives to close wounds from needles (percutaneous wounds), pediatric wounds or apply them in addition to deep sutures. Adhesives are painless. A common adhesive tape is Steri-Strips® https://my.clevelandclinic.org/health/treatments/15709-incision-care
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
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on observations, family interview, and staff interviews, the facility staff failed to properly care for a percutaneous endoscopic gastrostomy (PEG) tube for 1 of 12 residents (Resident #8), in t...
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Based on observations, family interview, and staff interviews, the facility staff failed to properly care for a percutaneous endoscopic gastrostomy (PEG) tube for 1 of 12 residents (Resident #8), in the survey sample.
The findings included:
Resident #8 was originally admitted to the facility 03/03/2023 after an acute care hospital stay. The current diagnoses included vascular dementia and chronic gastric outlet obstruction status post PEG tube placement.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/01/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 3 out of a possible 15. This indicated Resident #8's cognitive abilities for daily decision making were severely impaired.
On 3/25/25 at approximately 12:43 PM during the initial tour an interview was conducted with Resident #8's daughter who was visiting. The daughter lifted the resident's top which revealed a PEG tube. The PEG's external bumper was observed to be position too far from the abdominal skin and the insertion site had leakage and presented with small red and raised irritation. The daughter removed gauze from the closet and wiped the site dry, afterwards she applied a split drain sponges around the insertion site.
A review of the resident's person centered care plan failed to have a problem secondary to the PEG tube and a review of the current physician's orders failed to reveal an order for the PEG tube, but here were orders for management of the PEG. The orders included one dated 7/15/24 to cleanse and place a dressing to the PEG tube site every day and an order dated 5/08/24 which stated PEG tube - flush with thirty milliliters of water every eight hours for patency.
On 3/27/25 at approximately 10:14 AM the resident's PEG site was observed again after the resident lifted her shirt, The area was again very wet and the split drain sponge was disheveled around the tubing. An interview was conducted with Certified Nursing Assistant (CNA) #6 on 3/27/25 at approximately 10:21 AM. CNA #6 stated it was not the CNA's responsibility to clean Resident's #8's PEG site and apply the sponges. CNA #6 stated her role was to let the nurse know if changes were observed or if the PEG appeared to need care.
On 3/27/25 at approximately 1:37 PM an interview was conducted with Resident #8's hospice nurse. The hospice nurse stated the residents PEG tube insertion site was irritated because of a fungus and an antifungal had been ordered.
On 3/27/25 at approximately 5:30 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, and [NAME] President of Operations and Corporate Nurse Consultant. The above findings were conveyed to the administrative team. The Director of Nursing stated they had obtained new orders for the residents PEG insertion site.
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, clinical record review, and in the course of a complaint investigation, it was determined that facilit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and in the course of a complaint investigation, it was determined that facility staff failed to maintain a complete record for 1 of 12 residents in the survey sample; Resident #1
The findings included:
Resident #1 was originally admitted to the facility on [DATE] and discharged on 11/11/24. The current diagnoses included major depressive disorder.
The admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 04/21/24, coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of 15.
The care plan dated 4/27/24 read Resident #1 had open areas related to dermatitis of the right buttock and perineum. The goal for Resident #1 is for open areas to be free of infection and in a healing state through the following care plan review on 05/01/2024. The interventions for Resident #1 were: Encourage proper nutrition. If a resident refuses a meal, offer an alternative and provide medication/treatment as ordered by the physician, observe for effectiveness, and provide pressure-reducing seats/mattresses as necessary.
According to medical records and Family Member #1, the resident had a biopsy of her right breast on 10/22/24.
An interview was conducted on 3/27/25 at approximately 4:00 PM with Corporate Staff #2, the DON, and the Facility Administrator. The administrator said that Resident #1 had a work-up for a breast mass, intermittent discharge, and an inverted nipple at the diagnostic center on 10/22/24. We saw no progress notes. We should monitor for s/s of infections. The PA and the Medical Director were contacted by telephone during this interview. The DON said that if they came back with no orders (The Diagnostic Breast Center) you would call the hospital). Corporate Staff #2, asked the PA did you see anything. The PA said he wasn't aware at all that the resident had a biopsy until the resident went out to another facility (after hospital admission, the resident was discharged to another facility). The PA was asked what the facility was doing to monitor and care for the resident's right breast. The PA said, That was outpatient. I was not aware of a discharge at that time.
On 3/27/25 at approximately 4:25 PM, a document was presented by Corporate Staff #2. Corporate Staff #2 said that the document could not be found in the Medical Records under Point Click Care (PCC) a cloud-based electronic health records (EHR) system; (Optimize care collaboration by connecting to a national-level health data network with hospitals, active resident and patient records, to exchange timely clinical data). The PA and staff present said they were not aware of this system until now. Corporate Staff #2 said that the staff would be educated on Point Click Care Connect because they can access it. The surveyors could not retrieve any notes or documents as they had not been informed of this system until 3/27/25. The retrieved document from Point Click Care Connect was presented to the surveyors by Corporate Staff #2, dated 10/29/24 at 9:45 AM, which read: Called patient and gave negative biopsy results. Patient very happy with the results, patient has no signs of infection around the biopsy site. Steri strips on and precautions reviewed per protocol. Post operative Biopsy results-Unspecified lump in right breast, subareolar. Pathology from right breast twelve o'clock radius subareolar margin demonstrates benign squamous epithelium with focal acute and chronic inflammation, including giant cells, suggestive of ruptured cyst. Findings are benign. At minimum suggest a 3 month follow-up.
On 3/27/25 at approximately 7:45 p.m., the above findings were shared with the Administrator, Corporate Consultant and the Regional Vice-President of Operations. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation staff interviews and a clinical record review, the facility staff failed to establish/provide collaborative...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation staff interviews and a clinical record review, the facility staff failed to establish/provide collaborative care (Hospice) for 3 of 12 residents (Resident #7, 8, and 12), in the survey sample.
The findings included:
1. Resident #7 was originally admitted to the facility 09/17/2021 after an acute care hospital stay. The current diagnoses included advanced dementia, paranoid schizophrenia, and severe protein-calorie malnutrition.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/10/25 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired daily decision making abilities.
A physician order dated 2/12/24 stated (name of the hospice agency) to evaluate and treat. A hospice agency document dated 2/14/24 stated the resident elected hospices services 2/14/24.
A review of the resident's clinical record failed to reveal collaboration between the facility and the hospice agency in development of a plan of care between the facility and the hospice agency and evidence of the hospice agency's participation in the resident's interdisciplinary care plan meeting.
On 3/27/25 at 1:37 PM an interview was conducted with the resident's visiting hospice primary care nurse. The hospice nurse stated she does not participate in the resident care plan meetings at this facility and the facility's staff is not permitted to participate in their biweekly care planning meetings. The hospice nurse further stated she does not combine her care documents and assessments with the facility's documents because hospice documents are kept in a book at the nurse's station. She also stated the facility can call the hospice agency's office and request other documentation they would like.
A review of the resident's clinical record revealed some dates the hospice disciplines visited the resident and general forms of what they did such as assessments, case manage, wound care and refill medications, no specifics or details regarding the resident's care was documented.
An interview was conducted with the facility's Social Services Director (SSD) on 3/27/25 at approximately 5:20 PM. The SSD stated she had no documentation to support that the hospice agency participated in Resident #7's care plan conferences but she would make sure they were invited and participated going forward.
On 3/27/25 at approximately 5:30 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, and [NAME] President of Operations and Corporate Nurse Consultant. The above findings were conveyed to the administrative team, and they had no comments and voiced no concerns.
2. Resident #8 was originally admitted to the facility 03/03/2023 after an acute care hospital stay. The current diagnoses included vascular dementia and chronic gastric outlet obstruction status post PEG tube placement.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/01/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 3 out of a possible 15. This indicated Resident #8's cognitive abilities for daily decision making were severely impaired.
A physician's order dated 7/19/24 stated to consult (name of the hospice agency) to evaluate related to unspecified intestinal obstruction, unspecified as to partial versus complete obstruction.
A document completed by a hospice agency representative on 7/21/24 titled Hospice IDG comprehensive assessment and Plan of Care Update Report revealed the resident was a new admission for hospice services. The resident's record has no order to be admitted for hospice services. Otherwise there is only a progress note of a care plan meeting dated 7/24/24 which stated the resident recently entered hospice services. The participants did not include a representative from the hospice agency.
On 3/27/25 at 1:37 PM an interview was conducted with the resident's visiting hospice primary care nurse. The hospice nurse stated she does not participate in the resident care plan meetings at this facility and the facility's staff is not permitted to participate in their biweekly care planning meetings. The hospice nurse further stated she does not combine her care documents and assessments with the facility's documents because hospice documents are kept in a book at the nurse's station.
The hospice nurse also stated until recently she did not provide wound measurements to the facility because they were hospice measurements and not for the facility. The hospice nurse stated the facility's staff requested the wound assessment documents therefore they were provided by the hospice office A review of the resident's clinical record revealed some dates the hospice disciplines visited the resident and general forms of what they did such as assessments, case manage, wound care and refill medications, no specifics or details regarding the resident's care was documented.
An interview was conducted with the facility's Social Services Director (SSD) on 3/27/25 at approximately 5:20 PM. The SSD stated she had documentation to support the hospice agency participated in Resident #8's care plan conferences on 1/3/24 and 11/6/24, but the hospice agency did not participate in the care plan conferences in between 1/3/24 and 11/6/24 or the most recent care plan conference on 2/5/25.
On 3/27/25 at approximately 5:30 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, and [NAME] President of Operations and Corporate Nurse Consultant. The above findings were conveyed to the administrative team, and they had no comments and voiced no concerns.
3. The facility's staff failed to provide a Hospice Care Plan, nurses notes and other dispositions for Resident #12. Resident #12 was originally admitted to the facility 1/13/23 and readmitted [DATE] after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; End Stage Renal Disease.
The significant Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/24/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 5 out of a possible 15. This indicated Resident #12 cognitive abilities for daily decision making were severely impaired.
The person-centered care plan dated 1/27/25 read Resident #12 is on hospice relating to end of life care. The Goal for Resident #12 Patient will be comfortable and have needs meet. The interventions for Resident #12 were: Evaluate effectiveness of medications/interventions to address comfort and Respect patient and family wishes.
In Section O Special Treatments and Programs. K1= Coded resident as receiving Hospice Care.
A care plan review note dated 02/05/2025 at 2:31 PM., read:
Resident had her care plan meeting. In attendance was the SSD, MDS, and UM. Resident declined to attend. Resident is staying at the facility for LTC and has a code status of DNR.
According to the above care plan meeting note. Hospice was not in attendance.
On 3/27/25 at 1:37 PM an interview was conducted with the resident's visiting hospice primary care nurse. The hospice nurse stated she does not participate in the resident care plan meetings at this facility and the facility's staff is not permitted to participate in their biweekly care planning meetings. The hospice nurse further stated she does not combine her care documents and assessments with the facility's documents because hospice documents are kept in a book at the nurse's station. She also stated the facility can call the hospice agency's office and request other documentation they would like.
An interview was conducted with the facility's Social Services Director (SSD) on 3/27/25 at approximately 5:20 PM. The SSD stated she had no documentation to support that the hospice agency participated in Resident #12's care plan conferences, but she would make sure they were invited and participated going forward.
On 3/27/25 at approximately 7:45 p.m., the above findings were shared with the Administrator, Corporate Consultant and the Regional Vice-President of Operations. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observations and staff interviews the facility staff failed to ensure resident equipment was kept clean for 1 of 12 residents (Resident #7), in the survey sample.
The findings included:
Res...
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Based on observations and staff interviews the facility staff failed to ensure resident equipment was kept clean for 1 of 12 residents (Resident #7), in the survey sample.
The findings included:
Resident #7 was originally admitted to the facility 09/17/2021 after an acute care hospital stay. The current diagnoses included advanced dementia, paranoid schizophrenia, and severe protein-calorie malnutrition.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/10/25 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired daily decision making abilities.
The resident's person centered care plan with a revision date of 10/25/24 had a problem which stated I am at risk for falls related to cognitive impairment, poor safety awareness, and psychotropic medication use. The goal stated I will not fall and injure myself through next care plan review. The interventions included two mats left and right side of bed for safety/fall risk.
On 3/25/25 at 12:50 PM, Resident #7 was observed in a low bed with bilateral mats. The mat between the resident's bed and the roommate's bed was observed with dark stains on it as well as bread crumbs, debris and shoe prints. The fall mats were also observed on 3/26/25 with dark stains, shoe prints, debris and staff standing on the one between the two beds.
On 3/27/25 at approximately 5:30 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, and [NAME] President of Operations and Corporate Nurse Consultant. The above findings were conveyed to the administrative team. The Director of Nursing stated the mats had been removed and new ones put in place. She also stated that staff had been educated that they were not to be walked on and that the environmental services staff would be paying more attention to the fall mats for all residents with them, for they are to be cleaned and disinfected on a regular schedule and removed when they are no longer in good repair.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
Based on observations, family interview, and staff interviews, the facility staff failed to develop person-centerd care plan for a percutaneous endoscopic gastrostomy (PEG) tube for 1 of 12 residents ...
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Based on observations, family interview, and staff interviews, the facility staff failed to develop person-centerd care plan for a percutaneous endoscopic gastrostomy (PEG) tube for 1 of 12 residents (Resident #8), in the survey sample.
The findings included:
Resident #8 was originally admitted to the facility 03/03/2023 after an acute care hospital stay. The current diagnoses included vascular dementia and chronic gastric outlet obstruction status post PEG tube placement.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/01/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 3 out of a possible 15. This indicated Resident #8's cognitive abilities for daily decision making were severely impaired.
On 3/25/25 at approximately 12:43 PM during the initial tour an interview was conducted with Resident #8's daughter who was visiting. The daughter lifted the resident's top which revealed a PEG tube. The PEG's external bumper was observed to be position too far from the abdominal skin and the insertion site had leakage and presented with small red and raised irritation. The daughter removed gauze from the closet and wiped the site dry, afterwards she applied a split drain sponges around the insertion site.
A review of the resident's person centered care plan failed to have a problem secondary to the PEG tube and a review of the current physician's orders failed to reveal an order for the PEG tube, but here were orders for management of the PEG. The orders included one dated 7/15/24 to cleanse and place a dressing to the PEG tube site every day and an order dated 5/08/24 which stated PEG tube - flush with thirty milliliters of water every eight hours for patency.
On 3/27/25 at approximately 5:30 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, and [NAME] President of Operations and Corporate Nurse Consultant. The above findings were conveyed to the administrative team, and they had no comments and voiced no concerns.
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
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
2. The facility staff failed to provide showers to a dependent resident (Resident #6).
Resident #6 was originally admitted to the facility 1/9/25 after an acute care hospital stay. The resident's curr...
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2. The facility staff failed to provide showers to a dependent resident (Resident #6).
Resident #6 was originally admitted to the facility 1/9/25 after an acute care hospital stay. The resident's current diagnoses included a stroke resulting in left hemiplegia, spatial neglect of left side, left visual deficit and obstructive sleep apnea. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/15/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #6's cognitive abilities for daily decision making were moderately impaired. In section GG0130 (Self-Care) of the 1/15/25 MDS assessment the resident was coded as requiring substantial/maximal assistance with shower/bathe.
An interview was conducted with Resident #6 on 3/26/25 at approximately 2:06 PM. The resident stated he was admitted to the facility in early January, and he had received only one shower since his admission. He stated he was told that two showers were scheduled weekly for each resident. The resident further stated he believed if he showered more he would feel better. The resident also stated he was to be shaved on 3/26/25 but he assumed the staff ran out of time because they did not come back to shave him. The resident stated on 3/27/25 at 10:30 AM that CNA #3 stated she would be giving him a shower and shave later on 3/27/25.
A review of the Shower/Bathe documentation on the Documentation Survey Reports revealed no showers were provided in January 2025, one was documented on 2/4/25 and one was documented on 2/18/25 with the resident providing all care after he was set-up and the March documentation stated he received showers 3/3/25, 3/6/25, and 3/10/25. The resident identified CNA #6 as the staff member who provided him with the one shower and denied that CNA #5 had provided him with any showers. All shower/bathe entries by CNA #5 were coded the resident was dependent and a shower was provided.
On 3/27/25 at approximately 5:30 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, and [NAME] President of Operations and Corporate Nurse Consultant. The above findings were conveyed to the administrative team and they had no comments and voiced no concerns.
Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to provide hygiene care for dependent residents for 2 of 12 residents (Residents #2 and #6), in the survey sample.
The findings included:
1. The facility staff failed to remove unwanted hair from the neck and chin of Resident #2.
Resident #2 was originally admitted to the facility 12/11/24 after an acute care hospital stay. The current diagnoses included; end stage renal disease, type 2 diabetes mellitus with hyperglycemia, essential hypertension, and muscle weakness.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/18/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #2's cognitive abilities for daily decision making were intact.
On 3/25/25 at 12:45 PM an interview was conducted with Resident #2. It was observed that Resident # 2's was rubbing her fingers through a large amount of hair on her neck and chin. Resident #2 stated, I wish they would shave this hair off of my neck and chin. Resident #2 also stated, they have never asked me if I want to have this hair shaved off of my neck and chin.
On 3/27/25 at 12:05 PM an interview was conducted with Resident #2. It was observed that Resident # 2 still had a large amount of hair on her neck and chin. Resident #2 stated, I wish they would clean me up and shave me. Resident #2 also stated, I feel so dirty and just want them to clean me and shave me.
On 3/27/25 at 2:51 PM an interview was conducted with Certified Nursing Assistant (CNA) #1. CNA #1 stated, I saw the hair on her neck and chin. I will be honest with you, I did not ask her if she wanted me to shave her today and I should have. CNA #1 also stated, I should have shaved her today and I will before I leave if you want me too.
On 3/27/25 at 6:11 PM an interview was conducted with the Administrator. The Administrator stated, We will be shaving the resident.
The Care Plan with an initiated date of 12/23/24 read that Resident #2 has a physical functioning deficit related to: Mobility impairment, Self care impairment. The goal is resident will improve my current level of physical functioning. The intervention for Resident #2 was Personal Hygiene assistance of (dependent) 1 person.
In section GG (Functional Abilities) the resident was coded dependent with Personal Hygiene: the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands(excludes baths, showers, and oral hygiene).
On 3/27/25 at approximately 8:30 PM, a final interview was conducted with the Administrator, Director of Nursing, Regional Director of Clinical Services, and Regional [NAME] President of Operations. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information.
CONCERN
(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
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
Based on observations, resident interview, staff interviews, and clinical record review, the facility staff failed to provide required care to prevent complications while utilizing an indwelling cathe...
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Based on observations, resident interview, staff interviews, and clinical record review, the facility staff failed to provide required care to prevent complications while utilizing an indwelling catheter for 1 of 12 residents (Resident #4), in the survey sample.
The findings included:
Resident #4 was originally admitted to the facility 03/01/24 after an acute care hospital stay. The current diagnoses included neurogenic uropathy with urinary retention.
The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 03/09/25 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired daily decision making abilities. At section H0100 A - the resident was coded for requiring use of an indwelling catheter.
A physician order dated 3/6/24 stated Foley Catheter 16 french with a 5 milliliter balloon every shift related to urinary retention. The person centered care plan dated 9/13/24 had a problem which stated I have a Foley catheter 16 french with a 5 milliliter balloon related to a neurogenic uropathy with urinary retention. The goal stated I will not experience an infection until next review. The interventions included Position catheter below bladder, ensure tubing has no kinks, and secure for safety.
On 3/25/25 at 1:37 PM Resident #4 was observed in bed with a bedside drainage bag and yellow urine in the tubing. An interview was conducted with Resident #4 regarding the indwelling catheter. The resident pulled back her linens and revealed the upper indwelling catheter tubing. The stat lock (a device to stabilize an indwelling catheter) was observed wrapped around the catheter tubing at the point of the aspiration port. Again on 3/26/25 at 12:49 PM the resident's tubing was observed unstabilized and the stat lock was observed wrapped around the tubing.
This information was obtain from the Internet on 3/31/25 - If urinary catheters are not secured appropriately, they can lead to severe trauma of a patient's urethra, potential damage to bladder neck, infection and inflammation, pain and irritation, possible bypassing, accidental dislodging of a catheter and a cleaving (condition whereby the catheter splits the penile or labial tissues). https://pubmed.ncbi.nlm.nih.gov/24335791/
On 3/27/25 at approximately 5:30 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, and [NAME] President of Operations and Corporate Nurse Consultant. The above findings were conveyed to the administrative team, and the Director of Nursing stated her observation on 3/27/25 also revealed the catheter tubing was unsecured. The Director of Nursing further stated that the stat locks supplied by the facility were not of a good quality and the catheter was likely to become unsecured because of the adhesive on the product, therefore she authorized the central supply personnel to order a different indwelling catheter stabilizer.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
Based on observations, resident interview, and clinical record review, the facility staff failed to necessary respiratory care and services for 1 of 12 residents (Resident #6), in the survey sample.
...
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Based on observations, resident interview, and clinical record review, the facility staff failed to necessary respiratory care and services for 1 of 12 residents (Resident #6), in the survey sample.
The findings included:
Resident #6 was originally admitted to the facility 1/9/25 after an acute care hospital stay. The resident's current diagnoses included a stroke resulting in left hemiplegia, spatial neglect of left side, left visual deficit and obstructive sleep apnea. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/15/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #6's cognitive abilities for daily decision making were moderately impaired.
The physician's order summary had an order dated 1/20/25 for a C-PAP at previous home settings at bedtime for acute and chronic respiratory failure with hypercapnia and as needed.
The person centered care plan with a problem dated 1/29/25 which stated alteration in respiratory status due to sleep apnea. The goal read the resident will have adequate gas exchange as evidenced by no adventitious breath sounds, absence of respiratory distress, and absence of shortness of breath thru the next review. The interventions included monitor to ensure the C-PAP mask in place at nighttime/sleeping time.
An interview was conducted with Resident #6 on 3/26/25 at approximately 2:06 PM. The resident stated he utilized a C-PAP (a machine which keeps your airways open while you sleep). The resident stated some nights the C-PAP is not applied at all and other times it is misapplied. The resident stated that sometimes the staff applies the C-PAP while he is asleep and he is awaken by water entering his nose or splashing all over him.
The resident stated as a result of the water splashing he had to remove the mask because he was no longer capable of draining the tubing and repositioning the C-PAP mask himself. The resident stated that no one asked him why he removed the C-PAP, if they had he would explained that it was not applied appropriately to remain in place, for the water should not have been inside the tubing.
On 3/27/25 at approximately 5:30 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, and [NAME] President of Operations and Corporate Nurse Consultant. The above findings were conveyed to the administrative team and the Corporate Nurse Consultant stated they identified the resident needs to be shaved more often so they can get the good fit of the C-PAP mask.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observations and staff interview the facility staff failed to secure resident medications on 3/27/25.
The findings included:
On 3/27/25 at approximately 10:47 AM Licensed Practical Nurse (LP...
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Based on observations and staff interview the facility staff failed to secure resident medications on 3/27/25.
The findings included:
On 3/27/25 at approximately 10:47 AM Licensed Practical Nurse (LPN) #2 was observed passing medications on the 200's hall. LPN #2 went from room to room for seven rooms pulling and administering the medications. In between pulling the medication and administering it to the residents the medication cart was left unlocked making the medications accessible to unauthorized individuals.
At 11:06 AM the Administrator was observed coming onto the 200's hall with a visiting male and female to visit a resident. The Administrator observed the unattended, unlocked medication cart in the hallway and went over to it and closed the locking mechanisms without saying anything to LPN #2, who was inside a resident's room. When LPN #2 returned to the medication cart, he pulled at a medication drawer but it did not open, he looked around but said nothing. LPN #2 was observed removing the medication cart key from his pocket, unlocked the medication cart and resumed pulling medications for other residents.
On 3/27/25 at approximately 4:05 PM LPN #2 was sought for an interview but he was not located. The Director of Nursing stated he was gone for the day.
On 3/27/25 at approximately 5:30 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, and [NAME] President of Operations and Corporate Nurse Consultant. The above findings were conveyed to the administrative team, and they had no comments and voiced no concerns.
Aug 2024
12 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and facility documentation, the facility staff failed to ensure a resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and facility documentation, the facility staff failed to ensure a resident's right to a dignified existence and self-determination for 1 Resident (#21) in a survey sample of 35 Residents.
The findings included:
For Resident #21, the facility staff failed to appropriately dress the resident, supply a top sheet and blanket and respond to his request to wear something other than an incontinent brief.
Resident #21 was admitted to the facility on [DATE] with diagnoses that included but were not limited to dysphagia after stroke, Diabetes Type II, dialysis-dependent end-stage renal disease, hypertension, congestive heart failure, lack of coordination, major depressive disorder, muscle weakness (generalized) hemiplegia and hemiparesis following stroke affecting the right dominant side, contracture of the right hand and contracture of the right elbow. Resident #21's most recent MDS (Minimum Data Set), dated 7/7/24, coded Resident #21 as having a BIMS (Brief Interview of Mental Status) score of 15/15, indicating no cognitive impairment.
On 8/26/24 at approximately 7:00 p.m., the resident was heard yelling out. Resident #21's door was closed, but he could be heard yelling, Hey! Resident #21 was observed dressed only in an incontinent brief with no top sheet or blanket. He had a right elbow splint and right palm guard in place; the call bell was wrapped around the bed rail on the right side of the bed; however, upon closer look, it was disconnected from the wall. The bed was elevated to the highest position, and the foot of the bed was elevated. Resident #21 said, Hey, are you going to get me some clothes? I don't want to be here like this. I can't get nobody to help me. When asked if he had utilized the call bell, the resident said someone had come in, turned it off, and said they would be back. When asked how long that was, he said, A long time ago.
During the above observation, CNA #1 was asked if the bed was the appropriate height, and she stated that it was not the proper height for safety. When asked if the call bell should be on the right side of the bed (the stroke-affected side where the Resident has splints and a palm guard), she stated it was the Resident's choice. Resident #21 was asked where he preferred the call bell, and he said, Over here, indicating the left side of the bed (his unaffected side). When asked if the call bell should ever be left unplugged from the wall, she said it should not, and it was the only way residents could call for assistance. When asked why Resident #21's door was shut, she stated it was the resident's preference. CNA #1 asked Resident #21 how she could help him, and he replied I got no clothes on I want some clothes. Why y'all leave me here like this? CNA #1 responded that it was nighttime, and he was getting ready for bed, to which the Resident responded, I still need something on. CNA#1 was asked why the Resident did not have a top sheet and blanket CNA #1 stated she did not know and would get them.
On 8/29/24, during the end-of-day meeting, the Administrator was made aware of the concerns, but no further information was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0577
(Tag F0577)
Could have caused harm · This affected 1 resident
Based on observations and interviews, the facility staff failed to ensure the survey results book was readily accessible during the initial entrance of the facility.
The findings included:
On 8/26/24 ...
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Based on observations and interviews, the facility staff failed to ensure the survey results book was readily accessible during the initial entrance of the facility.
The findings included:
On 8/26/24 at approximately 7:05 PM., during the facility entrance of the main lobby a sign was noticed on a table in the main lobby that read Survey Book is kept in the main lobby. No Survey Book was observed.
08/26/24 at approximately, 7:09 PM., an interview was conducted with the administrator concerning the survey book whereabout. The administrator pulled the survey book from a table in his office, saying that he had the survey book since Friday (8/23/24) because he was expecting us to come in at any time to survey the facility.
The above findings were shared with the Administrator, The Director of Nursing (DON) and corporate staff on 8/28/24 at approximately 1:30 PM., during the final interview.
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, interview, and clinical record review, the facility staff failed to provide a clean, comfortable, home-lik...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and clinical record review, the facility staff failed to provide a clean, comfortable, home-like environment for 3 of the 14 Resident rooms in Hall 100.
The findings included:
For the Residents who resided in rooms [ROOM NUMBERS], the facility staff failed to make repairs to the walls by the head of the bed, where there were gouges in the drywall from the bed impacting the wall. For the Residents in rooms [ROOM NUMBERS], the facility staff failed to provide linens that were in good repair and without holes or stains.
On 8/26/24 at approximately 6:45 p.m. during the initial tour of the facility, the following observations were made:
room [ROOM NUMBER] A & B - Deep gouges in the drywall by the head of the bed were observed and had not been repaired.
room [ROOM NUMBER] A Bed - Resident asleep and the blanket was noted to have brownish colored stain at foot of bed
room [ROOM NUMBER] A Bed - Small hole in bottom sheet and no top sheet on bed.
room [ROOM NUMBER] A Bed - Large gouges in drywall near head of bed, hole in bottom sheet and no top sheet or blanket and the resident visibly lying in bed wearing a brief with no blanket or top sheet.
On 8/26/24, an interview was conducted with CNA #1, who stated that the resident was ready for bed, which is why he did not have any clothes on. When asked why the Resident did not have a top sheet and blanket, she stated she did not know and would get them.
On 8/27/24, an interview was conducted with LPN #1, who stated that repairs are put in for maintenance to complete, but if they are not reported, maintenance cannot do the repairs. When asked if she knew if the gouges in the drywall were reported, she stated that she did not. When asked if holes in the stained sheets and blankets are acceptable for Resident use, she stated that when the beds are made, the CNAs should not be using stained or torn linens; they should let the laundry know so they can remove them.
A review of the maintenance logs did not reveal any reports of damaged drywall in rooms.
On 8/28/24 during the end of day meeting the Administration was made aware of the findings and no further information was provided.
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. For Resident #21, the facility staff failed to review and revise the care plan to discontinue fall mats, including a splint a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #21, the facility staff failed to review and revise the care plan to discontinue fall mats, including a splint and palm guard for right elbow and hand contractures.
Resident #21 was admitted to the facility on [DATE] with diagnoses that included but were not limited to dysphagia after stroke, Diabetes Type II, dialysis-dependent end-stage renal disease, hypertension, congestive heart failure, lack of coordination, major depressive disorder, muscle weakness (generalized) hemiplegia and hemiparesis following stroke affecting the right dominant side, contracture of the right hand and contracture of the right elbow. Resident #21's most recent MDS (Minimum Data Set), dated 7/7/24, coded Resident #21 as having a BIMS (Brief Interview of Mental Status) score of 15/15, indicating no cognitive impairment.
On 8/26/24, at approximately 7:00 p.m., Resident #21 was observed in bed with an elbow splint to the right elbow and palm guard to the right hand in place. There were no floor mats at the bedside. On 8/27/24, the resident was out to dialysis, and no floor mats were observed in his room.
On 8/27/24, a review of the clinical record revealed the following:
FOCUS: Falls- [Resident name redacted] is at risk for falls related to poor sense of safety awareness and possible sedation due to use of psychoactive medication. Date Initiated: 09/18/2019
GOAL: [Resident name redacted] risk for falls will be minimized through next review. Date Initiated: 09/18/2019 Revision on: 05/02/2024 Target Date: 07/24/2024
INTERVENTIONS: 3/1/2023- Bilateral floor Mats Date Initiated: 03/01/2023
Assess for pain. Date Initiated: 09/18/2019 Revision on: 09/18/2019
Call light and personal items available and in easy reach. Date Initiated: 09/18/2019 Revision on: 09/18/2019
Keep environment well-lit and free of clutter. Date Initiated: 09/18/2019 Revision on: 09/18/2019
Observe for side effects of Medications. Date Initiated: 09/18/2019 Revision on: 09/18/2019
On 8/27/24 at approximately 11:45 a.m., Other Staff #1 was interviewed. She was asked if she knew whether Resident # 21 had any adaptive equipment. She stated that they were using an elbow splint and palm guard to manage his contractures. When asked about floor mats, she stated that he was not a high fall risk; he could not turn himself, so they did not use them with him. She stated that she thought they used them in the past.
On 8/27/24, at approximately 2 p.m., CNA #1 was interviewed. She was asked if Resident #21 used floor mats in his room, and she stated that he did not.
On 8/28/24 at approximately 3:00 p.m., an interview was conducted with the DON, who was asked the purpose of the care plan, and she stated that it was to outline all the resident's care needs. When asked when it should be updated, she stated quarterly and with any changes in resident care. When asked if this included discontinuing interventions that were no longer used and updating to add new interventions, she stated that it should. When asked if this should consist of splints, palm guards, and fall mats, she said that it should.
On 8/28/24, during the end-of-day meeting, the Administrator was made aware of the findings, and no further information was provided.
Based on observation, staff interview, clinical record review and facility documentation review, the facility failed to review and revise the care plan for 2 Residents (Residents #2, and #21) in a survey sample of 35 Residents.
The findings included:
1. For Resident #2, the the facility staff failed to document resident specific measurable goals, and failed to derive and implement a behavioral modification care plan for a Resident with documented brain injury and behaviors.
Resident #2 was initially admitted to the facility on [DATE], and most recently readmitted on [DATE]. Diagnoses included; hypertension, seizure disorder, dementia, depression, pulmonary embolus, and traumatic brain injury with behaviors, stroke and convulsions/movement disorders/muscle weakness. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 7-17-24. He was coded with a Brief Interview of Mental Status score of 15 indicting no cognitive impairment. He required assistance with activities of daily living care. He was unable to walk and self propelled slowly in a manual wheel chair.
The Resident was interviewed upon entrance to the facility and found to be non-verbal, with a communication deficit. He was pleasant, welcoming and smiling throughout the exchange. He used a writing pad successfully to communicate, although it was difficult for him to write and hold the pad as he he exhibited weakness in his upper extremities, and a tremor which resulted in involuntary shakiness and scribbled shaky writing, though mostly legible.
Resident #2 had current physician's orders for the following;
Seroquel 25 milligrams (mg) once per day at 9:00 PM
Depakote 250 mg once per day at 9:00 PM
Depakote 500 mg once per day at 9:00 PM
Aricept 10 mg once per day at 9:00 PM
The Resident's care plan was reviewed and revealed Focus statements and interventions as follows;
FOCUS:
Swung at another Resident after being hit by wheel chair (3-15-2019).
Resident continues to have outbursts with other Residents (11-16-2019), (11-18-2019).
(name) and his room mate had an angry episode over the doorway being blocked by a wheel chair.
Another (female) Resident thought (Resident #2) was her husband and followed and yelled at him. He tried to get away from her. He did not hit her. He had an altercation with another resident over a woman. Resident to Resident verbal altercation (date unknown) (6-17-19?) per interventions in the careplan dates.
INTERVENTION:
Encourage Resident to not hit other residents, when another Resident is agitated with me remove me from the situation, offer something I like as a diversion 4-17-19.
Resident will not talk with the other Resident, and will stay away from the woman in the incident 6-17-19.
If I don't like what I'm doing let me choose something else, if I'm upset please redirect the conversation or task.
New focuses were not care planned for 2020 through 2023, however interventions were added. Those follow below; please avoid things that make me more anxious 8-16-22.
One to one observation 2-27-23.
Velcro stop sign across Residents door per his request 5-15-23.
Medication review, psyche referral, and one to one observation 8-3-23.
two to one staff observation 11-7-23.
On 2-27-23 the psychiatric evaluation was completed by a physician and notes from the physician revealed that the Resident did remember the altercations and felt justified in his self preservation. The doctor further documented that the Resident seemed unconcerned that striking out at a demented person was morally wrong, and that the psychotherapeutic techniques used were attempts to alleviate the emotional disturbances, and attempts to reverse or change maladaptive patterns of behavior. The session lasted 23 minutes. There was no behavior management program ever instituted for this Resident. Interventions for the Resident were not defined nor measurable, and not Resident specific. The Psychiatric evaluation entered into the care plan on 8-3-23 was never obtained.
FOCUS:
Resident to resident (2-15-2024)
Resident attempted to yell and point at another resident during bingo (3-20-24)
Resident to Resident altercation (4-13-24)
Resident to Resident altercation when a wandering female with dementia was in his room. (progress notes 6-18-24).
INTERVENTIONS:
One on one observation for 5 days 2-16-24.
Resident will sit away from other residents during activities 3-20-24.
Observe for triggers for physically abusive episodes and intervene at first sign of trigger(s) 4-15-24. No triggers were defined. Redirect resident and remove from area to provide calm 4-15-24.
The behaviors follow a pattern of other residents entering his space or blocking his escape. There appears no evaluation of the Resident's behaviors with regard to his specific triggers, and fears. The Resident has known depression and a brain injury, and supervision of other residents with dementia entering his space and or his desire to protect himself, reveals a potential fear for his well being.
Progress notes and the care plan document refusing care, refusing therapy, refusing weights being taken, non-compliance with staff, and refusing skin assessments, which is his right, and staff convenience is not a reason for a behavioral care plan. The care plan documents cursing at staff, however, since the Resident only speaks in a whisper or has to write it on a pad of paper, cursing at staff should not impact others around him. There was an addition to the careplan on Focus which stated that this cursing behavior is not his usual.
The entire clinical record was reviewed and no documentation was found that a Registered Pharmacist (RPH) had completed the required monthly Medication Regimen Review (MRR) form for Resident #2, who was administered Psychotropic medications with a diagnosis of dementia.
The Director of Nursing (DON) was interviewed by surveyors in the conference room and asked to provide the missing documents. The DON stated that she had some in a binder in her office which were not available to staff in her absence. She further stated that she was a new employee who started November of 2023. She went on to state that the MRR reviews had not yet been scanned into the Resident's electronic healthcare clinical record.
The binder was reviewed and no MRR records for 2024 could be found for this Resident. No recommendations for gradual dose reductions for Psychotropic medications were made. Further no evaluations nor recommendations regarding a Resident with dementia being administered psychotropic medications were made, and no Laboratory blood tests were recommended by the RPH.
On 8-28-24 at 4:00 PM during a meeting with the Administrator and DON they were informed of the failure to adequately care plan the Resident's documented behaviors, and the failure of medication oversight by a Registered Pharmacist for dementia with behaviors while taking psychotropic medications. On 8-29-24 at the time of exit they stated they had no further documents to provide.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review, and review of facility documents, The facility staff faile...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review, and review of facility documents, The facility staff failed to follow a physician's order to ensure two resident received physician ordered medications for two (2) of 35 residents (Resident #38, #21), in the survey sample.
The findings included:
1. Resident #38 was originally admitted to the facility on [DATE] after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Essential (Primary) Hypertension.
The quarterly revised Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 7/13/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #38 cognitive abilities for daily decision making were intact.
In sectionGG(Functional Abilities and Goals) the resident was coded as being independent with eating, dependent with personal hygiene, showers/bathing, dressing, and toileting.
In Section GG (Mobility) the resident was coded as requiring partial/moderate assistance with toilet transfers.
The May 2024 Physician's Order Summary read: Senna S Oral Tablet 8.6-50 MG (Sennosides-Docusate Sodium) Give 2 tablet by mouth every 24 hours as needed for constipation.
According to the Medication Administration Record (MAR) Resident #38 received her prescribed Docusate Sodium Capsule 100 MG one time a day for constipation every day at 9:00 AM.
According to the August 2024 Medication Administration Record (MAR), no prn Senna was administered.
On 08/27/24 at approximately 12:56 PM., during the initial tour Resident #38 said that she has not had a bowel movement in a week. Resident #38 also said that she's had issues with her bowel movements for 30 years.
A review of Bowel Elimination Report showed that Resident #38 had a large Bowel Movement (BM) on 8/21/24 at 6:51 PM.
According to the Bowel Elimination Report, Resident #38 had a medium BM on 8/27/24 at 2:59 PM.
A review of the above Bowel elimination report show that Resident #38 had not had a BM in 6 days.
On 08/28/24 at approximately 10:43 AM., an interview was conducted with Licensed Practical Nurse (LPN) #4 concerning Resident #38. LPN #4 said that there's usually a dashboard that will alert nursing if a resident hasn't had a Bowel Movement (BM) in 3 days but they did not receive an alert. LPN #4 also said that 3 days of having no BM is the facility cut off time. LPN #4 also mentioned the resident would be given an as needed (prn) medication or if there's no prn order, the physician should be notified.
On 08/29/24 at approximately 10:00 AM., an interview was conducted with Certified Nursing Assistant (CNA) #4. CNA #4 said that the facility has a tracking system that will notify nursing if a resident hasn't had a BM in 3 days. CNA #4 also mentioned that she would have alerted the nurse if she was aware that a resident hadn't had a BM in 3 days.
The above findings were shared during the Pre-exit, with the Administrator, The Director of Nursing (DON) and corporate staff on 8/29/24 at approximately 1:30 PM., The DON said they (nurses) should have been notified and checked the dashboard and called the physician for an as needed (prn) medication if not available.2. For Resident #21, the facility staff failed to give the ordered medication, gabapentin.
On 8/27/24, a review of the clinical record revealed that Resident #21 had an order that read:
Gabapentin Oral Capsule 100 MG - Give 100 mg by mouth one time a day for Neuropathy-Order Date- 08/26/2024
On 8/29/24 at approximately 1 p.m., a review of the EMAR (Electronic Medication Administration Record) revealed that the gabapentin ordered on 8/26/24 was not given on 8/27, 8/28, and 8/29/24. The EMAR was coded as #7, which meant see nurse's notes. The nurse's notes reflected that the medication was unavailable on order from the pharmacy, causing the Resident to miss three doses. A review of the stat box contents revealed that gabapentin was available in the 100 mg capsule form in the stat box.
On 8/29/24, an interview was conducted with the ADON, who stated that when nurses get an order, they are to check the stat box for availability if the medication is not in the Residents' drawer. When asked if gabapentin is available in the stat box but nurses write unavailable, what would that signify? She stated that it signified they did not check the stat box.
On 8/29/24, during the end-of-day meeting, the Administrator was made aware of the findings, and no further information was provided.
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 interview, clinical record review and facility documentation the facility staff failed to provide necessary services to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review and facility documentation the facility staff failed to provide necessary services to maintain good grooming and personal hygiene for 1 Resident in a survey sample of 35 Residents.
The findings included:
For Resident #21 the facility staff failed to provide 2 showers per week for Resident who is unable to provide self-care.
Resident #21 was admitted to the facility on [DATE] with diagnoses that included but were not limited to dysphagia after stroke, Diabetes Type II, dialysis-dependent end-stage renal disease, hypertension, congestive heart failure, lack of coordination, major depressive disorder, muscle weakness (generalized) hemiplegia and hemiparesis following stroke affecting the right dominant side, contracture of the right hand and contracture of the right elbow. Resident #21's most recent MDS (Minimum Data Set), dated 7/7/24, coded Resident #21 as having a BIMS (Brief Interview of Mental Status) score of 15/15, indicating no cognitive impairment.
On the morning of 8/28/24, Resident #21 was observed in the room. He had finished his breakfast tray and was still in the room. Resident #21 had a strong body odor present. Resident #21 was asked about his showers he stated that he did not like getting showers late at night. When asked if he sometimes refuses showers, he said yes; if it's late and he is already in bed, he will refuse. When asked if he was offered showers at a different time, he said he was not.
Reviewing the bathing schedule revealed that Resident #21's bath days were Mon. and Thurs on the 3-11 shift. A review of the POC (Point of Care) documentation in the electronic health record revealed that Resident #21's baths were coded as follows:
8/01/24 - 01, 1 (01 means Resident is dependent, and 1 means Shower given) at 9:08 pm
8/05/24 - NA at 11:46 p.m.
8/08/24 - 02, 03 (02 means max assist, 03 means bed bath) 5:52 p.m.
8/12/24 - NA at 11:59 p.m.
8/15/24 - 03, 03 (03 means partial or mod assist, and 03 means bed bath) at 4:42 p.m.
8/19/24 - NA at 11:44 p.m.
8/22/24 - 01, 1 (01 means Resident is dependent, and 1 means Shower given) at 7:23 p.m.
8/26/24 - NA at 10:59 p.m.
On the afternoon of 8/27/24, an interview was conducted with LPN #1, who was asked how many showers residents receive each week. She stated that Residents are scheduled for two showers a week but can have more if requested. When asked if they could switch shower days and times, she said they could if requested. When asked what should happen when a Resident refuses a shower, she stated they should be offered another time or a bed bath. When asked what NA means in the POC documentation, she said she was unsure. When asked if there is a code for resident refusal in the POC documentation, she stated that RR is resident refused.
On 8/29/24, during the end-of-day meeting, the Administrator was made aware of the findings, and no further information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 8/27/24 during clinical record review it was discovered that Resident #49 had no record of pharmacy medication regimen rev...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 8/27/24 during clinical record review it was discovered that Resident #49 had no record of pharmacy medication regimen review since 4/2023 available in the electronic health record.
On 8/27/24 at approximately 4 p.m. the DON was asked about the pharmacy review and recommendations, and she stated they are in a book in my office. The DON then produced the book that contained the pharmacy review and recommendations for 2024.
The DON was asked if she was aware of any irregularities noted by the pharmacist during their review and if so, could she show documentation of it being acted on by facility physician. The DON opened the book pulled a pharmacy recommendation out for Resident #49 and showed where it had been signed off by the physician and showed where the order had been changed in the EMAR (Electronic Medication Administration Record) however the document was kept in the book not scanned into the electronic health record.
On 8/28/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.
Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed for two residents (Residents #2, and #49) to ensure pharmacy recommendations were obtained and acted upon, in the survey sample of 35 Residents.
The findings included:
1. For Resident #2, the pharmacist recommendations were not obtained, nor acted upon, and not in the clinical record, in the preceding 8 months of 2024.
Resident #2 was initially admitted to the facility on [DATE], and most recently readmitted on [DATE]. Diagnoses included; hypertension, seizure disorder, dementia, depression, pulmonary embolus, and traumatic brain injury with behaviors, stroke and convulsions/movement disorders/muscle weakness. The most recent Minimum Data Set assessment was a quarterly assessment with an assessment reference date of 7-17-24. He was coded with a Brief Interview of Mental Status score of 15 indicting no cognitive impairment. He required assistance with activities of daily living care. He was unable to walk and self propelled slowly in a manual wheel chair.
The Resident was interviewed upon entrance to the facility and found to be non-verbal, with a communication deficit. He was pleasant, welcoming and smiling throughout the exchange. He used a writing pad successfully to communicate, although it was difficult for him to write and hold the pad as he he exhibited weakness in his upper extremities, and a tremor which resulted in involuntary shakiness and scribbled shaky writing, though mostly legible.
Resident #2 had current physician's orders for the following:
Seroquel 25 milligrams (mg) once per day at 9:00 PM
Depakote 250 mg once per day at 9:00 PM
Depakote 500 mg once per day at 9:00 PM
Aricept 10 mg once per day at 9:00 PM
The Resident's care plan was reviewed and revealed Focus statements and interventions as follows:
FOCUS:
Swung at another Resident after being hit by wheel chair (3-15-2019).
Resident continues to have outbursts with other Residents (11-16-2019), (11-18-2019).
(name) and his room mate had an angry episode over the doorway being blocked by a wheel chair.
Another (female) Resident thought (Resident #2) was her husband and followed and yelled at him. He tried to get away from her. He did not hit her. He had an altercation with another resident over a woman. Resident to Resident verbal altercation (date unknown) (6-17-19?) per interventions in the careplan dates.
INTERVENTION:
Encourage Resident to not hit other residents, when another Resident is agitated with me remove me from the situation, offer something I like as a diversion 4-17-19.
Resident will not talk with the other Resident, and will stay away from the woman in the incident 6-17-19.
If I don't like what I'm doing let me choose something else, if I'm upset please redirect the conversation or task.
New focuses were not care planned for 2020 through 2023, however interventions were added. Those follow below:
Please avoid things that make me more anxious 8-16-22.
One to one observation 2-27-23.
Velcro stop sign across Residents door per his request 5-15-23.
Medication review, psyche referral, and one to one observation 8-3-23.
two to one staff observation 11-7-23.
On 2-27-23 the psychiatric evaluation was completed by a physician and notes from the physician revealed that the Resident did remember the altercations and felt justified in his self preservation. The doctor further documented that the Resident seemed unconcerned that striking out at a demented person was morally wrong, and that the psychotherapeutic techniques used were attempts to alleviate the emotional disturbances, and attempts to reverse or change maladaptive patterns of behavior. The session lasted 23 minutes. There was no behavior management program ever instituted for this Resident. Interventions for the Resident were not defined nor measurable, and not Resident specific. The Psychiatric evaluation entered into the care plan on 8-3-23 was never obtained.
FOCUS:
Resident to resident (2-15-2024)
Resident attempted to yell and point at another resident during bingo (3-20-24)
Resident to Resident altercation (4-13-24)
Resident to Resident altercation when a wandering female with dementia was in his room. (progress notes 6-18-24).
INTERVENTIONS:
One on one observation for 5 days 2-16-24.
Resident will sit away from other residents during activities 3-20-24.
Observe for triggers for physically abusive episodes and intervene at first sign of trigger(s) 4-15-24. No triggers were defined. Redirect resident and remove from area to provide calm 4-15-24.
The behaviors follow a pattern of other residents entering his space or blocking his escape. There appears no evaluation of the Resident's behaviors with regard to his specific triggers, and fears. The Resident has known depression and a brain injury, and supervision of other residents with dementia entering his space and or his desire to protect himself, reveals a potential fear for his well being.
Progress notes and the care plan document refusing care, refusing therapy, refusing weights being taken, non-compliance with staff, and refusing skin assessments, which is his right, and staff convenience is not a reason for a behavioral care plan. The care plan documents cursing at staff, however, since the Resident only speaks in a whisper or has to write it on a pad of paper, cursing at staff should not impact others around him. There was an addition to the careplan on Focus which stated that this cursing behavior is not his usual.
The entire clinical record was reviewed and no documentation was found that a Registered Pharmacist (RPH) had completed the required monthly Medication Regimen Review (MRR) form for Resident #2 who was receiving psychotropic medications.
The Director of Nursing (DON) was interviewed by surveyors in the conference room and asked to provide the missing documents. The DON stated that she had some in a binder in her office which were not available to staff in her absence. She further stated that she was a new employee who started November of 2023. She went on to state that the MRR reviews had not yet been scanned into the Resident's electronic healthcare clinical record.
The binder was reviewed and no MRR records for 2024 could be found for this Resident. No recommendations for gradual dose reductions for Psychotropic medications were made. Further no evaluations nor recommendations regarding a Resident with dementia being administered psychotropic medications were made, and no Laboratory blood tests were recommended.
The facility policy was reviewed and stated in the document that the MRR's would be completed at least monthly and placed in the Resident's clinical chart. They would be available in an easily retrievable format to nurses, physician's, and the care planning team within 48 hours of MRR completion for review. The recommendations and findings will be documented and acted upon by the nursing care center and/or physician.
On 8-28-24 at 4:00 PM during a meeting with the Administrator and DON they were informed of the missing MRR documents. On 8-29-24 at the time of exit they stated they had no further documents to provide.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interviews, clinical record review, and facility documentation, the facility staff failed to ensure they were free ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interviews, clinical record review, and facility documentation, the facility staff failed to ensure they were free from unnecessary psychotropic medications for 1 Resident (#49) in a survey sample of 35 Residents.
The findings included:
For Resident # 49, the facility staff failed to ensure that the PRN (as needed) anti-anxiety drug Lorazepam was no more than 14 days duration without proper documentation.
Resident # was admitted to the facility on [DATE] with diagnoses that included but were not limited to dementia, without behavioral disturbance, psychotic disturbance and anxiety, acute kidney failure, generalized anxiety disorder, unspecified dementia with severe agitation, Alzheimer's disease with late onset, prediabetes and history of falls.
On 8/26/24, a review of the clinical record revealed that on 5/3/24, Resident # 49 received an order for Lorazepam (Ativan) 0.5 mg PO tabs, to be taken one tablet every 6 hours as needed for anxiety. There was no stop date for this order. A review of the MAR (Medication Administration Record) revealed the medication was utilized on 5/12, 6/5, and 6/12/24, and the order was current as of 8/27/24.
On 8/27/24, during the end-of-day meeting, the DON was asked if she was aware of any regulations regarding PRN psychotropic medications. She stated that there were, and psychotropic drugs are limited to 14 days unless the physician provides proper documentation as to the specific diagnosis and duration of treatment. The DON was unable to provide the supporting documentation.
On 8/27/24, during the end-of-day meeting, the Administrator was made aware of the concerns, but no further information was provided.
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 inspection of medications on one medication cart and the facility's Stat box, facility staff failed to ensure medications for resident administraton were not expired.
The findings included:
1...
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Based on inspection of medications on one medication cart and the facility's Stat box, facility staff failed to ensure medications for resident administraton were not expired.
The findings included:
1. A medication cart audit was conducted on 8/29/24 at approximately 11:57 AM., with Licensed Practical Nurse (LPN) #5. Stored inside the medication cart was 1 opened Humalog insulin pen with no open date, 1 opened Lantus insulin pen with no open date and 1 opened vial of mixed Humalog insulin with no resident name/identification. LPN #5 said that the dates should be written on the insulin pens because they expire in 28 days and that a name should be written on the vial.
The above findings were shared during the Pre-exit with the Administrator, the Director of Nursing (DON) and corporate staff on 8/29/24 at approximately 1:30 PM. The DON said that drugs and biologicals should be labeled with a date and resident name.
2. For the facility, the facility staff failed to ensure that all medications available for use in the Stat box were not expired.
On 8/27/24, a review of the stat box contents revealed that the facility had five (5) tablets of Lorazepam 0.5 mg (milligrams) on-site and available for use that expired on 4/2024.
On 8/27/24, an interview was conducted with LPN #2, who stated that the pharmacy changed the stat box regularly. When asked if the pharmacy is responsible for keeping up with expired medications, she noted that the pharmacy usually knows when they have sent the stat box out and when it should be changed, but it is up to the nurses to check it. When asked when this was usually done, she said it was on the night shift. When asked to look at the Lorazepam expiration date, she said it expired four (4) months ago.
On 8/28/24 at approximately p.m., an interview was conducted with the DON, who was asked who should be checking for three (3) expired medications, and she stated it is the responsibility of all the nurses who pass medications to check for expiration dates when passing meds or counting meds. She noted the pharmacy regularly changes out the box, but this does not negate the nurses' duty to check for expired medications and report to the pharmacy any medications needing replacement.
On 8/28/24, during the end-of-day meeting, the Administrator was made aware of the findings, and no further 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 and staff interview the facility staff failed to maintain a clean and sanitary food preparation area in accordance with professional standards for food service safety.
The finding...
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Based on observation and staff interview the facility staff failed to maintain a clean and sanitary food preparation area in accordance with professional standards for food service safety.
The findings included;
On 8-26-24 at approximately 6:40 PM, the kitchen area of the facility was inspected with the dining services manager. A metal drawer was observed under a long counter where food prep was conducted on the back wall of the kitchen. The drawer did not close under the counter, and was rusty, off of the track, and littered with food debris which could not be removed by simply wiping, as the debris was adhered with a sticky greasy substance.
The inspection observations continued in the walk in freezer, dry storage room, and refrigerator. The dry storage food room contained canned goods, pasta, boxed goods, bagged cereals, and pantry storage of shelf stable items. Three large rolling bins of flour, sugar, and rice were observed open, which were dirty with a dried film on them and presumably a white food debris substance in the crevices of the sliding tops. The floor had food debris and a black sticky substances around the base boards and in the corners of the room. Mouse droppings (excrement) were on the floor of the room close to a mouse trap with a dead mouse in it. Behind the main door into the room was a Sticky trap which captures everything crawling across it, and the insect or animal would be trapped in the glue covered top to die as they are unable to escape. The sticky trap was covered in insect and spider carcasses, some of which were dried and dessicated, indicating the trap had been in place for a substantial amount of time. A black mildew substance was found covering the backside of a closet door in the dry storage room, and empty cardboard boxes, a broken shelf, and more food debris on the floor was found within the closet.
The Dining Services Manager stated that they would begin to clean the kitchen immediately, and that she had forgotten to ask anyone to take care of the mouse trap, and stated Yes there was a problem with mice I will admit, and so the maintenance director was unaware of the situation.
On 8-27-24 the Regional manager and Dining Services Manager were made aware of the issues, and had no further information to provide. On 8-29-24 prior to exit, the same sticky trap full of insects remained as unchanged in it's location behind the door of the dry food storage room, the mouse droppings were gone, however, either the same mouse trap, or an identical one was in the same location also.
No further information was provided.
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 and interview, the facility staff failed to implement an effective pest control program affecting dining services and as a result the facility as a whole.
The findings included:
F...
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Based on observation and interview, the facility staff failed to implement an effective pest control program affecting dining services and as a result the facility as a whole.
The findings included:
For the Residents of the facility the facility staff failed to ensure the facility was free of pests to include mice.
On 8-26-24 at approximately 6:40 PM, the kitchen area of the facility was inspected with the dining services manager.
The inspection observations continued in the dry storage room of the kitchen which contained canned goods, pasta, boxed goods, bagged cereals, and general pantry storage of shelf stable items. Three large rolling bins of flour, sugar, and rice were observed open, which were dirty with a dried film on them and presumably a white food debris substance in the crevices of the sliding tops. The floor had food debris and a black sticky substances around the base boards and in the corners of the room. Mouse droppings (excrement) were on the floor of the room close to a mouse trap with a dead mouse in it. Behind the main door into the room was a Sticky trap which captures everything crawling across it, and the insect or animal would be trapped in the glue covered top to die as they are unable to escape. The sticky trap was covered in insect and spider carcasses, some of which were dried and dessicated, indicating the trap had been in place for a substantial amount of time. A black mildew substance was found covering the backside of a closet door in the dry storage room, and empty cardboard boxes, a broken shelf, and more food debris on the floor was found within the closet.
The Dining Services Manager stated that they would begin to clean the kitchen immediately, and that she had forgotten to ask anyone to take care of the mouse trap, and stated Yes there was a problem with mice I will admit, and so the maintenance director was unaware of the situation.
On 8-27-24 the Regional manager and Dining Services Manager were made aware of the issues, and had no further information to provide. On 8-29-24 prior to exit, the same sticky trap full of insects remained as unchanged in it's location behind the door of the dry food storage room, the mouse droppings were gone, however, either the same mouse trap, or an identical one was in the same location also.
No further information was provided.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected most or all residents
Based on staff interviews and review of facility documents, the facility staff failed to ensure that twelve hours of in-service education/training within twelve months was completed by five of five sa...
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Based on staff interviews and review of facility documents, the facility staff failed to ensure that twelve hours of in-service education/training within twelve months was completed by five of five sampled Certified Nurse Aides (CNA) #7, 6, 3, 8 and 9.
The findings included:
A review of the five CNA training transcripts and education records revealed that they had not completed the mandatory 12- hours of in-service education/training including dementia management and resident abuse prevention training.
An interview was conducted with CNA #7 on 8/28/24 at 10:05 AM. CNA #7 stated she did not recall if she had completed twelve hours of in-service training to include working with residents with dementia and resident abuse prevention training. An interview was also conducted with CNA #3 on 8/28/24 at 10:17 AM. CNA #3 stated she could not remember if she had received twelve hours of training within the last year.
On 8/28/24 at 11:24 AM, an interview was conducted with the Director of Nursing (DON) regarding CNAs mandatory training. The DON stated that training and education were areas they had not focused a lot of attention on, but there was an ongoing plan for all CNAs to become compliant with mandatory training.
On 8/29/24 at approximately 2:00 PM, a final interview was conducted with the Administrator, DON and two Corporate Consultants. They had no comments and voiced no concerns regarding the above findings.
Apr 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based staff interviews, clinical record and facility documentation, the facility staff failed to notify the physician and Reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based staff interviews, clinical record and facility documentation, the facility staff failed to notify the physician and Resident Representative of a change in condition for one resident (Resident #6) and a change in psychiatric medications for one resident (Resident #2) in the survey sample of six residents.
The findings included:
1. The facility staff failed to notify Resident #6's physician and Resident Representative of a change in condition, blood in Foley (Brand name of indwelling urinary catheter) tubing, and no urine output for an entire shift.
Resident #6 was admitted to the nursing facility on 02/24/23. The Minimum Data Set (MDS - an assessment protocol) an admission Assessment with an Assessment Reference Date (ARD) of 03/03/23 coded Resident #06 with a 08 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating moderate impaired cognitive skills for daily decision-making. Diagnosis for Resident #6 included but are not limited to urinary retention, hydronephrosis with ureteral stricture, and obstructive and reflux uropathy.
In section G (Physical functioning) the MDS coded Resident #6 requiring total dependence of one with bathing, extensive assistance of two with bed mobility, transfer, and toilet use, extensive assistance of one with dressing and personal hygiene, and supervisor with eating for Activities of Daily Living (ADL) care. Under section H (Bladder and Bowel) was coded for the use of an Indwelling Foley catheter.
A phone interview was conducted with License Practical Nurse (LPN) #1 on 04/26/23 at 11:33 a.m. She stated when she arrived to work on the 04/07/23 (7p-7a) shift, the off-going nurse, LPN #2 reported Resident #6 had a decline in condition. She stated the nurse reported Resident #6 had not eaten for the day and had no urine output. She stated she immediately did an assessment on Resident #6, completed a change in condition form, and notified the physician of the assessment. She stated the physician gave new orders to start an IV, apply oxygen and obtain blood work (labs.) She stated the IV and oxygen were started immediately but the labs were not drawn at that time. She stated she attempted to contact the Responsible Representative (RR), but they were not available, so the emergency contact person from Resident #6's profile page was notified. She stated the emergency contact person informed her that no one from the facility had notified the RR or himself that Resident #6 had a change in condition prior to her calling.
An interview was conducted with Certified Nursing Assistant (CNA) #1 on 04/26/23 at 11:20 a.m. The CNA was assigned to Resident #6 on the 04/07/23 (7a-3p) shift. She stated she informed LPN #1 that Resident #6 had blood in his Foley catheter tubing. The Certified Nursing Assistant (CNA) stated LPN #2 flushed the Foley catheter with no more blood in the Foley tubing or bag.
A phone call was placed to CNA#3 on 04/26/23 at approximately 3:22 p.m. The CNA was assigned to the 04/07/23 (11-7) shift. A message was left, but the CNA never returned the call.
On 04/27/23 at 9:55 a.m., a phone call was placed to LPN #4. The LPN was assigned to Resident #6 on the 04/06/23 (11-7) shift. Unable to leave a message due to a recording that stated the describer you have dialed is no longer in service.
A phone call was placed to CNA #4 on 04/26/23 at approximately 10:44 a.m. The CNA was assigned to the 04/06/23 (11-7) shift. A message was left, but the CNA never returned the call.
A review of Resident #6's clinical record did not include the resident's RR or emergency contact was informed the resident had not eaten, observed with blood in his Foley catheter tubing and without urine output for a complete shift.
An interview was conducted with the Assistant Director of Nursing (ADON) on 04/27/23. The ADON stated after reviewing Resident #6's clinical record did not indicate the resident had a change in condition. He (ADON) stated if the resident had blood in his Foley tubing/catheter and not having urine output for a shift, the nurse should complete an assessment, and notify the MD and RR of those changes. The ADON stated that having blood in a resident's urine and not having a urine output is a change in condition that required notification.
On 04/27/23 at 4:47 p.m., the Administrator, Director of Nursing, Assistant Director of Nursing, and [NAME] President of Operations were informed of the above findings. No further information was provided prior to exit.
The facility's policy titled Reporting Change in Condition: Power of Attorney (POA), Responsible party (RP), or Emergency Contact revised on 01/2020. It is the facility's policy to report changes in condition to the correct party per HIPPA guidance.
2. The facility staff failed to notify the Resident Representative (RR) that Resident #2's psychiatric medications were changed on 3/30/22.
Resident #2 was originally admitted to the facility on [DATE] and was last discharged from the facility to a local hospital on 5/31/22 and returned on 6/5/22. Resident #2's diagnoses included Alzheimer's disease, hyperlipidemia, hypertension, and an anxiety disorder.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/16/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 4 out of a possible 15. This indicated Resident #2's cognitive abilities for daily decision-making were severely impaired. In section G (Physical functioning) the resident was coded as requiring total care of two people with bathing, extensive assistance of two people with bed mobility, transfers, personal hygiene, dressing, and toileting, and supervision of one person with locomotion and eating and walking once or twice a week with set-up.
A face-to-face interview was conducted with Resident #2's RR on 4/25/23 at 1:40 p.m. The RR stated when the resident was admitted to the facility her medications were working well for her and she was not hallucinating, and her anxiety was minimal. She stated the primary Nurse Practitioner (NP) took her off Seroquel and some other medications and added other medications and changed dosages because she felt like the resident did not need them. The Resident Representative stated the resident was doing well because she was on the right medications at that time, and she was supposed to be notified of medication changes and she was not.
On 3/30/22 Resident #2's psychiatric medications were evaluated by a psychiatric Nurse Practitioner. The review revealed the resident's psychiatric medications at admission were, Risperidone 0.25 mg at (hour of sleep) HS for a sleep disorder (per PCP), Quetiapine 25 mg at HS for a sleep disorder (per PCP), Duloxetine 30 mg every morning for a major depressive disorder and Clonazepam 1 mg two times daily for an anxiety disorder.
The following recommendations were made and instituted; DAY 1: discontinue Risperidone (appears to be most recently added), DAY 7: REDUCE Quetiapine to 12.5 mg at HS x 7 days, DAY 14: DISCONTINUE Quetiapine. The Clonazepam will be re-evaluated for a gradual dose reduction later. There was no documentation in the record which stated the medication changes were reported to the resident's daughter but there was documentation a message was left for the daughter prior to the changes.
On 4/4/22 at 10:29 a.m., the primary NP met with the resident's daughter because the resident was experiencing confusion, insomnia, and depression and the daughter was concerned about her being more fatigued than usual. A medication review was conducted with the daughter. The conclusion of the review was depending on the urine results the resident may benefit from Buspar for anxiety due to age and side effects which were discussed with the daughter, but the primary NP felt the resident's biggest problem was boredom. The certified nursing assistant (CNA) stated the resident gets up and participates a good amount and they would continue to encourage her to leave her room.
On 4/27/23 at approximately 1:30 p.m., the above allegations were shared with the Administrator, Director of Nursing, and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided, and no concerns were voiced.
May 2021
36 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, facility documentation review and clinical record review the facility staff failed to e...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, facility documentation review and clinical record review the facility staff failed to ensure 3 residents (Resident #43, #17, #7) of 34 residents in the survey sample, received care to prevent pressure ulcers from developing prior to an advanced stage which constitutes harm; facility staff failed to do initial and weekly assessments for 1 of 34 residents in the survey sample, Resident #19 and facility staff failed to provide pressure ulcer care as ordered by the physician for 1 of 34 residents in the survey sample, Resident #346.
The findings included:
1. For Resident #43, the facility staff failed to prevent pressure ulcer on the sacrum from developing to an advanced stage which constitutes harm.
Resident #43 was initially admitted to the facility on [DATE]. Resident #43 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnosis included but were not limited to, Unspecified Fracture of Left Femur and Depression. Resident #43's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 04/12/2021 was not coded with a BIMS (Brief Interview for Mental Status) score. The Minimum Data Set coded Resident #43 as requiring extensive assistance of 1 for eating, extensive assistance of 2 for bed mobility, transfer and toilet use and total dependence of 2 for dressing, personal hygiene and bathing.
On 5/04/2021 review of Resident #43's clinical record revealed the following:
Review of Progress Notes for Resident #43 revealed General Note dated 5/01/2021 time 19:34 which read as follows: Note Text: This nurse noticed two open areas on Resident #43's bottom. AN open are on the coccyx bone and one on the right butt cheek. Notified MD (Medical Doctor) (Other #2) N. O. (New Order) to apply barrier cream and see wound doctor. This nurse made RP (Responsible Party) aware.
Review of Progress Notes for Resident #43 revealed Weekly Skin Review dated 5/3/2021 time 15:17 which read as follows: Weekly Skin Review Info (Information): Sacrum - Pressure: Length = 1.5 cm (Centimeter), Width = 2.5 cm, Depth = 0, - Stage Unstageable Healed? No Drainage? No drainage . No tunneling or undermining. Barrier cream. No complaints/evidence of pain r/t (Related To) pressure area The wound has no change. Unable to evidence any previous Weekly Skin Reviews since Resident #43's readmission to facility on 4/8/2021.
Resident #43's Pressure Injury Weekly Measurement (rev) - V 4 dated 5/3/2021 time 15:17 was reviewed and revealed the following: A. Pressure Injury 2b. Location of Pressure Injury Site 53) Sacrum Type Pressure Length 1.5 cm Width 2.5 cm Depth 0 Stage Unstageable. (There is a definition for Unstageable on the form that reads as follows: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and /or eschar (tan, brown or black) in the wound bed.) 6. TX. (Treatment) barrier cream.
Resident #43's Initial Non - Decubitus Skin Injury Record dated 5/3/2021 time 15:21 was reviewed and revealed the following: A. 1. Date first observed: 5/2/2021 2. Date Physician notified: 5/2/2021 3. Description of site/location r (Right) gluteal 4. Describe type of skin condition popped blister 5. Size in CM (Length x Width x Depth) 2.0 cm x 2.5 cm x 0.1 cm 6. Drainage: No 7. Odor 0 8. Color: red
Review of Clinical Physician Orders on 05/04/2021 did not evidence an order for barrier cream.
On 05/05/2021 review of Weekly Skin Integrity Check dated 5/4/2021 time 17:01 for Resident #43 revealed the following: 1. Weekly Skin Integrity Checks 1. Skin clear, no change of condition assessed. 2. New wound/change of condition noted. See skin/Condition Assessment Form, for initial/ongoing documentation of assessed Wound or Skin Condition. 3. Wound/Skin condition Present/No new change of condition. Documentation already established on all existing Wound/Skin Conditions.
On 05/05/2021 at approximately 9:00 a.m. requested Resident #43's Treatment Administration Record (TAR) for May 2021?
On 05/05/2021 received copy of Treatment Administration Record for May 2021 as requested. Review of the Treatment Administration Record revealed that it was printed on May 5, 2021 at 11:13:35 EDT (Eastern Daylight Time). Review of the Treatment Administration Record did not evidence a treatment order for the resident's buttocks, coccyx or sacrum or for barrier cream.
On 05/05/2021 at approximately 12:00 p.m., Resident #43 was observed sitting on Comfort Pro Cushion in wheelchair.
An interview was conducted with Licensed Practical Nurse (LPN) #7 on 05/05/2021 at 2:45 p.m. When asked what treatment is being done to Resident #43's sacrum, LPN #7 stated, She gets barrier cream. It's applied 3 times a day and PRN (A Needed). When asked to provide a copy of the order, LPN #7 stated, I noticed today that she didn't have an order but I saw the nurse note and transcribed the order. LPN #7 provided surveyor copy of order dated 05/05/2021. Review of order revealed the following: Order Date: 5/5/2021 12 29 Description: apply barrier cream to sacrum/coccyx until seen by wound MD. Order Summary: apply barrier cream to sacrum/coccyx until seen by wound MD every shift for wound care.
On 05/05/2021 at 3:41 p.m., at Resident #43's bedside to observed LPN #7 perform wound care on Resident #43. LPN #7 cleaned overbed table. LPN #7 performed hand hygiene, obtained needed wound care supplies and placed on overbed table. LPN #7 performed hand hygiene and gloved. LPN #7 cleansed open area on right buttock with Peri Care Rinse Free Peri Cleanser and gauze pad. Area noted to be pink in color with some light white coloring in the center. LPN #7 cleansed wound on sacrum with Peri Care Rinse Free Peri Cleanser and gauze pad. Wound on sacrum noted to have gray black necrotic tissue in the center. LPN #7 cleansed area on coccyx with Peri Care Rinse Free Peri Cleanser and gauze pad, unable to determine if area was open. LPN #7 removed her gloves and performed hand hygiene, regloved and applied Derma Cream Skin Protectant Cream to all areas.
On 05/06/2021 at 7:51 a.m., review of Treatment Administration Record for May 2021 in Resident #43's clinical record revealed the following: Apply barrier cream to sacrum/coccyx until seen by wound MD every shift for wound care. Order Date 05/05/2021 1229.
On 05/06/2021 at 10:00 a.m., an interview was conducted over the telephone with LPN #6. When asked were you the nurse for Resident #43 on 05/01/2021, LPN #6 stated, Yes. LPN #6 stated, The CNA told me that the resident had an area on her coccyx and right butt cheek. I called other #2 and he told me to order barrier cream. When asked did you write the order for barrier cream, LPN #6 stated, I was told by (Nurse Name) LPN #8 that barrier cream order was already in place in the facility and didn't need to write the order. LPN #6 stated, All of the residents get barrier cream applied after each incontinent episode by the CNA's. When asked did the physician give parameters of how often to apply the barrier cream and when to apply the barrier cream, LPN #6 stated, No. When asked do the CNA's document when they apply barrier cream, LPN #6 stated, I don't know how the CNA's document. When asked did you apply barrier cream to Resident #43 that evening, LPN #6 stated, No, I told the CNA's to apply. When asked to explain what the areas looked like on Resident #43, LPN #6 stated, The coccyx had a small scab and the cheek, looked like a blister that popped.
On 05/06/2021 at approximately 11:00 a.m., when asked if the facility had any standing orders, Corporate Staff Member #5 stated, I will have to find out and get back to you.
On 05/06/2021 at 1:00 p.m., Corporate Staff Member #5 stated, No standing orders in facility.
An interview was conducted with Certified Nursing Assistant (CNA) #4 on 05/06/2021 at 2:05 p.m. When asked is Resident #43 incontinent of Bowel and bladder, CNA #4 stated, Yes and she goes to the bathroom. When asked how often do you check her for incontinent episodes, CNA #4 stated, Every 2 hours because she does have dementia. When asked do you apply barrier cream to Resident #43, CNA #4 stated, Yes but I can't say everyone does.
An interview was conducted with CNA #3 on 05/06/2021 at 2:25 p.m. When asked if Resident #43 needs assistance with transferring, CNA #3 stated, (Resident Name) can transfer with stand by assist and will transfer on her own at times. When asked if Resident #43 is confused, CNA #3 stated, Yes. When asked is Resident #43 incontinent, CNA #3 stated, Yes, she is incontinent of bowel and bladder. When asked how often you offer to toilet Resident #43, CNA #3 stated, She will let you know when she needs to go to the restroom. When asked do you apply barrier cream to Resident #43, CNA #3 stated, Apply barrier cream to residents after they have incontinent episodes.
On 05/06/2021 Resident #43 was seen in the facility by other #7. An interview was conducted with other #7 on 05/06/2021 at 3:25 p.m. When asked what stage is Resident #43's wound on her sacrum, other #7 stated, Unstageable. When asked what the wound on the sacrum due to was, other #7 stated, Pressure. When asked what was the wound on the right buttocks due to, other #7 stated, Friction. When asked what the area on the coccyx due to was, other #7 stated, DTI (Deep Tissue Injury). When asked for wound measurements from today's visit, other #7 stated, Measurements on the right buttocks 2 x 2 x 0.1, sacrum 2 x 1 x 0.2 and coccyx 0.5 x 0.5. Other #7 said that she only makes recommendations and the resident's physician gives the orders. When asked what treatments she was recommending, other #7 stated, Santyl to the sacrum, Skin Prep to the Coccyx and Hydrogel for the right buttocks. Other #7 also said that she would recommend a gel cushion for Resident #43. Other #7 stated, The nurses try to wait for me to stage pressure ulcers. The nurses usually tell me they have an Unstageable. Other #7 stated, R.N.'s (Registered Nurses) can stage. Other #7 stated, I come once a week.
On 05/06/2021 copy of facility policy and procedure on pressure ulcers was requested.
On 05/06/2021 received copy of Trio Healthcare Policy and Procedure Manuals - Wound Prevention Program. Review of manual revealed the following: SKIN PROGRAM Page 6 - Residents with wounds will have appropriate treatment.
On 05/07/2021 requested copy of Wound Physician Progress Notes for 05/06/2021.
An interview was conducted with RN #1 on 05/07/2021 at 12:35 p.m. When asked to review Pressure Injury Weekly Measurement note for Resident #43 dated 05/03/2021, RN #1 stated, I was sent to get the measurements on 05/03/2021 by the Director of Nursing (DON) after they viewed the notes from the weekend. When asked to describe what the areas on Resident #43 looked like, RN #1 stated, Right butt cheek looked like a popped blister and I documented it on a Non-Pressure form on 05/03/2021. When asked did you measure an area on the coccyx bone, RN #1 stated, I did not see an area on the coccyx bone, I measured the area on the sacrum. RN #1 stated, I had been asked to measure the area on the sacrum. It was discussed that the progress note from 05/01/2021 identified an area on the coccyx bone but not the sacrum. RN #1 stated, I didn't think anything about it because nurses uses the term sacrum and coccyx and mean the same thing. When asked to describe what the sacrum looked like, RN #1 stated, It looked dry, had some yellow tinge on the left and blackened area was on the right. When asked was the physician made aware of the area on the sacrum, RN #1 stated, Yes, talked to the Nurse Practitioner (Name) (Other #8). When asked did you document that the Nurse Practitioner was made aware, RN #1 stated, No. When asked was an order obtained for the sacrum, RN #1 stated, No, per my understanding the DON and Corporate Nurse were working on getting the Wound Nurse to come out. That was Monday. When asked why you contacted the Nurse Practitioner on Monday if you thought the sacrum wound was the coccyx wound that was in the note, RN #1 stated, Just to follow up and cover the bases. RN #1 stated, I made the Nurse Practitioner aware that the wound was identified as unstageable and made her aware of the order for barrier cream and asked her did she want another treatment order and the Nurse Practitioner said no, that's all right someone will be in to see it tomorrow. When asked did you apply barrier cream to the wounds on Monday, RN #1 stated, I don't know. When asked did you document applying the barrier cream, RN #1 stated, Yes on the TAR. Surveyor provided copy of May 2021 TAR to RN #1 to review. After RN #1 reviewed TAR RN #1 stated, No, it just stated to put dry dressing on staples. When asked did you apply barrier cream to Resident #43 yesterday, Thursday, RN #1 stated, No. I knew you wanted wound measurements and the wound doctor came in. When asked have you seen new orders written for wound care for Resident #43 today, RN #1 stated, No, I have not.
On 05/07/2021 at 3:20 p.m. An interview was conducted with CNA #3. When asked how was it communicated to you to apply barrier cream to Resident #43, CNA #3 stated, Already knew to apply barrier cream to residents after incontinent episodes. When asked did you document applying barrier cream to Resident #43, CNA #3 stated, No ma'am.
On 05/07/2021 at 3:45 p.m., reviewed concerns with Interim Administrator and Corporate Nurse regarding Resident #43's unstageable wound located on the sacrum and looking at possible harm. Discussed unable to locate treatment orders for wounds identified on 05/01/2021 and no documented evidence that treatment was done. Corporate Nurse stated, They wrote an order and documented treatments. Requested evidence of orders written for 05/01/2021 and documented evidence that treatments were provided.
On 05/10/2021 at approximately 10:00 a.m., requested copy of Wound Physician Progress Notes for Resident #43 for 05/06/2021. Also requested any new orders obtained for Resident #43's wounds on her sacrum, coccyx and right buttocks.
On 05/10/2021 at approximately 11:45 a.m. An interview was conducted with CNA #4. When asked how is it communicated to you to apply barrier cream to Resident #43, CNA #4 stated, We apply barrier cream as precautions, if any body's bottom gets red we put cream on. When asked where do you document that you have applied the barrier cream, CNA #4 stated, Nowhere on the kiosk to document putting on barrier cream.
On 05/10/2021 received copy of Wound Physicians Initial Wound Evaluation and Management Summary Dated 5/6/2021. Received new orders written for Resident #43. Review of new orders revealed the following: Order Date: 5/10/2021 1245 Description: Clean wound/DTI to sacrum with normal saline, pat dry. Apply Santyl to wound bed, skin prep surrounding skin. Cover with dry dressing. Order Date: 5/10/2021 1245 Description: Clean right lateral buttock with normal saline, pat dry. Apply Hydrogel to wound bed and cover with dry dressing. Order Date: 5/10/2021 1245 Description: Apply skin prep to DTI over coccyx.
The Interim Administrator, Interim Director of Nursing and Corporate Nurse was informed of the findings on 05/10/2021 at approximately 8:30 p.m. at the pre-exit meeting. When asked if they had any further information to provide, Corporate Nurse stated, Order put barrier cream on and continued barrier cream until physician seen her and order changed today.
On 05/11/2021 at 12:35 p.m. an interview was conducted by telephone with the Interim Director of Nursing. When asked concerning the wounds identified on 05/01/2021, did the resident have a treatment order for the open areas on the buttocks, sacrum and coccyx, Interim Director of Nursing stated, No specific order, were applying barrier cream. On 05/05/2021 received order to continue barrier cream. When asked do you have evidence that barrier cream was applied, Corporate Nurse stated, In the progress note. When asked was barrier cream an appropriate treatment for an unstageable pressure ulcer, Corporate Nurse stated, This is the order the doctor gave. When asked what your expectations of nurses are when wounds are identified, Interim Director of nursing stated, Assess the wound, obtain measurements and notify the physician for treatment orders. To provide pressure relief to any area of concern, offloading heels, floating heels. The Corporate Nurse stated, We replaced the cushion in her chair with a gel cushion on 05/03 or 05/04. The facility did not present any further information about the finding.
5. For Resident #346, the facility staff failed to provide pressure ulcer care as ordered by the physician.
Resident #346 was admitted to the facility on [DATE]. Diagnosis for Resident #346 included but are not limited to Stage IV sacral pressure ulcer. The resident's Minimum Data Set (MDS) assessment was not due. Review of Resident #346's admission assessment dated [DATE] documented the residents was independent in decisions regarding task of daily life, indicating no cognitive impairment.
In addition, during the review of Resident #346's admission assessment dated [DATE] documented the following under skin: sacral pressure ulcer measuring 11.5 cm x 8 cm x 3 cm (stage IV pressure ulcer.)
Resident #346's record did not reveal a 48 hour baseline care or an interim care plan.
A phone interview was conducted with Resident #346 on 05/05/21 at approximately 9:25 a.m., who stated, The nurse did not do my treatment to sacrum (butt area) yesterday; 05/04/21.
Review of Resident #346's Treatment Administration Record (TAR) for May 2021 revealed the following treatment order:
Sacral ulcer: Santyl ointment - apply to sacrum topically every day shift - cleanse sacral wound with Dakin's, apply Santyl to moist Dakin's roll gauze, pack and apply ABD pad and secure with tape.
Further review of the May 2021's (TAR) was not initialed and documented that Resident #346's sacral wound treatment as being completed on 05/04/21 (day or evening shift.) Review of the nurses notes did not indicated the reason why Resident #346's sacral ulcer treatment was not done.
A phone interview was conducted with the Director of Nursing (DON) on 05/05/21 at approximately 11:09 a.m. If the resident stated the nurse did not do his treatment and the nurse did not signed off as treatment being completed or a clinical note saying why the treatments was not done; then I have to believe his treatment was not done. The DON provided the phone number for License Practical Nurse (LPN) #1, who was assigned to Resident #346 on 05/04/21 (7a-7p shift.) On the same day at approximately 12:03 p.m. a phone call was placed to LPN #1, unable to leave a message, (this number is no longer is service or temporally unavailable.)
On 05/05/21 the following sacral order was written: Clean sacrum wound with wound cleanser and apply medihoney to sacral wound then apply ABD pad and secure with tape every shift for wound care until Santyl is available.
On 05/06/21 at approximately 7:50 p.m., surveyor #2 observed wound care with License Practical Nurse (LPN) #13. An excessive amount of drainage was observed through the existing dressing. Once removed, the sacral area and bilateral buttocks fell open to be a large surface area with necrosis and slough, as well as brown drainage. This area was cleansed with normal saline and medihoney, but the LPN stated she did not have near enough medihoney due to the size of the pressure ulcer cavity. She covered the wound with large ABD pads and secured it with paper tape.
A pre-exit conference was conducted with the Administrator, Director of Nursing (DON) and Cooperate Nurse on 05/10/21 at approximately 6:30 p.m. No further information was provided prior to exit.
Definitions:
Pressure Injury - Stage 4 (Full-thickness skin and tissue loss)
Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages.)
Santyl is used to help the healing of burns and ulcers. Collagenase is an enzyme. It works by helping to break up and remove dead skin and tissue. This effect may also help to work better and speed up your body's natural healing process (antibiotics <http://www.webmd.com/cold-and-flu/rm-quiz-antibiotics-myths-facts.)
Dakin's solution is a type of hypochlorite solution. It is made from bleach that has been diluted and treated to decrease irritation. Chlorine, the active ingredient in Dakin's solution, is a strong antiseptic that kills most forms of bacteria and viruses (http://www.webmd.com/drugs/2/drug-62261/dakin's-misc/details.)
2. For Resident #17, the facility staff failed to provide necessary care and services to prevent a pressure ulcer from developing at an advanced stage which constitutes harm.
Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to type two diabetes without complications, obesity due to excess calories, atrial fibrillation, post COVID -19, and cognitive social or emotional deficit following unspecified cerebrovascular disease. Resident #17's most recent MDS (Minimum Data Set) assessment was an annual assessment with an ARD (Assessment reference date) of 12/31/20. Resident #17 was coded as being severely impaired in cognitive function scoring 05 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #17 was coded as requiring total dependence on two staff members with bed mobility. Resident #17 was coded in Section M (Skin Conditions) as having (1) one unstageable pressure ulcer* (1).
Review of Resident #17's clinical record revealed that the only Braden Scale for Predicting Pressure Ulcer Risk was on 11/27/18. Resident #17 was coded as being at high risk for developing pressure sores scoring a 12.0.
Review of Resident #17's clinical record revealed that it was documented that Resident #17 developed MASD (Moisture Associated Skin Damage) to the right buttock starting on 11/3/20 and documented as Resolved on 11/10/20. An order was put into place to: Clean right buttock with soap and water blot dry apply zinc and silver sulfadiazine every shift. This order was initiated on 10/27/20 and continued even after the MASD was resolved on 11/10/20.
There was no evidence that Resident #17 had developed any other skin areas until 12/17/20 when a Stage 3 (2) pressure ulcer was documented as being identified to his right buttock.
Review of the Initial Pressure Injury Record dated 12/17/20 documented the following: Date first observed: 12/17/20. Location: right buttock. Stage: 3 Length in CM (centimeters): 2. Width in CM: 2. Depth in CM: 0 (zero) Drainage: none. Odor: none. Granulation. None. Describe current treatment plan: cleanse left buttock with N/S (normal saline) apply medihoney (3) and calcium alginate (4) and dry dressing daily and PRN (as needed). This assessment was documented by a LPN (Licensed Practical Nurse).
There was no evidence that an RN (Registered Nurse) had went behind the LPN to reassess the wound.
The weekly skin assessment directly prior to 12/17/20 was dated 12/14/20. The following was documented: Wound/Skin Condition Present/No new change of condition. Documentation already established on all existing Wound/Skin Conditions.
There was no evidence in the clinical record that after 11/10/20 and directly prior to 12/17/20 an existing wound condition was present.
Review of Resident #17's December 2020 TAR (Treatment Administration Record) revealed that staff were applying his zinc and silver sulfadiazine cream every shift on 12/16/20 through 12/17/20 until the wound was found on 12/17/20 day shift. Further review of Resident #17's December TAR revealed 7 blank spaces on 12/1, 12/2, 12/3, 12/8, 12/9 and 12/15; indicating the cream was not applied on those shifts to Resident #17.
Review of Resident #17's pressure ulcer care plan dated 9/27/13 documented the following interventions prior to the development of his documented Stage 3 wound: (Name of Resident #17) is a risk for pressure ulcers due to decreased mobility and obesity and co morbidity diagnosis of HTN (high blood pressure), Diabetes .CNA (Certified Nursing Assistant) to observe skin during care/bathing with a report to the nurse of any areas of skin breakdown, bruising or redness Conduct weekly skin inspections .Ensure skin folds are kept clean and dry .provide pressure reduction/relieving mattress .treatments as ordered .Turning and repositioning schedule per assessment .
Further review of Resident #17's clinical record revealed a dietary note dated 12/11/20 that documented the following: Review for weight loss, 5.5% . x 30 days, Diet: CCD with recent decreased intake 30% average. supervision needed and now more total dependence in recent days .Recommend to d/c (discontinue) ice cream with lunch and dinner, add Mighty Shake with breakfast and lunch, add vitamin C 500mg BID and zinc 220 x 14 days. Review of Resident #17's record revealed these recommendations were implemented on 12/14/20.
Further review of Resident #17's clinical record revealed his weight (last recorded weight) prior to the development of the pressure ulcer was on 12/4/20. Resident #17 weighed 232.0 pounds.
Review of a physician note dated 12/16/20 revealed an order for a CBC (Complete Blood Count), CMP (Complete Metabolic Panel), AC (average blood glucose) and TSH (Thyroid stimulating Hormone) for an increase in fatigue. There was no evidence that this order was followed up on prior to the resident's hospitalization on 12/17/20 at 9:45 p.m.
Further review of Resident #17's clinical record revealed that he was sent out to the hospital on [DATE] at 9:45 p.m. The following nursing note was documented: R (Resident) lethargic, will not close mouth to drink water, starting off to the right. R vitals B/P (blood pressure) 88/43, P (pulse) 56, R (16), T (Temp)-97.1, 02 (Oxygen) Sats 87. R c/o (complaints), sob (short of breath), chest pain. NP (Nurse Practitioner) (Name) notified, new order to send to ER (emergency room) for eval (evaluation) and treat .Transport arrived at 2145 (9:45 p.m.) to transport resident R .
Review of Resident #17's hospital Discharge summary dated [DATE] documented in part, the following: Per HPI (history and physical): .The patient is not responsive, so all history was obtained from the ED report .The ED was able to get in touch with a worker at the NH (Nursing Home) who states he is normally talkative and interactive, but has not been eating, drinking or interacting for the last several days .Per EMS, they were told he has COVID pneumonia .In the ED he was afebrile .CXR (Chest x-ray) looks clear to my eye .On exam he does have sacral decub (decubitus) ulcers, however they do not appear to be infected at this time .Wound Buttocks .Pre-existing: Yes.
Further review of the hospital discharge summary revealed that on 12/27/20 it was documented that Resident #17's buttock wounds had Eschar, open, red; Pink .Drainage .Small Primary discharge diagnosis: Sepsis with acute renal failure and acute respiratory failure and acute respiratory failure with hypoxia, with septic shock due to COVID -19 infection .
Review of Resident #17's clinical record revealed that he was admitted back to the facility on [DATE].
Review of Resident #17's Initial Pressure Injury Record dated 12/28/20 revealed that Resident #17 arrived back to the facility with an unstageable pressure ulcer to his sacrum. The following was documented: Date First Observed: 12/28/20. Location: sacrum. Length in CM: 9. Width in CM 7. Depth in CM 0. Drainage: 0 Odor: none. Granulation: 0 Describe current treatment plan: alginate.
Review of Resident #17's clinical record revealed that the wound care physician had seen the wound on 1/7/21. The following was documented: Pressure .Unstageable Necrosis .9 x 7 x not measurable .Periwound radius: Odor .Exudate: Heavy Serous .Thick adherent black tissue: 100 % (percent).
On 5/6/21 at 11:46 a.m., wound care observation was made with OSM #7, the wound care nurse. Resident #17's wound was now a stage 4 pressure ulcer (5) with the following measurements in centimeters: 4.4 x 4 x 1.8. The wound was documented as having No Change on the weekly wound summary and surgical debridement was performed at the bedside to assist with healing.
On 5/6/21 at 3:05 p.m., an interview was conducted with the Wound Care Physician, OSM (Other Staff Member) #7. OSM #7 stated she was not following Resident #17's wound until he arrived back from the hospital with an unstageable. When asked if LPNs could stage wounds, OSM #7 stated that typically the RNs (Registered Nurses) staged wounds or staff would make a description of the wound when first found and wait for her to come in to stage. When shown OSM #7 the documented paperwork on 12/17/20 from the LPN regarding Resident #17's wound; OSM #7 stated that a stage three would have depth to it and the nurse documented a zero for depth. OSM #7 also stated that the treatment ordered however was for a wound at a three or higher. OSM #7 stated that Medihoney would be used to debride sloth and the calcium alginate would be used for drainage. OSM #7 also observed that it was documented that there was no drainage to this wound on 12/17/20. OSM #7 stated that the treatment orders wouldn't make sense if the wound was less than a three and if there was no drainage.
On 5/7/21 at 9:00 a.m., an interview with conducted with LPN (Licensed Practical Nurse) #7, the nurse who first identified the wound to Resident #17's right buttock on 12/17/20. When asked what she saw upon the initial assessment, LPN #7 stated that she saw A lot of necrotic tissue upon her initial assessment. When asked if LPNs were allowed to stage wounds, LPN #7 stated that LPNs were not allowed to stage wounds, that an RN would have to go behind her and assess the wound as well. When asked why her documentation noted that a Stage 3 pressure was first identified to Resident #17's right buttock, LPN #7 stated she is not sure why she would document that; that she was not allowed to stage wounds. When asked if there was any depth or drainage to the wound when first seen, LPN #7 stated that she could not remember; that she didn't remember measuring the wound. LPN #7 stated that all she knew is that there was A lot of slough observed. When asked who was responsible for applying the Zinc cream that was ordered prior to the development of the wound, LPN #7 stated that the nurses were responsible. LPN #7 confirmed that she had worked the day before 12/16/20 and signed that she had applied the zinc cream the 7-3 shift prior to 12/17/20. When asked if she noticed any skin areas then developing to Resident #17 right buttock, LPN #7 stat[TRUNCATED]
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0553
(Tag F0553)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility document review staff interviews and family interview the facility staff failed to ensu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility document review staff interviews and family interview the facility staff failed to ensure one resident's daughter was called for a zoom care plan meeting after an invitation was sent for 1 of 34 residents in the survey sample, Resident #5.
The findings included:
Resident #5 was admitted to the facility on [DATE] with diagnoses to included but not limited to Major Depressive Disorder, Dementia, Anxiety Disorder and Hypertension.
The most recent Minimum Data Set (MDS) was an Annual with an Assessment Reference Date (ARD) of 2/10/21. The Brief Interview for Mental Status (BIMS) for Resident #5 was coded as a 15 out of a possible 15 which indicates the resident is cognitively intact and capable of daily decision making.
On 05/3/21 at 09:53 AM a phone interview was conducted with Resident #5. During the interview Resident #5 stated, My last care plan meeting my daughter received an invite but the facility never called her for the meeting.
On 5/6/20 at 9:46 A.M. a phone interview was conducted with Resident #5's Daughter about the most recent care plan meeting. Resident #5's Daughter stated, 'I received a care plan invitation by mail like I always do. The meeting was scheduled for February 18th at 10:15 a.m. Since COVID we have been doing the meetings via phone from my mother's room. Well on February 18th I was all ready for the call, but no one from the facility ever called. My mom likes me on the calls because she forgets things at times. I don't know what happened but I never received a call for her care plan or even a call that it was moved to another day.
Resident #5's Care Plan Invitation provided by the facility was reviewed and is documented in part, as follows:
Date: 01/27/2020
Dear Name (Resident #5's Daughter),
I am sending you this letter to notify you of the upcoming care plan meeting for Name (Resident #5). The meeting has been scheduled for Feb. 18, 2021 at 10:15 a.m. As we are currently still not allowing visitors on the nursing unit, this meeting will be held via phone conference. We will call you when the care plan meeting is ready to begin.
Resident #5's Care Plan Attendance Record provided by the facility was reviewed and is documented in part, as follows:
Dietary: Blank
Nursing: Blank
MDSC (Minimum Data Set Coordinator): Blank
Family: Blank
Resident: Blank
Social Worker: Blank
Activities: Blank
Rehab: Blank
Resident Name: Name (Resident #5)
Date: 02/18/2021
Resident #5's electronic medical record progress notes were reviewed for 2/18/21, 2/19/21 and 2/21/21 and there was no note to reference the Resident #5's care plan meeting that was scheduled for 2/18/2021 at 10:15 a.m.
The facility policy titled Family Involvement in Resident Care effective 11/2020 was reviewed and is documented in part, as follows:
Policy: Residents and their representative will be provided with an opportunity to participate in the care planning process and be included in decisions, changes of care, treatment, and/or interventions.
Care plan meetings will be held to accommodate residents. Facility staff will attempt to meet all reasonable request for Care Plan meetings (time, place, etc.)
Family members will be invited to quarterly Care Plan Meetings or Care Plan Meetings that occur due to a change in resident condition.
On 5/10/21 at 12:15 P.M. a pre-exit debriefing via phone was conducted with the Interim Administrator, the Acting Director of Nursing and the Regional Director of Clinical Services where the above information was shared. The Interim Administrator was asked what would have been the expectation for ensuring that Resident #5's daughter was included in the care plan meeting The Acting Director of Nursing stated, The daughter should have been called, if she received an invite then the call should have happened on the day listed on the invite.
Prior to exit no further information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0555
(Tag F0555)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a complaint investigation, a medical record view, staff interviews and family a interview the facility staff failed to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a complaint investigation, a medical record view, staff interviews and family a interview the facility staff failed to follow-up with a resident's choice of an attending physician in March of 2020 to determine if the provider could meet the requirements for care for 1 of 34 residents in the survey sample, Resident #9.
The finding included:
Resident #9 was admitted to the facility on [DATE] with diagnoses to included but not limited to Major Depressive Disorder, Diabetes Mellitus, Anxiety Disorder and Hypertension.
The most recent Minimum Data Set (MDS) was an Annual with an Assessment Reference Date (ARD) of 3/18/21. The Brief Interview for Mental Status (BIMS) for Resident #9 was coded as a 12 out of a possible 15 which indicates the resident is cognitively intact and capable of daily decision making.
On 5/4/21 at 2:00 P.M. a phone interview was conducted with Resident #9's daughter who is also the Complainant. Resident #9's daughter stated, I took my mother to a primary care physician outside of the facility on my own in march because she was having abdominal pain. After the appointment I told the facility Social Worker that I wanted to change my mother's primary care physician to Name ( Outside Nurse Practitioner) when we returned. A few days later I received a call from the Social Worker stating that I could not change my mother's primary care physician because it would be a conflict of interest.
Resident #9's Progress Notes were reviewed and are documented in part, as follows:
3/8/2020 12:26 General Note Late Entry: Note Text: SOCIAL SERVICES NOTE
Conversation with the daughter about the upcoming appointment with the outside PCP. Social services mentioned that she cannot have an outside PCP while she remains in the facility. Told her that Name (Current Facility Primary Care Physician) is her PCP (primary care physician), and that any information was given to the NP(Facility Nurse Practitioner) for her to review. Per staff and Name (Current Facility Primary Care Physician) that is the policy.
3/9/2020 13:57 General Note Note Text: SOCIAL SERVICES NOTE Conversation with the daughter to state that while the resident is at Bayside that the resident cannot have another PCP as Name (Current Facility Primary Care Physician) is her PCP. The daughter stated that she is now aware of that and that she will call the Dr. (doctor's) office to let them know she will not be coming to them. Continue to follow.
On 5/10/21 at 5:59 P.M. a phone interview was conducted with the outside Nurse Practitioner. The outside Nurse Practitioner was asked if anyone from the facility called her in March of 2020 and asked if she would be willing to take Name (Resident #9) on as a patient while in the facility and follow all regulations required if so. The outside Nurse Practitioner stated, No, no one every called me from the facility and asked if I would take her on as a patient in the facility.
On 5/10/21 at 12:15 P.M. a pre-exit debriefing via phone was conducted with the Interim Administrator, the Acting Director of Nursing and the Regional Director of Clinical Services where the above information was shared. The Interim Administrator was asked what would have been the expectation when Name (Resident #9's) daughter requested changing primary care physicians. The Acting Director of Nursing stated, To have the Social Worker contact the primary care physician and ask if they were interested in following the resident and adhering to all regulations. The Acting Administrator was also asked if there was a facility policy for a resident's choice of a primary care physician. The Acting Administrator stated, No we do not have a policy we go by the Resident's Rights and the regulations.
Prior to exit no further information was shared.
THIS IS A COMPLAINT DEFICIENCY
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
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 document review, it was determine...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, clinical record review and facility document review, it was determined that the facility staff failed to ensure call bells were within resident reach for two of 34 residents in the survey sample, Resident #17 and #42.
The findings included:
1. Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to type two diabetes without complications, obesity due to excess calories, atrial fibrillation, post COVID -19, and cognitive social or emotional deficit following unspecified cerebrovascular disease. Resident #17's most recent MDS (Minimum Data Set) assessment was an annual assessment with an ARD (Assessment reference date) of 12/31/20. Resident #17 was coded as being severely impaired in cognitive function scoring 05 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Resident #17 was coded as requiring total dependence on two staff members with bed mobility, bathing, personal hygiene, and toileting and extensive assistance with one staff member with eating. Resident #17 was coded in Section H (Bowel and Bladder) as always being incontinent of bowel and bladder.
Review of Resident #17's care plan dated 12/27/13 documented the following: (Name of Resident #17) has a physical functioning deficit related to: Self Care impairment and obesity .Interventions: call bell within reach .
On 5/4/21 at 12: 15 p.m. and 1:13 p.m., an observation was made of Resident #17. His call bell was observed to be on the floor.
On 5/5/21 at 1:14 p.m. and 2:00 p.m., an observation was made of Resident #17. His call bell was wrapped around his side rail with the button hanging off the bed at the level of his mattress. When asked Resident #17 if he was able to reach over and grab the bell cord and pull it towards him, Resident #17 stated, No. When asked if he could try to reach over and grab his bell, Resident #17 could not demonstrate. When asked if it would be easier for him if his call bell was clipped to his bed closer to him; Resident #17 stated, Yes. Resident #17 stated that he could use his bell if it was in front of him in close reach.
Review of an OT (Occupational) Therapist Discharge summary dated [DATE] documented in part, the following: Patient continues to require maximum assistance for all aspects of bed mobility and ADLS. Patient has progressed with self-feeding tasks requiring assistance with set up.
On 5/6/21 at 1:36 p.m., an interview was conducted with OSM (Other Staff Member) #6, the Therapy Director. OSM #6 stated that Resident #17 did not have full ROM of his upper extremities, OSM #6 stated that he could eat meals independently after set up but didn't think he would be able to reach over and grab a call bell hanging off to he side of him.
On 5/7/21 at 11:24 a.m., an interview was conducted with RN (Registered Nurse) #1, an agency nurse. When asked what nursing staff should ensure is near the resident prior to leaving a room, RN #1 stated that all staff should make sure items that the resident frequently uses and the call bell is within reach for each resident who is able to utilize the call bell. When asked some of the consequences for not having the call bell in reach, RN #1 stated that resident's can have falls and not be able to call the nurse or they cannot call the nursing staff to make any of their needs known. When asked if Resident #17 had full ROM (Range of Motion) of his upper extremities, RN #1 stated that Resident #17 Doesn't seem to move. RN #1 stated that she hasn't seen Resident #17 even feed himself. When asked if she thought Resident #17 could reach over and grab his call bell that is hanging off the bed railing, RN #1 stated that she would have to say no to that question.
On 5/7/21 at 1:28 p.m., an interview was conducted with CNA (Certified Nursing Assistant) #3, a CNA assigned to Resident #17. When asked what she will check for prior to leaving any resident's room; CNA #3 stated that she will make sure that the call bell, bedside table and water pitcher are within reach of the resident. When asked some of the consequences if the call bell is not within reach to a resident; CNA #3 stated, You don't know if they have an emergency such as choking; it's the only way to make needs known. When asked if Resident #17 had full ROM (Range of Motion) of his upper extremities and could reach the call bell if it was hanging over the side of railing, CNA #3 stated that she thought that he could, however he will refuse to move.
On 5/10/21 at 5:59 p.m., ASM (Administrator Staff Member) #1, the Interim Administrator, ASM #2, the Acting DON (Director of Nursing) and ASM #4, the Regional Director of Clinical Services were made aware of the above concerns.
2. Resident #42 was admitted to the facility on [DATE] with diagnoses that included but were not limited to atherosclerotic heart disease, high blood pressure, hypothyroidism, unspecified convulsions, history of falling, and muscle weakness. Resident #42's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (Assessment Reference Date) of 1/8/21. Resident #42 was coded as being moderately impaired in cognitive function scoring 13 out of possible 15 on the BIMS (Brief Interview for Mental Status exam. Resident #42 was coded as requiring extensive assistance from two or more staff with bed mobility, transfers, dressing, and personal hygiene; and total dependence on two or more staff with bathing and toileting. Resident #42 was coded as being Not steady, only able to stabilize with human assistance when moving from a Standing to sitting position. Resident #42 was coded as not having any falls since the last MDS assessment dated [DATE].
Review of Resident #42's ADL care plan dated 7/11/16 documented the following: I have a physical functioning deficit related to: Self care impairment due to dx (diagnoses) of Dementia and Mobility impairment Call bell within reach .
On 5/4/21 at 12:30 p.m., an observation was made of Resident #42 on tour. Her call bell was clipped high on her privacy curtain, not within reach of the resident; if the resident was sitting in her wheelchair.
On 5/4/21 at 2:00 p.m., an observation was made of Resident #42 on tour. Her call bell was clipped high on her privacy curtain, not within reach of the resident; if the resident was sitting in her wheelchair.
On 5/4/21 at 2:30 p.m., an interview was conducted with Resident #42. Resident #42 had a complaint regarding call bell response time. Resident #42 then stated to look at her call bell (which was still clipped to the privacy curtain). Resident #42 stated that she could not reach where it was placed. Resident #42 then stated that if it was clipped to her bed, at least she could propel to it and ring it.
On 5/7/21 at 11:24 a.m., an interview was conducted with RN (Registered Nurse) #1, an agency nurse. When asked what nursing staff should ensure is near the resident prior to leaving a room, RN #1 stated that all staff should make sure items that the resident frequently uses and the call bell is within reach for each resident who is able to utilize the call bell. When asked some of the consequences for not having the call bell in reach, RN #1 stated that resident's can have falls and not be able to call the nurse or they cannot call the nursing staff to make any of their needs known. When asked if it was ever okay to clip the call bell up high on the privacy curtain, RN #1 stated that it was never okay. RN #1 stated that she wonders if the nursing aides had clipped the call bell while making the bed and forgot to put it back.
On 5/7/21 at 1:28 p.m., an interview was conducted with CNA (Certified Nursing Assistant) #3, a CNA assigned to Resident #17. When asked what she will check for prior to leaving any resident's room; CNA #3 stated that she will make sure that the call bell, bedside table and water pitcher are within reach of the resident. When asked some of the consequences if the call bell is not within reach to a resident; CNA #3 stated, You don't know if they have an emergency such as choking; it's the only way to make needs known. When asked if it was ever okay to clip a call bell high onto the privacy curtain; CNA #3 stated that was never okay.
On 5/10/21 at 5:59 p.m., ASM (Administrator Staff Member) #1, the Interim Administrator, ASM #2, the Acting DON (Director of Nursing) and ASM #4, the Regional Director of Clinical Services were made aware of the above concerns.
A policy could not be provided regarding call bells in reach. A Fall Interventions policy was given to this writer that documented the following: Call light within reach at all times.
No further information was presented prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0577
(Tag F0577)
Could have caused harm · This affected 1 resident
Based on staff interview, and facility document review, it was determined that facility staff failed to ensure that the state inspection results were easily accessible to all residents.
The findings ...
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Based on staff interview, and facility document review, it was determined that facility staff failed to ensure that the state inspection results were easily accessible to all residents.
The findings included:
On 5/5/21 at 9:57 a.m., a group interview was conducted with five residents. The five residents interviewed were not aware of where the state inspection results were located.
On 5/5/21 at 11:00 a.m., observation of the state inspection results were conducted. The state survey results was in a large three ring binder sitting in a wall mount affixed to the wall. There was no table or anywhere to place the binder once it was out of the wall mount. The wall mount was at a level where it would be difficult for some residents to reach if sitting in a wheelchair. The survey result book also felt heavy.
On 5/6/21 at approximately 3:55 p.m., a Resident that was in group (Resident #5); was asked if she could reach the state survey results. Resident #5 was wheelchair bound and had all ROM (Range of Motion) of her upper extremities. Resident #5 stated that she wouldn't be able to quite reach the book from her wheelchair; as she would have to lift the book up and out of the wall mount. Resident #5 stated if she stood up, she would be able to reach it, however she was not supposed to stand on her own. This writer lifted the book up for the resident. Resident #5 was able to hold the book. Resident #5 denied it being too heavy for her to carry.
On 5/7/21 at 1:15 p.m., an interview was conducted with the Activities Director, OSM (Other Staff Member) #8. When asked where the state survey results were located, OSM #8 stated that the survey results were located in the binder hanging on the wall. OSM #8 stated the results were in a big binder and also confirmed that the binder was heavy. When asked if she thought most residents could reach the state survey binder by lifting the book up and out of the wall mount and then manage the binder (flipping through pages) on their lap; OSM #8 stated, I don't think a lot of residents could do that. OSM #8 then stated that the staff could help each resident access the binder. When asked if residents should have to ask staff to see the survey results binder, OSM #8 stated that they shouldn't have to.
On 5/10/21 at 2:58 p.m., it was observed that the survey results binder was moved to a low table in the front lobby easily accessible for residents to flip through the pages while on the table.
On 5/10/21 at 5:59 p.m., ASM (Administrator Staff Member) #1, the Interim Administrator, ASM #2, the Acting DON (Director of Nursing) and ASM #4, the Regional Director of Clinical Services were made aware of the above concerns.
Review of the List of Resident Rights Under Federal Law document presented by OSM #8, documented in part, the following: The resident has the right to examine the results of the most recent survey of the Facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the Facility.
No further information was presented prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on observation, resident interview, staff interview, and clinical record review, the facility's staff failed to ensure privacy during wound care for 1 of 34 residents (Resident #7), in the surve...
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Based on observation, resident interview, staff interview, and clinical record review, the facility's staff failed to ensure privacy during wound care for 1 of 34 residents (Resident #7), in the survey sample.
The findings included:
Resident #7 was originally admitted to the facility 10/21/20 and has never been discharged from the facility. The current diagnoses included; glaucoma, a seizure disorder, end stage renal disease requiring dialysis, diabetes and coronary artery disease.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/28/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #7's cognitive abilities for daily decision making was intact. In sectionG (Physical functioning) the resident was coded as requiring total care of two people with transfers, toileting, and bathing, total care of one with off unit locomotion, extensive assistance of two people with bed mobility and dressing, extensive assistance of one person with personal hygiene and locomotion on unit, and supervision after set-up with eating. In section M (Skin Condition) the MDS assessment was coded No at M1040C, Other open lesion(s) on the foot (e.g., cuts, fissures). At M1200I, the resident was coded for Application of dressings to feet (with or without topical medications).
On 5/5/21, at approximately 1:45 p.m., a wound care observation was made of Resident #7's right ankle wound. Licensed Practical Nurse (LPN) #7 cleaned the bedside table, applied a barrier, and assembled needed supplies. LPN #7 and LPN #1 positioned the resident to expose the right ankle wound. LPN #7 removed the negative pressure wound vacuum system, cleaned the wound with saline soaked gauze, skin prepped the outer edges of the wound, applied a wet to dry dressing and a border dressing. LPN #1 stated the above treatment was ordered until the negative pressure system became available. The right lateral ankle wound wasn't measured but the wound bed presented with light red tissue with a moderate amount of serous drainage. The resident didn't indicate the wound was painful.
During the entire wound observation the privacy curtain remained opened except between the two residents. Off and on the two nurses went outside the door to obtain various items which allowed the resident's lower body to be viewable from the door.
An interview was conducted with LPN #7, about the privacy curtain immediately after wound care was completed. LPN #7 offered no rationale for not closing the curtain completely before the resident's wound was exposed.
An interview was also conducted with the resident at approximately 2:20 p.m., about the privacy curtain not closed during the wound care observation. Resident #7 stated the curtain doesn't close completely, if I had been asked I could have told them that. The resident further stated it closes enough that I can't see my roommate and he can't see me but it can't move beyond the left corner at the foot of the bed.
An interview was conducted with the Housekeeping supervisor on 5/5/21 at 2:35 p.m., the inability to close privacy curtain. The Housekeeping Supervisor stated she hadn't been informed of a problem with the privacy curtain but she took a look at it. She stated there was a problem with the curtain's track and she would have maintenance fix it. The Housekeeping supervisor stated it is necessary for staff to notify them of problems like the privacy curtain issue.
At approximately 5:15 p.m., on 5/5/21, the Maintenance Director informed me the privacy curtain tract in Resident #7's room had been repaired and it was capable closing completely.
On 5/10/21 at approximately 7:00 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Director of Clinical Services. An opportunity was afforded the facility to provide additional documentation but they did not.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #36 was originally admitted to the facility 7/14/21 and readmitted [DATE] after an acute care hospital stay. The cur...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #36 was originally admitted to the facility 7/14/21 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; lower back pain, lumbar diskitis, arthritis, polyneuropathy and a history multiple back surgeries.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/2/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15.
Review of the Facility's Reported Incidents revealed, Resident #36 voiced a complaint against Licensed Practical Nurse (LPN) #18 on 3/4/21. The FRI stated on 3/3/21, the LPN #18 refused to apply as needed medication in a timely manner and had also withheld a narcotic pain medication when requested by the resident.
The physician's order summary revealed; Resident #36 had the following medications ordered for administration;
Order Date 11/12/2020 - Bio freeze Gel 4 % (a menthol topical pain medication), apply to effected areas topically every 8 hours as needed for pain
Order Date 11/12/20 - oxycodone HCl Tablet 5 MG, Give 1 tablet by mouth every 4 hours as needed for post op pain related to LOW BACK PAIN (M54.5)
Order Date 11/12/20 - Acetaminophen Tablet Give 650 mg by mouth every 8 hours as needed for pain related to LOW BACK PAIN (M54.5)
The resident had a person-centered care plan problem dated 5/15/20 which read; the resident needs Pain management and monitoring related to: chronic lower back pain, polyneuropathy, and osteoarthritis of foot and ankle. The goal read; the resident will maintain adequate level of comfort as evidenced by no signs/symptoms of unrelieved pain or distress, or verbalizing satisfaction with level of comfort through next review, 8/10/21. The interventions included; Administer Pain medication as ordered, Utilize pain monitoring tool to evaluate effectiveness of interventions and Evaluate and Establish level of pain on numeric scale/evaluation tool.
On 5/5/21 at approximately 1:00 p.m., an interview was conducted with Resident #36. The resident stated on 3/3/21, he asked for the ordered BioFreeze gel (a menthol topical pain medication) to be applied but LPN #18, sat there and didn't administer it until she decided to do so. The resident explained that BioFreeze is instrumental in cooling and decreasing his pain to enable him to function. The resident also stated LPN #18 has behaved the same way when he has request his oral pain medication and he felt it was her means of controlling him while causing him to be in pain longer than he really has to. Resident #36 stated other residents in the community experiences the same problem with LPN #18.
The facility's investigation revealed LPN #18 stated the BioFreeze wasn't available on 3/3/21, when requested by the resident and LPN #18 hadn't instituted the facility's protocol for obtaining medications when they were not readily available. The investigation also revealed LPN #18 was often unprofessional (not nice, banged on resident doors and verbally inappropriate) with Resident #36, others residents and family members. The facility's investigation substantiated Resident #36's allegation and LPN #18 was terminated from the company and other staff were in-serviced on the abuse policy and on how to obtain over the counter medications.
On 5/10/21 at approximately 7:00 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Director of Clinical Services. An opportunity was afforded the facility to provide additional information but they did not.
Based on observations, clinical record review, staff and resident interviews, the facility staff neglected to provide the necessary care and services for 1 of 34 residents (R#147) in the survey sample and failed to ensure a resident was free from abuse resulting in needless pain for 1 of 34 residents (Resident #36), in the survey sample.
The findings included:
1. Resident #147 was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus, chronic diabetic wounds of right and left foot with status post bilateral transmetatarsal amputations and skin graft infections, end stage renal disease with dependence on renal dialysis.
The 5-day Minimum Data Set (MDS) assessment was dated 4/30/21 and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible score of 15 which indicated the resident had the necessary cognitive skills for daily decision making. The resident had no problems understanding the staff and was understood. The resident was assessed without mood or behavioral problems. Resident #147 required extensive assistance from 2 staff for bed mobility and toilet use. He was not assessed to be able to ambulate (walk in and out of room). He had bilateral lower extremity impairment in range of motion. The wheelchair was the resident's primary mode of transportation. The resident was coded with surgical wounds and infection of feet. The assessment was signed by the MDS Coordinator as completed on 5/10/21.
There was no care plan to include a baseline 48-hour care plan or interim care plan available to this surveyor during the time of the survey.
The following observations were made of Resident #147 that constituted neglect of goods and services:
On 5/4/21 at 1:05 p.m., Resident #147 was observed sitting on the side of the bed with a full lunch meal tray, his call light was on. The call light over his door was visibly operational and could be heard from the nurse's station. The left and right foot dressing exhibited serous bloody drainage which was also visible on the floor where the resident placed his feet. The Kling wrap on the left foot was unraveled and intertwined itself around the wheels of his over bed table. The resident stated that his dressing had been in that condition all night and he had been asking someone to change his dressings. The foot of his bed exhibited the same drainage on his sheets at the foot of the bed. There was also brown chunked material on the floor between the two beds along with trash, debris, alcohol wipes, chuck pad and accumulated dried blood that remained until inquired by Surveyor #2 on 5/6/21. The resident also stated he ask for someone to clean his floor of the blood from his foot wounds and pick up the fecal material. A foul order was apparent upon entering the room and it was discovered the biohazard trash and linen receptacles in the bathroom were full, over flowing and soiled items of trash and linen piled on top of the receptacles. This also remained until inquiry by Surveyor #2 on 5/6/21.
During the above observation, the Resident #147 stated when they served him his lunch meal around 12:15 p.m., he took one bite from a pork chop and could not consume it because it was tough with no taste, and thus he spit it out. He also stated he wanted coffee and they gave him iced tea with no sugar substitute. He stated he put his call light on around 12:20 p.m. and again at 12:30 and both times no one came in, but when the licensed Practical Nurse (LPN) #1 came to hang my IV antibiotic a few minutes ago that was due at 9:00 a.m., turned off the light, never asked him what he wanted, at which time he stated he told her he had been calling to get someone to send for a different meal, at which time she told him she was behind and did not have time. He stated, So I tried again after she left out because I am so hungry. The IV was infusing via the IV pump. The IV infusion pump beeped around 1:40 p.m. and the nurse entered the room at 2:03 p.m. (58 minutes from Surveyor #2's observation) she hesitated and made eye contact with this surveyor (Surveyor #2), turned off the light, took down the IV, flushed the central line and said, While I am here, what can I do for you. The resident responded, You can get me what I asked for when you came in to hang my IV antibiotic and said you were busy and did not have time. I would like a different meal for my lunch. LPN #1 stated she would come back to perform the dressing changes to his feet later. At approximately 2:10 p.m., the assigned Certified Nursing Assistant (CNA) # 6 was outside the resident's room donning her Personal Protective Equipment (PPE). CNA #6 entered the room, proceeded to pick up the resident's tray when it was asked if she would get the resident another meal. CNA #6 said, It is late and I don't think I can get a meal now. I am not sure how that works in this building. The resident told CNA #6 he had to eat something. CNA #6 stated she would try but could not promise he would get a meal. CNA #6 also stated that she did not see the call light over and it was difficult to view through the plastic partition. CNA #6 also stated the call light did not light up and she did not think it sounded at the nurse's station. She added that she was relatively new to the facility and had not been oriented to the resident's on the quarantine unit.
On 5/4/21 at 7:30 p.m., it was determined Resident #147 did not receive anything to eat until 2:30 p.m. He stated he got a hamburger and told the CNA to make sure it did not take place of his dinner. In addition, the resident said he was told he would receive double portions, but to date he had not. Random call lights were checked in each hallway to be fully operational as lit over the resident's door, as well as lit and heard at the nurse's station.
On 5/5/21 at 9:30 a.m., Resident #147 arrived from dialysis. LPN #1 hung the resident's IV antibiotic at around 10:00 a.m. She stated, I am agency staff and yesterday was my first day. I did not know anything about this building or the residents and I got behind in passing my medications. That's why his 9:00 a.m. IV antibiotic was hung at 1:00 p.m. I was not sure if he was getting this antibiotic through a midline or a central line because it was in his neck and I wanted to flush it correctly. The LPN was not able to explain why she could not have had the aide or another nurse to offer and provide the alternate/substitute meal.
On 5/6/21 at 12:42 p.m., the Wound Care Physician (WCP), accompanied by a first day agency LPN (#2). When the WCP cut the soiled outer Kling wrap off of the resident's feet, the taped portion revealed a date of 5/4/21 which indicated the facility staff neglected to perform the resident's wound care once a day and as needed per physician's order dated 5/3/21. The wound exhibited a foul odor with heavy serous exudate.
On 5/6/21 at approximately 2:00 p.m., the Administrator donned full PPE and was shown the condition of the resident's room and the over flowing trash and soiled linen in the resident's bathroom, as well as blood, trash, feces and other debris identified on the floor. The Administrator requested the housekeeper to assist to empty the biohazard receptacles and clean the room. The Administrator was informed that this Surveyor #2 performed random checks of the call light system to reveal no problems. The Administrator was also informed of all of the aforementioned issues that constituted neglect of care and services for Resident #147; call bell response time, refusing to retrieve an alternate meal, late administration of the IV antibiotic, infection control issues of blood and feces on the floor and over flowing trash and linen in the bathroom, and lack of daily dressing changes to foot wounds and as needed.
On 5/10/21 at 5:59 p.m., a debriefing was conducted with the Administrator, the Director of Nursing (DON) and the Regional Director of Clinical Services. The DON stated and the Administrator concurred that it was an expectation that call bells were answered timely, rooms are clean, and treatments and medications are to be performed as ordered by the physician.
The facility's policy and procedures titled Resident Abuse-Staff to Resident dated 2/2017 and revised 4/2020 indicated that neglect was the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. It may include, but not limited to . Failing to answer call bells to provide needed assistance.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to ensure Resident #346's Plan of Care Summary to include his care plan goals was sent upon or shor...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to ensure Resident #346's Plan of Care Summary to include his care plan goals was sent upon or shortly after transfer/discharge to the hospital on [DATE].
Resident #346 was admitted to the facility on [DATE]. Diagnosis for Resident #346 included but not limited to Acute Renal Failure.
The resident's Minimum Data Set (MDS) assessment was not due. Review of Resident #346's admission assessment dated [DATE] documented the residents was independent in decisions regarding task of daily life, indicating no cognitive impairment.
The Discharge MDS assessments was dated for 05/08/21 - discharged with return anticipated.
On 05/08/21 at approximately 1:28 p.m., according to the facility's documentation, Resident #346 was administered Tylenol 500 mg for an elevated temperature of 100.8 and was unable to sit up without having severe pain. Resident #346 was reassessed, temperature at 101.7. The physician was notified of change in condition with new order to send to (name of hospital) for evaluation for fever and shaking.
A phone interview was conducted with the Administrator and Director of Nursing (DON) on 05/10/21 at approximately 4:10 p.m. The DON said Resident #346's Care Plan Summary should have been sent to with him to the hospital or shortly after. He said the Care Plan Summary allows the receiving provider to maintain and continue with continuity of care.
A pre-exit conference was conducted with the Administrator, Director of Nursing and Cooperate Nurse on 05/10/21 at approximately 6:30 p.m. No further information was provided prior to exit.
Facility policy titled, Transfer of Residents from the Facility did not address the above concerns.
Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to send all the necessary documentation; including care plan goals with the resident upon transfer to the hospital for 2 of 34 residents in the survey sample, Resident #17 and #346.
The findings included:
1. Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but were not limited to type two diabetes without complications, obesity due to excess calories, atrial fibrillation, post COVID -19, and cognitive social or emotional deficit following unspecified cerebrovascular disease. Resident #17's most recent MDS (Minimum Data Set) assessment was an annual assessment with an ARD (Assessment reference date) of 12/31/20. Resident #17 was coded as being severely impaired in cognitive function scoring 05 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam.
Review of Resident #17's clinical record revealed that he was sent out to the hospital on [DATE] at 9:45 p.m. The following nursing note was documented: R (Resident) lethargic, will not close mouth to drink water, starting off to the right. R vitals b/p (blood pressure) 88/43, P (pulse) 56, R(16), T(Temp)-97.1, 02 (Oxygen) Sats 87. R c/o (complaints), sob (short of breath), chest pain. NP (Nurse Practitioner) (Name) notified, new order to send to ER (emergency room) for eval (evaluation) and treat .Transport arrived at 2145 (9:45 p.m.) to transport resident R .
There was no evidence that all the required documentation; including care plan goals was sent with Resident #17 at the time of discharge.
Further review of Resident #17's clinical record revealed a nursing note dated 12/18/20 (following day) that documented the following: Note Text: Recv'd (received) request from (Name of hospital) and residence (sic) medication list, code status and last notes prior to transfer to the ER. All documents faxed to (Number).
There was still no evidence that care plan goals were sent with Resident #17 at the time of transfer.
On 5/6/21 at 2:52 p.m., an interview was conducted with LPN (Licensed Practical Nurse) #9, the nurse who discharged Resident #17 to the hospital. When asked if she had discharged Resident #17 to the hospital, LPN #9 stated, I think I did, he was in acute respiratory distress. When asked if she sent any documents with Resident #17 to the hospital; LPN #9 stated that she sent the resident's medication list, treatment list, face sheet, by fax to the hospital. LPN #9 confirmed that she had sent these items after he had been transferred when the hospital physician had called and asked for any recent lab tests. LPN #9 stated that Resident #17 had to be sent out urgently and that the facesheet was the only document that was actually sent with the resident at the time of transfer. When asked if she had send the care plan or care plan goals; LPN #9 stated, No, not from me. I don't know what staff did in terms of paperwork. LPN #9 stated that she didn't work at the facility full time, that she picked up shifts if needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review and clinical record review the facility staff failed send a copy of the ...
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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 send a copy of the Bed-Hold Policy upon discharge/transfer for 1 of 34 resident's (Resident #346) after being transferred and admitted to the hospital.
The findings included:
The facility staff failed to ensure that Resident #346 or his resident's representative was provided a copy of the bed hold policy upon discharge/transfer to the hospital on [DATE]. Resident #346 was admitted to the facility on [DATE]. Diagnosis for Resident #346 included but not limited to Acute Renal Failure.
The resident's Minimum Data Set (MDS) assessment was not due. Review of Resident #346's admission assessment dated [DATE] documented the residents was independent in decisions regarding task of daily life, indicating no cognitive impairment.
The Discharge MDS assessments was dated for 05/08/21 - discharged with return anticipated.
On 05/08/21 at approximately 1:28 p.m., according to the facility's documentation, Resident #346 was administered Tylenol 500 mg for an elevated temperature of 100.8 and was unable to sit up without having severe pain. Resident #346 was reassessed, temperature at 101.7. The physician was notified of change in condition with new order to send to (name of hospital) for evaluation for fever and shaking.
A phone interview was conducted with the Administrator and Director of Nursing (DON) on 05/10/21 at approximately 4:10 p.m. The Administrator said the Bed Hold policy should have been given or sent shortly after discharge to the hospital. When asked, What the purpose of giving the bed hold policy the Administrator, replied It gives the resident/representative the opportunity to do a bed hold while they are in the hospital.
A pre-exit conference was conducted with the Administrator, Director of Nursing and Cooperate Nurse on 05/10/21 at approximately 6:30 p.m. No further information was provided prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility staff failed to ensure a comprehensive care plan was developed within seven (7) days after completion of the compre...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility staff failed to ensure a comprehensive care plan was developed within seven (7) days after completion of the comprehensive assessment for 1 of 34 residents in the survey sample, Resident 40.
1. For Resident #40, the facility staff failed to ensure resident had a comprehensive care plan developed within 7 days after completion of the comprehensive assessment. Resident #40 was admitted to the facility on [DATE]. Diagnosis included but were not limited to Vascular Dementia Without Behavioral Disturbance, Cerebrovascular Disease, Unspecified and Type 2 Diabetes Mellitus With Other Circulatory Complications. Resident #40's admission Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 04/05/2021 was coded with a BIMS (Brief Interview for Mental Status) score of 13 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #40 as requiring supervision of 1 with eating, extensive assistance of 2 for bed mobility, transfer and dressing, total dependence of 1 for personal hygiene and bathing and total dependence of 2 for toilet use.
On 05/05/2021 at approximately 10:00 a.m. review of Resident #40's admission Minimum Data Set revealed the following: A2300. Assessment Reference Date Observation end date: 4/5/2021
On 05/05/2021 at approximately 10:00 a.m. review of Resident #40's clinical record was reviewed and revealed no evidence of comprehensive care plan.
On 05/05/2021 at 2:00 p.m., an interview was conducted with MDS Coordinator. When asked for a copy of Resident #40's comprehensive care plan, MDS Coordinator stated, I just started today. This surveyor reviewed with MDS Coordinator that Resident #40 was admitted to the facility on [DATE]. When asked when should Resident #40's comprehensive care plan be completed, MDS Coordinator stated, Within 14 days of admission. When asked does Resident #40 have a comprehensive care plan, MDS Coordinator stated, I don't see the completed comprehensive care plan. It was initiated on 03/30 but was not completed. MDS Coordinator provided a copy of Resident #40's Baseline Care Plan to surveyor.
The Interim Administrator, Interim Director of Nursing and Corporate Nurse was informed of the finding on 05/10/2021 at approximately 8:30 p.m. at the pre-exit meeting. When asked should the resident have a completed comprehensive care plan, Corporate Nurse stated, Yes, 7 days after the MDS was completed.
The facility did not present any further information about the findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interviews, clinical record review, and review of facility's documents, the facility staff fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interviews, clinical record review, and review of facility's documents, the facility staff failed to ensure 1 of 34 residents in the survey sample (Resident #346's) abdominal surgical wound had an alternate treatment until the primary treatment (a negative pressure wound vac) was available.
2. The resident's Minimum Data Set (MDS) assessment was not due. Review of Resident #346's admission assessment dated [DATE] documented the residents was independent in decisions regarding task of daily life, indicating no cognitive impairment. In addition, the admission Assessment was coded for having an abdominal surgical wound requiring surgical wound care (wound vac.) The admission Assessment under skin was coded for having an abdominal surgical wound - area measured 2.8 cm x 3.8 cm x 1.1 cm.
Resident #346's record did not reveal a 48 hour baseline care or an interim care plan.
Review of Resident's #346 discharge summary 05/03/21 read in part: Instructions for follow-up (Routine wound vac changes to midline abdomen surgical wound.)
On 05/05/21 at approximately 9:25 a.m., a phone interview was conducted with Resident #346. Resident #346 said, he was shot in the stomach and had surgery; there is a wound to my stomach but it's not being treatment. He said there was a machine attached to my stomach when I was in the hospital (wound vac.)
Review of Resident #346's Physician Order Summary (POS) and Treatment Administration Record (TAR) for May 2021 did not include an abdominal wound treatment or a wound vac.
A phone interview was conducted with the Director of Nursing (DON) on 05/05/21 at approximately 1:26 p.m. The
DON stated, If the wound vac was not available then the physician should have been notified for alternative order until the wound vac arrived.
A phone interview was conducted with the medical supply clerk on 05/05/21 at approximately 3:05 p.m. She stated, The agency nurse informed me on Monday, 05/03/21 that Resident #346 was being admitted and needed a wound vac. She said I was not sure if we rented the machine or if we had one here in the facility. She proceed to stay; I was waiting for the order so I could order the wound vac but an order was never given to me.
On 05/10/21 at approximately 2:25 p.m., a phone interview was conducted with Chief Clinical Officer of Operations (CCOO). She said on Sunday (05/09/21) the staff informed her that a wound vac was needed for Resident #346 and there wasn't one in the building. The CCOO stated, We had a back-up wound vac in the building. The CCOO said she walked into the supply room, the wound vac was located on the bottom shelf in a box (ready to go.) When asked how the box was labeled, she replied, The box was labeled Cardinal - Negative Pressure Wound Therapy (NPWT) and next to the wound vac was a plastic container with wound vac supplies. The CCOO said she walked the supply clerk to the supply room and showed her where the wound vac was located.
A phone interview was conducted with the central supply clerk on 05/10/21 at approximately 3:29 p.m. She said there was a backup wound vac in the medical supply room. She said, The box was not labeled as a wound vac and that was what I was looking for.
A phone interview was conducted with the Administrator and Director of Nursing (DON) on 05/10/21 at approximately 4:10 p.m., and was informed that Resident #346's Discharge summary dated [DATE] revealed to continue with a wound vac to the mid-line surgical wound; but the treatment for the wound vac was never initiated. They were also made aware that there was a wound vac in the supply room the day Resident #346 entered the building but the staff did not realize the Cardinal - Negative Pressure Wound Therapy (NPWT) was actually the wound vac. No further information was provided
A pre-exit conference was conducted with the Administrator, Director of Nursing and Cooperate Nurse on 05/10/21 at approximately 6:30 p.m. No further information was provided prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff and resident interviews, the facility staff failed to follow physician orde...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff and resident interviews, the facility staff failed to follow physician orders to provide foot care for 1 of 34 residents (R#147) in the survey sample.
The findings included:
Resident #147 was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus, chronic diabetic wounds of right and left foot with status post bilateral transmetatarsal amputations and skin graft infections, end stage renal disease with dependence on hemodialysis.
The 5-day Minimum Data Set (MDS) assessment was dated 4/30/21 and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible score of 15 which indicated the resident had the necessary cognitive skills for daily decision making. Resident #147 had no problems understanding the staff and was understood. Resident #147 was assessed without mood or behavioral problems. Resident #147 required extensive assistance from 2 staff for bed mobility and toilet use. Resident #147 was not assessed to be able to ambulate (walk in and out of room). Resident #147 had bilateral lower extremity impairment in range of motion. The wheelchair was Resident #147's primary mode of transportation. Resident #147 was coded with surgical wounds and infection of feet. The assessment was signed by the MDS Coordinator as completed on 5/10/21.
There was no care plan to include a baseline 48-hour care plan or interim care plan available to this surveyor during the time of the survey.
The following observations were made of Resident #147's foot:
On 5/4/21 at 1:05 p.m., Resident #147 was observed sitting on the side of the bed. The left and right foot dressing exhibited serous bloody drainage which was also visible on the floor where the resident placed his feet. The Kling wrap on the left foot was unraveled and intertwined itself around the wheels of his over bed table. Resident #147 stated that his dressing had been in that condition all night and he had been asking someone to change his dressings. The foot of his bed exhibited the same drainage on his sheets at the foot of the bed.
On 5/6/21 at 12:42 p.m., the Wound Care Physician (WCP), accompanied by a first day agency LPN (#2). When the WCP cut the soiled outer Kling wrap off of Resident #147's foot, the taped portion revealed a date of 5/4/21 which indicated the the facility staff failed to perform the resident's wound care once a day and as needed per physician's order dated 5/3/21. The wound exhibited a foul odor with heavy serous exudate.
On 5/6/21 at approximately 2:00 p.m., the Administrator was informed of the facility's failure to follow physician orders for Resident #147's foot care.
On 5/10/21 at 5:59 p.m., a debriefing was conducted with the Administrator, the Director of Nursing (DON) and the Regional Director of Clinical Services. The DON stated and the Administrator concurred that it was an expectation that treatments are to be performed as ordered by the physician.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a resident interview and staff interviews the facility staff failed to ensure 1 of 34 residents in the survey sample re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a resident interview and staff interviews the facility staff failed to ensure 1 of 34 residents in the survey sample received appropriate sized incontinent products for 3 days, Resident #5.
The findings included:
Resident #5 was admitted to the facility on [DATE] with diagnoses to included but not limited to Major Depressive Disorder, Dementia, Anxiety Disorder and Hypertension.
The most recent Minimum Data Set (MDS) was an Annual with an Assessment Reference Date (ARD) of 2/10/21. The Brief Interview for Mental Status (BIMS) for Resident #5 was coded as a 15 out of a possible 15 which indicates the resident is cognitively intact and capable of daily decision making. Under Section H Bladder and Bowel H0300 Urinary Continence and H0400 Bowel Incontinence Resident #5 was coded as a 2 Frequently Incontinent.
Resident #5's current comprehensive care plan was reviewed and is documented in part, as follows:
Focus:
Name (Resident #5) has an alteration in elimination of bladder related to urinary urgency due to use of Diuretic as evidenced by urinary incontinence-at risk for skin breakdown. 2/18/2021
Interventions: Check resident frequently for incontinence and assist with incontinence care as needed. 11/23/2020
On 5/4/21 at 2:00 P.M. during an onsite interview about resident supplies Resident 5# stated, They are always running short on pull ups. Name (Central Supply Staff Member) does her best but supplies never get here on time. One time I had to wear the wrong size briefs for 3 days.
On 5/5/21 at 1:29 P.M. a phone interview was conducted with the Central Supply Staff Member regarding Resident #5's claim that she had to wear the wrong size pull up for 3 days.
Central Supply Staff Member stated, There was an issue, we had a bad storm a few months ago I think in early February and the trucks were late. Name (Resident #5) wears 2 extra large pull ups and during that time she had to wear a men's extra large for about 2 to 3 days. The aids let me know she was running low on the briefs and I let them know her right size had come in and they could give her the right size now.
On 5/10/21 at 12:15 P.M. a pre-exit debriefing via phone was conducted with the Interim Administrator, the Acting Director of Nursing and the Regional Director of Clinical Services where the above information was shared. The Interim Administrator was asked what would have been the expectation for ensuring that Resident #5 had appropriate incontinent supplies. The Acting Director of Nursing stated, If we did not have her size we would need to go to Walmart or somewhere else to get what would fit her. The Interim Administrator was asked if there was a facility policy for maintaining resident supplies and he stated, No, we do not have a policy.
Prior to exit no further information was shared.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record review and facility documentation, the facility staff failed to ensure 1 of 6 residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record review and facility documentation, the facility staff failed to ensure 1 of 6 residents (Resident #346) in the survey sample had dialysis orders.
The findings included:
The facility staff failed to ensure dialysis order were obtained for Resident #346.
Resident #346 was admitted to the facility on [DATE]. Diagnosis for Resident #346 included but are not limited to Acute Kidney Failure (on dialysis). The resident's Minimum Data Set (MDS) assessment was not due. Review of Resident #346's admission assessment dated [DATE] documented the residents was independent in decisions regarding task of daily life, indicating no cognitive impairment. In addition, the admission Assessment under special treatment was coded for dialysis.
The facility did not provide a dialysis care plan.
Review of Physician Progress note dated 05/06/21 read in part: Resident #346 has a right IJ temporal dialysis catheter placement as his renal function worsened and he was started on hemodialysis.
Review of Resident #346's Physician Order Summary (POS) for May 2021 did not include orders for Dialysis.
On 05/05/21 at approximately 10:45 a.m., a phone interview was conducted with License Practical Nurse (LPN) #7. LPN #7 was asked to review Resident #346's current dialysis orders. After LPN #7 reviewed Resident #346's orders, she replied, I'm not able to locate dialysis orders for Resident #346. She said, I have never been assigned to Resident #346 as his nurse but there should be orders for dialysis to include his days to attend dialysis and to monitor his dialysis site every shift for s/s of infection.
A phone interview was conducted with the Director of Nursing (DON) on 05/05/21 at approximately 1:26 p.m. The DON said Resident #346 should have had dialysis orders on the day of his admission [DATE]) to include the following: location of the dialysis site, day(s) the resident is to attend dialysis, chair time, and to assess the dialysis site every shift.
During the clinical record review for Resident #346, revealed the following order dated 05/05/21 at 3:38 p.m.: Dialysis on Tuesday, Thursday and Saturday; transport (name of company) to pick up at 10:30 a.m., with a chair time of 11:30 a.m.
A pre-exit conference was conducted with the Administrator, Director of Nursing and Cooperate Nurse on 05/10/21 at approximately 6:30 p.m. No further information was provided prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review the facility staff failed to ensure the physician reviewed pharmacy recommen...
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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 the physician reviewed pharmacy recommendations for 2 residents (Resident #4, #43) of 34 residents in the survey sample.
The findings included:
1. Resident #4 was admitted to the facility on [DATE]. Diagnosis included but were not limited to, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side and Major Depressive Disorder. Resident #4's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 02/09/2021 was coded with a BIMS (Brief Interview for Mental Status) score of 08 indicating moderate cognitive impairment. The Minimum Data Set coded Resident #4 as requiring extensive assistance of 2 for bed mobility and dressing, total dependence of 1 for eating and total dependence of 2 for transfer, toilet use, personal hygiene and bathing.
On 05/05/2021 at approximately 2:00 p.m., review of Resident #4's clinical record revealed the following:
Pharmacy Review dated 02/07/2021 was reviewed and revealed the following: 1. Patient Recommendations 2. Recommendations made, review Clinical Pharmacy Report.
On 05/06/2021 requested Clinical Pharmacy Report for Pharmacy Review dated 02/07/2021.
On 05/10/2021 at approximately 10:00 a.m., requested copy of facility policy and procedure regarding Medication Regimen Reviews.
On 05/10/2021 at approximately 10:15 a.m., Clinical Pharmacy Report for Pharmacy Review dated 02/07/2021 was received and review revealed the following: MRR Date: 2/7/2021 This resident has been taking Citalopram, Ativan, and Amitriptyline since 8/14/2020. Please evaluate to see if any can be reduced.
On 05/10/2021 at approximately 11:00 a.m. review of Medication Administration Record for August 2020 revealed the following: Citalopram Hydrobromide Tablet 20 MG (Milligram) Give 1 tablet via PEG-Tube one time a day for depression Order Date - 08/14/2020 1205.
On 05/10/2021 at approximately 11:00 a.m. review of Medication Administration Record for September 2020 revealed the following: Amitriptyline HCI Tablet 25 MG Give 2 tablet via PEG-Tube at bedtime for depression Order Date - 09/02/2020 2304; Ativan Tablet 1 MG (Lorazepam) Give 1 tablet via G-Tube three times a day for Restlessness/Agitation Order Date - 09/17/2020 0555.
On 05/10/2021 at approximately 11:00 a.m. review of Medication Administration Record for May 2021 revealed the following: Amitriptyline HCI Tablet 25 MG Give 2 Tablet via PEG-Tube at bedtime for depression Order Date - 09/02/2020 2304; Citalopram Hydrobromide Tablet 20 MG Give 1 tablet via PEG-Tube one time a day for depression Order Date - 08/14/2020 1205; Ativan Tablet 1 MG (Lorazepam) Give 1 tablet via G-Tube three times a day for Restlessness/Agitation Order Date - 09/17/2020 0555.
On 05/10/2021 at approximately 11:15 a.m. review of Physician Progress Notes in Resident #4's clinical record did not evidence documentation that the attending physician reviewed the identified irregularity and what, if any, action was taken to address it. Unable to locate evidence of documented rationale for no change in the medication.
The Interim Administrator, Interim Director of Nursing and Corporate Nurse was informed of the finding on 05/10/2021 at approximately 8:30 p.m. at the pre-exit meeting. When asked what is the process for Medication Regimen Reviews, Interim Director of nursing stated, Pharmacy comes in, DON (Director of Nursing) to review and give to attending physician to agree or disagree with recommendation. The facility did not present any further information about the finding.
2. Resident #43 was initially admitted to the facility on [DATE]. Resident #43 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnosis included but were not limited to, Unspecified Fracture Of Left Femur and Depression. Resident #43's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 04/12/2021 was not coded with a BIMS (Brief Interview for Mental Status) score. The Minimum Data Set coded Resident #43 as requiring extensive assistance of 1 for eating, extensive assistance of 2 for bed mobility, transfer and toilet use and total dependence of 2 for dressing, personal hygiene and bathing.
On 05/05/2021 at approximately 3:00 p.m., review of Resident #43's clinical record revealed the following:
Medication Administration Record for May 2021 was reviewed and revealed the following: Xanax Tablet 0.25 MG (Alprazolam) Give 1 tablet by mouth every 24 hours as needed for anxiety. Order Date - 04/08/2021 1940.
Pharmacy Review dated 4/12/2021 was reviewed and revealed the following: 1. Patient Recommendations 2. Recommendations made, review Clinical Pharmacy Report.
On 05/06/2021 requested Clinical Pharmacy Report for Pharmacy Review dated 04/12/2021.
On 05/10/2021 at approximately 10:00 a.m., requested copy of facility policy and procedure regarding Medication Regimen Reviews.
On 05/10/2021 at approximately 10:15 a.m., Clinical Pharmacy Report for Pharmacy Review dated 04/12/2021 was received and review revealed the following: MRR (Medication Regiment Review): 4/12/2021 CMS (Centers For Medicare & Medicaid Services) regulations require a 14 day stop on all PRN orders for psychoactive medications, including orders for hospice patients. A longer stop date can be ordered if a rationale for the extended time is documented in the patient's medical records. Please consider one of the following for this patient's Xanax PRN order.
On 05/10/2021 at approximately 2:00 p.m., after review of Resident #43's clinical record, unable to locate documented evidence that the attending physician reviewed the identified irregularity and what, if any, action was taken to address it. Unable to locate evidence of documented rationale for continued use.
On 05/10/2021 at approximately 5:00 p.m., requested copy of facility policy and procedure regarding Medication Regimen Reviews.
The Interim Administrator, Interim Director of Nursing and Corporate Nurse was informed of the finding on 05/10/2021 at approximately 8:30 p.m. at the pre-exit meeting. When asked what is the process for Medication Regimen Reviews, Interim Director of Nursing stated, Pharmacy comes in, DON (Director of Nursing) to review and give to attending physician to agree or disagree with recommendation. The facility did not present any further information about the finding.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review the facility staff failed to ensure that PRN (As Needed) orders for psychotr...
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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 that PRN (As Needed) orders for psychotropic medication was not ordered for longer than 14 days without a documented rationale for continued use for 1 resident (Resident #43) of 34 residents in the survey sample AND failed to implement Gradual Dose Reduction (GDR) interventions for the use of psychotropic medication as used by Resident #15.
The findings included:
1. Resident #43, the facility staff failed to ensure PRN (As Needed) Xanax was not ordered for longer than 14 days, without a documented rationale for continued use. Resident #43 was initially admitted to the facility on [DATE]. Resident #43 was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Diagnosis included but were not limited to, Unspecified Fracture Of Left Femur and Depression. Resident #43's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 04/12/2021 was not coded with a BIMS (Brief Interview for Mental Status) score. The Minimum Data Set coded Resident #43 as requiring extensive assistance of 1 for eating, extensive assistance of 2 for bed mobility, transfer and toilet use and total dependence of 2 for dressing, personal hygiene and bathing.
On 05/05/2021 at approximately 3:00 p.m., review of Resident #43's clinical record revealed the following:
Medication Administration Record for May 2021 was reviewed and revealed the following: Xanax Tablet 0.25 MG (Milligram) (Alprazolam) Give 1 tablet by mouth every 24 hours as needed for anxiety. Order Date - 04/08/2021 1940.
Pharmacy Review Dated 4/12/2021 was reviewed and revealed the following: 1. Patient Recommendations 2. Recommendations made, review Clinical Pharmacy Report.
On 05/06/2021 requested Clinical Pharmacy Report for Pharmacy Review dated 04/12/2021.
On 05/10/2021 Clinical Pharmacy Report for Pharmacy Review dated 04/12/2021 was received and review revealed the following: MRR (Medication Regiment Review): 4/12/2021 CMS (Centers For Medicare & Medicaid Services) regulations require a 14 day stop on all PRN orders for psychoactive medications, including orders for hospice patients. A longer stop date can be ordered if a rationale for the extended time is documented in the patient's medical records. Please consider one of the following for this patient's Xanax PRN order.
On 05/10/2021 at approximately 2:00 p.m., after review of Resident #43's clinical record, unable to locate evidence of documented rationale for continued use.
The Interim Administrator, Interim Director of Nursing and Corporate Nurse was informed of the finding on 05/10/2021 at approximately 8:30 p.m. at the pre-exit meeting. Corporate Nurse stated, Initial order for set number of days can continue if a medical need and after the physician reviews it. The facility did not present any further information about the findings.
2. The facility staff failed to implement Gradual Dose Reduction intervention for the use of psychotropic medication.
Resident #15 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, alcoholic cirrhosis of liver without ascities, acute and chronic respiratory failure with hypoxia, anxiety, insomnia and delirium.
Resident #15 Quarterly Minimum Data Set (MDS) dated [DATE] assessed this resident as having scored a (5) on the Brief Interview for Mental Status (BIMS).
A Care Plan dated 03/24/21 indicated: Focus- Resident #15 has the potential for drug related complications associated with use of psychotropic medications: Anti-psychotic medication- Goals- Resident #15 risk for psychotropic drug related complications will be minimized through next review- Interventions- Monitor for side effects and report to physician: Anti-anxiety/Hypnotic medications-drowsiness, morning, hang over, ataxia, dry mouth, constipation, blurred vision, urinary retention, headache, vertigo, nausea, hypotension, weakness, sedation, lethargy, confusion, memory loss and dependence.
Nursing to continue to review/follow-up recommendations from monthly pharmacy review of medication regimen with physician.
Obtain consent from patient/responsible party for use of psychotropic medications.
A review of the clinical records indicated Resident #15 received Olanzapine tablets 10 mg (milligrams) at bed time for mood disorder.
A review of the clinical records indicated this resident began receiving Olanzapine tablets 10 mg on 4/20/20. A review of the clinical records did not indicate a GDR had been attempted.
During an interview on 05/11/21 with the Administrator he stated, no information could be found that Resident #15 had a GDR attempted.
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 a complaint investigation, observations, resident interview and facility documentation, the facility staff failed to pr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a complaint investigation, observations, resident interview and facility documentation, the facility staff failed to provide a separately locked, permanently affixed compartment for all controlled drugs to include those brought from resident homes on admission for 1 of 34 residents (Resident #146) in the survey sample.
The findings included:
Resident #146 was admitted on [DATE] to receive respite/palliative care. He was discharged home on 5/5/21.
There was no completed Minimum Data Set (MDS) due to the resident's short-stay.
The History and Physical (H&P) dated 5/3/21 indicated that the resident was in the facility under the care of hospice for respite. He was alert and responsive. No Intravenous fluids to be given or laboratory specimens obtained.
Resident was ordered Morphine Sulfate 20 mg/ml, give 0.5 ml by mouth every 4 hours as needed for pain or shortness of breath.
On 5/4/21 at 7:00 p.m. narcotic counts were observed by this surveyor (#2) for the facility's 2 medication carts, 100 and 200/300. All narcotics were accounted for in a affixed compartment on the locked medication cart except a discovered Morphine Sulfate 20 milligrams (mg)/1 milliliters (ml), give .5 ml (10 mg) every 4 hours by mouth (po) for a resident that was admitted for respite care (Resident #146), located in the bottom drawer of the medication cart 200/300. The Morphine Sulfate was found in a bag with several of Resident #146's personal non-narcotic medications. Licensed practical Nurse (LPN #4) said she knew it was there, but there should have been a Controlled Record narcotic flow sheet for the resident's narcotic medication and counted along with the other narcotics, 18 milliliters (ml) recorded as the count for Resident #146's Morphine Sulfate. It was also determined that the Morphine Sulfate was not maintained in the separate affixed compartment in the medication cart as the other resident's narcotics.
On 5/6/21 at 10:30 a.m., the Director of Nursing (DON) said Resident #146's narcotic medication brought from home should have been locked in the narcotic box with a slip and counted along with the other narcotics until picked up by the family or in the aforementioned case, picked up by hospice. He took this surveyor (#2) to demonstrate that the medication for resident's Morphine Sulfate narcotic was transferred behind a double lock and counted along with the other narcotics. The amount of Morphine Sulfate was as observed on 5/4/21, 18 ml remained. This resident was discharged home on 5/5/21.
On 5/10/21 at 5:59 p.m., a debriefing was conducted with the Administrator, the Director of Nursing (DON) and the Regional Director of Clinical Services. There aforementioned issues were re-reviewed and the DON and Administrator reiterated their expectations of the licensed nurses. There was no further documents or added information presented prior to survey's remote exit on 5/11/21.
The facility's policy and procedures titled Storage of Medication dated 2007 indicated that controlled medications must be stored separately from non-controlled medications. The access system (key, security codes) used to lock Schedule II medications and other medications subject to abuse, cannot be the same access system used to obtain the non-scheduled medications. Schedule II medications and preparations must be stored in a separately locked affixed compartment. Schedules III-IV and non-controlled medications that have been identified by the nursing care center, as having the potential for abuse may also be stored with the Schedule II medication.
COMPLAINT DEFICIENCY
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interviews, the facility's staff failed to ensure the midday meal served 5/5...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interviews, the facility's staff failed to ensure the midday meal served 5/5/21, at an appetizing temperature and palatable enough to encourage each resident to increase meal consumption for 2 of 34 residents (Resident #36 and #147), in the survey sample.
The findings included:
1. On 5/4/20 at approximately 12:40 p.m., observations of the midday meal were made in the main dining room. The menu read Baked ziti with meat sauce, Caesar salad, garlic bread and a strawberry shortcake square but they received herbed pork chop, sliced carrots, mashed potatoes and fruit. Eleven residents in the dining room received the regular (non-chopped or mechanically altered) meal and ten didn't consumed the pork chop.
Resident #36 was originally admitted to the facility 7/14/21 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Parkinson's Disease, depression, low back pain, lumbar diskitis, and arthritis.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/2/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15.
On 5/4/20 at approximately 1:15 p.m., an interview was conducted with Resident #36. Resident #36 stated, we ever know what we will be served and it's always terrible. Resident #36 further stated before the pandemic they took trips to Wal-Mart frequently, there he purchased snacks and items to consume when the meals were totally unacceptable. Resident #36 also stated there are never alternatives listed on the menus outside the dining room door therefore; you have no idea if to request the alternate or what the alternate is. The resident stated on occasion he had requested the alternate, to be told by the dietary staff that a one hour notice is necessary to get the alternate. The resident stated most of his weight loss was a result of the terrible food and no one has discussed with him preferences or substitutes for food dislikes.
On 5/5/21, at approximately 10:00 a.m., a group interview was conducted with 4 residents. The consensus of the group was the food quality is not good, the vegetables are always mushy from being over-cooked and even if you consume your meals in the dining room the food comes out of the kitchen cold.
As a result of the voiced concerns about meal; a test tray was obtained at the midday meal on 5/5/21. It was the last tray served, arriving at approximately 1:00 p.m. The meal consisted of barbeque pork regular texture, chopped pork and pureed pork, okra, mashed potatoes and broccoli. The kitchen temperatures readings were as followed; regular pork 190.5 degrees , okra 202 degrees, mashed potatoes 196 degrees and the Tater tots were 155 degrees.
On 5/5/21 at 12:20 p.m., the last food cart arrived on 100 hall. Trays were passed out and moved to 200 hall. On 5/5/21 at 12:47 p.m., the last person was served their lunch on the 200 hall. On 5/5/21 at 12:51 p.m., the test plate observed to have a lid but no bottom warmer, the items were obtained in the conference room by the District Dietary Manager. Food temperatures were as follows in degrees Fahrenheit:
Pork on a bun: 99.8, Mashed Potatoes: 112.1, Tator Tots: 90.6, Puree Pork: 100.0. The
food was tasted by three surveyors at 12:55 p.m. All items were at an unpalatable temperature. The tator tots were extremely hard and the mashed potatoes were bland. When asked the District Dietary Manager stated he thought a temperature of , 115 degrees on everything. was considered palatable to hold and serve food.
After the test tray and the results were discussed with the District Dietary Manager, he request another opportunity to prove himself with the meal for he stated it shouldn't have taken so long for the meal trays to be distributed to the resident. Another test tray wasn't request but meal distribution time was reassessed 5/7/21, during the breakfast meal. The last tray to be delivered to the resident was 8:54 a.m., that was well over one hour after leaving the kitchen.
On 5/10/21 at approximately 7:00 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Director of Clinical Services. The Director of Nursing stated it was their expectation that resident meals arrive at a temperature and taste that's appealing and enjoyable.
2. Resident #147 was not able to chew and consume the meat served to him during the lunchmeal on 5/4/21.
Resident #147 was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus, chronic diabetic wounds of right and left foot with status post bilateral transmetatarsal amputations and skin graft infections, end stage renal disease with dependence on renal dialysis.
The 5-day Minimum Data Set (MDS) assessment was dated 4/30/21 and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible score of 15 which indicated the resident had the necessary cognitive skills for daily decision making. The resident had no problems understanding the staff and was understood. The resident was assessed without mood or behavioral problems. Resident #147 required extensive assistance from 2 staff for bed mobility and toilet use. He was not assessed to be able to ambulate (walk in and out of room). He had bilateral lower extremity impairment in range of motion. The wheelchair was the resident's primary mode of transportation. The resident was coded with surgical wounds and infection of feet. The assessment was signed by the MDS Coordinator as completed on 5/10/21.
There was no care plan to include a baseline 48-hour care plan or interim care plan available to this surveyor during the time of the survey.
On 5/4/21 at 1:05 p.m., Resident #147 stated when they served him his lunch meal around 12:15 p.m., he took one bite from a pork chop and could not consume it because it was tough with no taste, thus he spit it out. He also stated he wanted coffee and they gave him iced tea with no sugar substitute. On 5/4/21 at 7:30 p.m., it was determined Resident #147 did not receive anything to eat until 2:30 p.m. He stated he got a hamburger and told the CNA (#6) to make sure it did not take place of his dinner. In addition, the resident said he was told he would recieve double portions, but to date he had not.
On 5/10/21 at 5:59 p.m., a debriefing was conducted with the Administrator, the Director of Nursing (DON) and the Regional Director of Clinical Services. They were informed of the issues with the resident's meal that was served to him on 5/4/21. No further information was provided prior to survey exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, and review of facility documents, the facility's staff failed to ensure on 5/10/21, the dishwasher temperature reached the appropriate wash temperature to saniti...
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Based on observation, staff interview, and review of facility documents, the facility's staff failed to ensure on 5/10/21, the dishwasher temperature reached the appropriate wash temperature to sanitize the after breakfast dishes.
The findings included:
On 5/10/21 at approximately 9:50 a.m., observations of were made of the dishwashing machine during washing of the resident serving trays. After the first set of trays entered the cycle the dietary aide recorded the high wash temperature as 111 degrees and the high rinse temperature as 191 degrees. The trays were removed and placed on a rack which suspended each tray separately after-which another set of trays were put in the dishwasher, this time the high wash temperature only reached 109 degrees.
On 5/1/21, at approximately 9:57 p.m., an interview was conducted with the Dietary Aide who stated the wash temperature requirement is 150 degrees and the rinse requirement temperature was 180 degrees. The Dietary Aide stated she would notify the District Dietary Manager that the dishwasher not reaching the recommended temperature and he would determine how she should proceed with getting the dishes washed.
On 5/10/21 at approximately 1:40 p.m., the District Dietary Manager stated the dishwasher had been out of service quite a bit over the last few months and they had invested a large amount of money repairing it therefore; the company who services the dish machine was contacted about the wash temperature. The District Dietary Manager stated the representative for the dishwashing machine company stated the dishwasher ran off of a heat sanitizing system therefore the temperature had to reach 150 degrees to sanitize the dishes. The District Dietary Manager also stated he would initiate use of disposable products until the machine was repaired.
On 5/10/21 at approximately 7:00 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Director of Clinical Services. On 5/11/21 the District Dietary Manager stated the dishwashing machine was repaired in time for the evening meal 5/10/21.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
Based on staff interview and a review of facility documents, the facility's staff failed to conduct an ongoing review for antibiotic stewardship for one person in a survey sample of 43 residents.
The ...
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Based on staff interview and a review of facility documents, the facility's staff failed to conduct an ongoing review for antibiotic stewardship for one person in a survey sample of 43 residents.
The findings included:
On 5/10/21 at approximately 12:45 PM., an appointment was made with the administrator concerning the Antibiotic Stewardship Program for 2:00 PM.
On 5/10/21 A review of the antibiotic Infection Control Surveillance infection report log showed that only the months of March, April and May were available to view. The months of January and February were not available. No other supporting documents or forms were available to view per onsite surveyor.
On 5/10/21 at approximately 3:25 PM a review of the Antibiotic Stewardship Program was conducted with the ADON (Acting Director of Nursing) and with the Regional Director of Clinical Services (RDCS). The Director of Clinical Services stated, If a staff recognize a person is suspicious for infection they go to the DON (Director of Nursing) for Skin infections, UTI's (Urinary Tract Infections) or fever of unknown origin we do a Mcgreers form and we keep a tracking and trending log. The surveyor asked the ADON if he could get a list of people currently on antibiotics and if they had the Antibiotic Stewardship binder with them. The RDCS stated, There is no one with infections right now that I know of. We didn't bring it (Binder). It's down the hall.
The ADON and RDCS never returned calls to resume our meeting.
A review of Infection Control Surveillance Monthly logs show from March to May (2021) show a total of 15 infections were listed. (Including 2 infections for the month of May 2021)
On 5/10/21 at approximately 6:00 PM a team meeting was held with the Administrator, ADON and RDCS concerning the Antibiotic Stewardship Program. They were asked by the surveyor if they were conducting an ongoing review for antibiotic stewardship prior to this survey? The ADON stated,We need to continue our reviews for February 2021. I don't see any other documentation from what I sent you. (Surveyor only received the Infection Control Surveillance Infection logs)The RDCS stated, They are working on it. April wasn't completed. (April only list 1 Resident with an infection).
The facility's policy titled/date: Infection Control Program-Antibiotic Stewardship F-881. Dated: 2/2018. Policy Statement: This facility has established an infection prevention and control program that includes protocols to establish a system for the use and monitoring of adverse effects of antibiotics.
Residents whom need antibiotics are prescribed an antibiotic.
Antibiotic Stewardship: A set of commitments and actions designed to optimize this treatment of infections while reducing the adverse effects associated with antibiotic use.
Mcgreer Criteria: Surveillance criteria.
Epidemiology worksheet: RCA process to evaluate infections.
Procedure: The basic tenants of an antibiotic stewardship program include:
a. Appropriate prescribing.
b. Appropriate Administration
c. Management practices to reduce inappropriate use to ensure that residents receive the right antibiotic for the right indication, right dose and right duration.
Core elements on an antibiotic stewardship program:
Appropriate staff accountable for promoting and overseeing antibiotic stewardship;
Track measures of antibiotic use on the facility,one process and one outcome measure;
The antibiotic stewardship program will be reviewed annually.
On 5/11/21 at approximately 9:30 AM the above findings were shared with the Administrator and The Acting Director of Nursing (ADON) An opportunity was offered to the facility's staff to present additional information but no additional information was provided. The ADON stated, The ADON Stated, We're missing February's Surveillance.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, and a review of facility documents, the facility staff failed to designate at least one qualified Infection Preventionist.
The findings included:
On 5/06/21 at a...
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Based on observation, staff interview, and a review of facility documents, the facility staff failed to designate at least one qualified Infection Preventionist.
The findings included:
On 5/06/21 at approximately 9:15 AM an interview was conducted with the ADON (Acting Director of Nursing) Concerning the Infection Preventionist (IP). He stated, We had an Infection Control Nurse (RN #3) but she left abruptly on April 28th. I'm assuming the role. I registered for class on yesterday. I'm going to try to start the training this weekend. He was asked by the said surveyor if he could email the Infection Control Training certificate of the former Infection Control Preventionist as well as a copy of his registration for the Infection Control class. He stated, Okay.
Received Infection Prevention and Control Certificates of Training on 5/07/21 for RN #3. The certificates show that out of fifteen modules only 14 were completed. Module #7 was not available.
The following email was sent to the Administrator on 5/07/21 at approximately 9:38 AM after receiving RN #3's Infection Prevention Training documents. It read: Good morning! I'm missing module 7 of RN (Registered Nurse) #3, Former Infection Preventionist Training. Did you find out if she has the completion certificate? When did she leave your facility? You also mentioned that the MDS Coordinator had completed the training-where is the completion certificate?
On 5/07/21 an interview was conducted with the administrator concerning the incomplete training certificates on RN #3 and the Antibiotic Stewardship program. He stated, I'll assign someone today.
Several attempts were made throughout the survey to speak with someone concerning the Infection and Prevention Program without much success.
On 5/07/21 at approximately, 11:00 AM an interview was conducted with RN #3. She was informed of the said surveyor receiving her incomplete IFC (Infection Control) Modules. She stated, that she no longer worked at the said facility but is now working at a sister facility. I'm helping out today. I will have them email you my completed certificate (IPC).
No IPC completion certificate was received during the survey.
On 5/11/21 at approximately 9:30 AM., the above findings were shared with the ADON and the Administrator. The ADON (Acting Director of Nursing) stated, We had an Acting DON, I'm not sure if she had the infection control program completed. The new DON started today. There was a gap of a week. The person walked out and I assumed the role for a couple of days. An opportunity was offered to the facility's staff to present additional information but no additional information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0886
(Tag F0886)
Could have caused harm · This affected 1 resident
Based on observations, staff interviews and facility documentation. The facility staff failed to implement COVID-19 testing to all staff.
The findings include:
The facility staff failed to test five n...
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Based on observations, staff interviews and facility documentation. The facility staff failed to implement COVID-19 testing to all staff.
The findings include:
The facility staff failed to test five nursing staff during their twice weekly COVID-19 testing. Therefore, increasing the chances of spreading COVID-19.
A review of the as worked schedule and Employee COVID-19 consent forms reveal that the following nursing staff were not tested for COVID-19.
LPN (License Practical Nurse) #15, CNA (Certified Nurses Aide) #1 and CNA #7 worked on 5/03/21 (Monday). LPN #3 worked on 5/05/21 (Wednesday). LPN #1 and LPN #7 worked on 5/06/21 (Thursday). LPN #15 and CNA #5 worked on 5/07/2. CNA #5 worked on 5/09/21.
An interview was conducted on 5/06/21 at approximately 2:55 PM with CNA (Certified Nursing Assistant) #1 concerning the COVID-19 test. She stated, We get tested twice weekly. Monday and Thursday. I received my first COVID19 vaccine shot on yesterday.
An interview was conducted with LPN (Licensed Practical Nurse) #15 on 5/10/21 at approximately 9:15 PM., Concerning the COVID-19 testing at the facility. She stated, I get tested on ce a week. Initially it was twice a week. They did a courtesy call today to tell me that they're testing tomorrow between 7:00 AM and 11:00 AM I wasn't tested last week. I did work. I waited around after getting off work and the person that does the testing wasn't there. I waited until 8 am.
On 5/10/21 (Monday) at approximately, 9:20 PM an interview was conducted with CNA #5, concerning the COVID-19 test. She stated, The next test is Friday. They told me to come fifteen minutes early for the test. I'm new here. I started two days ago on a Saturday I think. I wasn't tested for COVID-19 yet. I haven't received the vaccine either. They told me I will get tested Friday here.
On 5/11/21 at approximately 9:30 AM the above findings were shared with the Administrator and the Acting Director of Nursing (ADON) An opportunity was offered to the facility's staff to present additional information but no additional information was provided. The administrator stated, I have not been involved in reviewing the testing. The ADON stated, They should have been tested.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #346 was admitted to the nursing facility on 05/03/21. Diagnosis for Resident #346 included but not limited to Acute...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #346 was admitted to the nursing facility on 05/03/21. Diagnosis for Resident #346 included but not limited to Acute Kidney Failure. Diagnosis for Resident #346 included but not limited to Muscle weakness. The resident's Minimum Data Set (MDS) assessment was not due. Review of Resident #346's admission assessment dated [DATE] documented the resident was independent in decisions regarding task of daily life, indicating no cognitive impairment.
Review of Resident #346's Physician Order Sheet (POS) for May 2021 revealed the following order with a start date of 05/03/21: Full Code.
The review of Resident #346's clinical record did not show evidence of an Advance Directive.
A phone interview was conducted with the Social Worker (SW) on 05/06/21 at approximately 10:35 a.m. When asked if Resident #346 had an Advance Directive or given the opportunity to formulate an Advance Directive, she said let me review his clinical record. After reviewing Resident #346's clinical record, she replied, He is a Full Code but I do not see an Advance Directive. When asked who was responsible for ensuring Resident #346 was given the opportunity to formulate an Advance Directive, she replied, Not me, I believe the Director of admission is responsible for reviewing the Advance Directive on admission. On the same day at approximately 11:43 a.m., a phone interview was conducted with the Director of admission who stated, I did not review an Advance Directive with Resident #346; I did not know, no one ever told me I was suppose too.
A phone interview was conducted with the Administrator and Director of Nursing (DON) on 05/10/21 at approximately 4:10 p.m. The Administrator said the SW is responsible for ensuring the resident is educated and given the opportunity to formulate Advance Director upon admission.
The facility's Administration team was informed of the finding during a debriefing on 05/07/21 at approximately 6:30 p.m. The facility staff did not present any further information about the findings.
3. Resident #19 was admitted to the facility on [DATE] with diagnoses that included but were not limited to muscle weakness, anxiety disorder, depression, low back pain, COVID-19, vitamin D deficiency. Resident #19's most recent MDS (Minimum data set) assessment was a quarterly assessment with an ARD (Assessment reference date) of 1/8/21. Resident #19 was coded as being severely impaired in cognitive function scoring a 5 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam.
On 5/6/21 at approximately 10:00 a.m., a family interview was conducted with Resident #19's representative, her husband. He could not recall the facility going over advanced directives at the time of admission or since thereafter. Resident #19's RP had stated that all he did was make her a DNR (Do Not Resuscitate) as opposed to a Full Code.
Review of Resident #19's POS (Physician Order Summary) revealed an order for a DNR dated 7/20/20 that documented the following: DNR - Do Not Resuscitate.
Review of Resident #19's care plan dated 6/27/19 documented in part, the following: (Name of Resident #19) has an advance directive as evidence by DNR .Follow facility protocol for identification of code status. Obtain Advanced Directives with physician order and resident/responsible party signature.
Review of Resident #19's clinical record revealed no evidence that Resident #19 was afforded the opportunity to formulate an advanced directive.
On 5/7/21 at 1:22 p.m., an interview was conducted with OSM (Other Staff Member #5), the facility social worker. OSM #5 stated that advanced directives should be gone over with the resident and/or the representative upon admission. OSM #5 stated that she had started at the facility last Monday and had only done advanced directives for a couple new admissions so far. OSM #5 stated that advanced directives was more than just going over code status and included items such as IV (intravenous fluids), enteral nutrition and other life prolonging measures. When asked if a resident refuses to formulate an advanced directive if she would revisit the conversation; OSM #5 stated that during quarterly care plan meetings advanced directives should be revisited as well as documented. OSM #5 stated that she was not sure if the previous social worker was going over advanced directives with residents. OSM #5 could not provide evidence Resident #19's representative was given the opportunity to formulate an advanced directive.
On 5/10/21 at 5:59 p.m., ASM (Administrator Staff Member) #1, the Interim Administrator, ASM #2, the Acting DON (Director of Nursing) and ASM #4, the Regional Director of Clinical Services were made aware of the above concerns.
No further information was presented prior to exit.
Based on medical record review, staff interviews and facility document review the facility failed to ensure that 5 of 34 residents in the survey sample were afforded the opportunity to formulate an Advance Directive upon admission, Residents' #5, #9, #19, #346, and #15.
The findings included:
1. Resident #5 was admitted to the facility on [DATE] with diagnoses to included but not limited to Major Depressive Disorder, Dementia, Anxiety Disorder and Hypertension.
The most recent Minimum Data Set (MDS) was an Annual with an Assessment Reference Date (ARD) of 2/10/21. The Brief Interview for Mental Status (BIMS) for Resident #5 was coded as a 15 out of a possible 15 which indicates the resident is cognitively intact and capable of daily decision making.
Resident #5's electronic medical record was reviewed and there was no advance directive document located.
Resident #5's current comprehensive care plan was review and is documented in part, as follows:
Focus: Name (Resident #5) has an advance Directive as evidenced by Full code order.
Date Initiated: 3/26/2019
On 5/6/21 at 10:23 A.M. during a phone interview the Interim Administrator was asked if Resident #5's advance directive had been located, The Interim Administrator stated, No, Name (Resident #5) does not have an advance directive.
On 5/10/21 at 12:15 P.M. a pre-exit debriefing via phone was conducted with the Interim Administrator, the Acting Director of Nursing and the Regional Director of Clinical Services where the above information was shared. The Interim Administrator was asked what would have been the expectation for advance directives. The Acting Director of Nursing stated, We usually meet with the resident upon admission and get the advance directive or help to formulate one.
Prior to exit no further information was shared.
2. Resident #9 was admitted to the facility on [DATE] with diagnoses to included but not limited to Major Depressive Disorder, Diabetes Mellitus, Anxiety Disorder and Hypertension.
The most recent Minimum Data Set (MDS) was an Annual with an Assessment Reference Date (ARD) of 3/18/21. The Brief Interview for Mental Status (BIMS) for Resident #9 was coded as a 12 out of a possible 15 which indicates the resident is cognitively intact and capable of daily decision making.
Resident #9's electronic medical record was reviewed and there was no advance directive document located.
Resident #9's current comprehensive care plan was review and is documented in part, as follows:
Focus: Name (Resident #9) has an advance Directive as evidenced by Full code order.
Revision date: 7/1/2019
On 5/6/21 at 1:52 P.M. via email correspondence the Interim Administrator stated, Name (Resident #9), does not have an advance directive.
On 5/10/21 at 12:15 P.M. a pre-exit debriefing via phone was conducted with the Interim Administrator, the Acting Director of Nursing and the Regional Director of Clinical Services where the above information was shared. The Interim Administrator was asked what would have been the expectation for advance directives. The Acting Director of Nursing stated, We usually meet with the resident upon admission and get the advance directive or help to formulate one.
Prior to exit no further information was shared.
5. Resident #15 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, alcoholic cirrhosis of liver without ascities, acute and chronic respiratory failure with hypoxia, anxiety, insomnia and delirium. The facility staff failed to give Resident #15 an opportunity to formulate an Advance Directive.
Resident #15 Quarterly Minimum Data Set (MDS) dated [DATE] assessed this resident as having scored a (5) on the Brief Interview for Mental Status (BIMS).
A review of the clinical records did not indicate an Advance Directive had been formulated for this resident.
During an interview with the Administrator on 05/07/21 at 11:15 A.M., he stated the facility staff were not able to locate information that an Advance Directive had been offered or that Resident #15 had an Advance Directive.
The facility staff failed to give Resident #15 an opportunity to formulate an Advance Directive.
Facility policy titled, Advanced Directives- Admissions/Social Service, documented in part, the following: Upon admission, social services must inform residents, family members or responsible parties of: A. Their right to make choices concerning health care and treatments, including life sustaining treatments. The policy of the company regarding advance directives and withholding or withdrawal of treatment. They must be given a copy of this policy .Advanced directives will be reviewed at least annually as part MDS review.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and facility documentation, the facility staff failed to ensure Medicare Benefi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and facility documentation, the facility staff failed to ensure Medicare Beneficiary Notices in accordance with applicable Federal regulations, were issued to 3 of 34 residents (Resident #348, Resident #5 and Resident #9) in the survey sample.
The findings included:
1. The facility staff failed to issue a NOMNC (Notice of Medicare Provider Non-Coverage), letter to Resident #348 who was discharged from skilled services with Medicare days remaining. Resident #348 was admitted to the nursing facility on 01/25/21. Diagnosis for Resident #348 included but not limited to Muscle weakness. Resident #348's Minimum Data Set (MDS) an OBRA admission Assessment with an Assessment Reference Date (ARD) date of 02/01/21 coded Resident #348 a 14 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) which indicated the resident with no cognitive impairment.
Review of the SNF Beneficiary Notification Review provided by the facility to surveyor, was noted that Resident #348 was not listed for having been issued a NOMNC (Notice of Medicare Provider Non-Coverage.)
Resident #348 started a Medicare Part A stay on 01/25/21 and the last covered day of this stay was 02/11/21. Resident #348 was discharged from Medicare Part A services when benefit days were not exhausted. Resident #348 had only used 17 days of her Medicare Part A services with 83 days remaining. Resident #348 should have been issued a NOMNC.
A phone interview was conducted with the Social Worker (SW) on 05/10/21 at approximately 9:30 a.m. The SW reviewed Resident #348's clinical record. After the SW reviewed Resident #348's clinical record, she replied, Resident #348 should have been issued an NOMNC.
A phone interview was conducted with the Administrator and Director of Nursing (DON) on 05/10/21 at approximately 4:10 p.m., who were made aware the facility failed to issue Resident #348 a NOMNC letter.
A pre-exit conference was conducted with the Administrator, Director of Nursing (DON) and Cooperate Nurse on 05/10/21 at approximately 6:30 p.m. No further information was provided prior to exit.
2. Resident #5 was admitted to the facility on [DATE] with diagnoses to included but not limited to Major Depressive Disorder, Dementia, Anxiety Disorder and Hypertension.
The most recent Minimum Data Set (MDS) was an Annual with an Assessment Reference Date (ARD) of 2/10/21. The Brief Interview for Mental Status (BIMS) for Resident #5 was coded as a 15 out of a possible 15 which indicates the resident is cognitively intact and capable of daily decision making.
Resident #5's electronic medical record was reviewed and the following Medicare Notices of Non-Coverage were reviewed and are documented in part, as follows:
1. THE EFFECTIVE DATE COVERAGE OF YOUR CURRENT SKILLED SERVICES WILL END: 12/12/2020
Telephone Notification Date: 01/25/2021 Time: 12:13 P.M.
Spoke to: Name (Resident #5's) Daughter
Explained Notice of Non-Coverage and appeal rights. Made aware of effective date of 12/22/2020 as date of skilled service ending and date financial liability to begin 12/12/2020. Informed that a request for an immediate appeal should be made as soon as possible, but no later than noon on the day before the effective date.
Signed by previous Director of Social Services.
2. THE EFFECTIVE DATE COVERAGE OF YOUR CURRENT SKILLED SERVICES WILL END: 12/14/2020
I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting my QIO (Quality Improvement Organization).
Signature of Patient or Representative: Resident #5's (Daughter's name) via telephone at 1:04 P.M. Date: 12/30/2020 signed by previous Director of Social Services.
On 5/5/21 at 2:50 P.M. a phone interview was conducted with facility Director of Social Services regarding resident Notices of Medicare Provider Non-Coverage's. The Director of Social Services was asked to review let this surveyor know if the above noted Notices of Medicare Provider Non-Coverage's for Resident #5 were given timely. The Director of Social Services stated, No, they were not given timely. They should be given at least 48 hours prior to the last covered skilled day so that the resident or family has enough time to appeal the decision.
On 5/10/21 at 12:15 P.M. a pre-exit debriefing via phone was conducted with the Interim Administrator, the Acting Director of Nursing and the Regional Director of Clinical Services where the above information was shared. The Interim Administrator was asked what would have been the expectation for Medicare Notices of Non-Coverage's to residents. The Acting Director of Nursing stated, The Notice is to be given 48 hours prior to the last covered day so that they can plan for discharge.
Prior to exit no further information was shared.
3. Resident #9 was admitted to the facility on [DATE] with diagnoses to included but not limited to Major Depressive Disorder, Diabetes Mellitus, Anxiety Disorder and Hypertension.
The most recent Minimum Data Set (MDS) was an Annual with an Assessment Reference Date (ARD) of 3/18/21. The Brief Interview for Mental Status (BIMS) for Resident #9 was coded as a 12 out of a possible 15 which indicates the resident is cognitively intact and capable of daily decision making.
Resident #9's electronic medical record was reviewed and the following Medicare Notices of Non-Coverage were reviewed and are documented in part, as follows:
1. THE EFFECTIVE DATE COVERAGE OF YOUR CURRENT SKILLED SERVICES WILL END: 12/14/2020
I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting my QIO (Quality Improvement Organization).
Signature of Patient or Representative: Resident #9's signature, note under signature (Name Resident #9's Daughter) via telephone at 12:54 P.M.
Date: 12/30/2020
On 5/5/21 at 2:50 P.M. a phone interview was conducted with facility Director of Social Services regarding resident Notices of Medicare Provider Non-Coverage's. The Director of Social Services was asked to review let this surveyor know if the above noted Notice of Medicare Provider Non-Coverage for Resident #9 were given timely. The Director of Social Services stated, No, it was not given timely. They should be given at least 48 hours prior to the last covered skilled day so that the resident or family has enough time to appeal the decision.
The facility policy titled Notice of Medicare Provider Non-Coverage-Generic Notice effective date 11/2020 was reviewed and is documented in part, as follows:
Policy: A Notice of Medicare Provider Non-Coverage-Generic Notice will be utilized to notify resident of non-Medicare coverage.
Procedure: 1. The facility will give a completed copy of the notice to the resident receiving services no later than 2 days before the termination of skilled services.
On 5/10/21 at 12:15 P.M. a pre-exit debriefing via phone was conducted with the Interim Administrator, the Acting Director of Nursing and the Regional Director of Clinical Services where the above information was shared. The Interim Administrator was asked what would have been the expectation for Medicare Notices of Non-Coverage's to residents. The Acting Director of Nursing stated, The Notice is to be given 48 hours prior to the last covered day so that they can plan for discharge.
Prior to exit no further information was shared.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on general observations, clinical record review, staff and resident interviews, the facility staff failed to ensure reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on general observations, clinical record review, staff and resident interviews, the facility staff failed to ensure resident rooms were maintained clean comfortable and homelike for 3 resident rooms on the quarantine unit, room [ROOM NUMBER] (A&B), #204 (B) and #207 (A).
The findings included:
On 5/4/21 at 11:00 a.m., during the orientation tour, through 5/6/21 at 2:00 p.m., the biohazard receptacles were the over flowing trash and soiled linen in the resident's bathroom in room [ROOM NUMBER] and 207 as well as trash and other debris on the floors. Blood stains, trash, feces and other debris were identified on the floor in room [ROOM NUMBER].
Resident #147 who resided in room [ROOM NUMBER], unlike the residents in room [ROOM NUMBER] and 207 was able to express his discontent with the condition of his room. This resident was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus, chronic diabetic wounds of right and left foot with status post bilateral transmetatarsal amputations and skin graft infections, end stage renal disease with dependence on renal dialysis.
The 5-day Minimum Data Set (MDS) assessment was dated 4/30/21 and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible score of 15 which indicated the resident had the necessary cognitive skills for daily decision making. The resident had no problems understanding the staff and was understood. The resident was assessed without mood or behavioral problems. The assessment was signed by the MDS Coordinator as completed on 5/10/21.
On 5/4/21 at 1:05 p.m., Resident #147 was observed sitting on the side of the bed with a full lunch meal tray, his call light was on. The call light over his door was visibly operational and could be heard from the nurse's station. The left and right foot dressing exhibited serous bloody drainage which was also visible on the floor where the resident placed his feet. There was also brown chunked material on the floor between the two beds along with trash, debris, alcohol wipes, chuck pad and accumulated dried blood that remained until inquired by Surveyor #2 on 5/6/21. The resident also stated he ask for someone to clean his floor of the blood from his foot wounds and pick up the fecal material. A foul order was apparent upon entering the room and it was discovered the biohazard trash and linen receptacles in the bathroom were full, over flowing and soiled items of trash and linen pilled on top of the receptacles. This also remained until inquiry by Surveyor #2 on 5/6/21.
On 5/6/21 at 1:50 p.m., an interview was conducted with a housekeeper (#1). He stated that he was new, but worked for the past several days on the quarantine unit. According to this housekeeper, his job duties in the bathrooms and resident's rooms included daily sweeping and mopping floors, and emptying trash. He stated he went into each room at least twice and if there were any spills or special housekeeping concerns, he would take care of them. The Housekeeping Director was in the area and also asked about cleaning rooms. She confirmed that housekeeper #1 was new, but knew the protocol for cleaning room.
On 5/6/21 at approximately 2:00 p.m., the Administrator donned full PPE and was shown the condition of the resident's rooms and the over flowing trash and soiled linen in the biohazard receptacles in the resident's bathroom, as well as blood, trash, feces and other debris identified on the floor. The Administrator requested the housekeeper to assist to empty the biohazard receptacles and clean the room. The Housekeeping Director stated it was the responsibility of the nursing staff to empty the biohazard bags in the biohazard containers in the dirty utility room, but that they were able to retrieve those bags from her department.
On 5/6/21 at approximately 2:10 p.m., Certified Nursing Assistant (CNA #6), who was one of the CNA's assigned to the quarantine unit, said she was new and had not been oriented to the quarantine unit that used the red bags, but stated housekeeping emptied all trash that included the red bags.
On 5/10/21 at 5:59 p.m., a debriefing was conducted with the Administrator, the Director of Nursing (DON) and the Regional Director of Clinical Services. The DON stated Administrator concurred that it was an expectation that rooms are maintained clean and biohazard bags disposed of in the specified containers in the dirty utility rooms.
The facility's policy and procedures titled Housekeeping Procedures dated 6/2016 indicated that proper cleaning technique prevents the spread of infection and that every room to be cleaned is that resident's home-treat as such .the goal of cleaning is infection control .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a complaint investigation, observations, clinical record review, staff interviews and review of facility documentation,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a complaint investigation, observations, clinical record review, staff interviews and review of facility documentation, the facility staff failed to ensure 4 of 34 residents (#152, #151, #30, #43) were free of the misappropriation of their narcotic medications, and ensure their standards and practices prevented reoccurrence.
The findings include:
1. The facility staff failed to ensure Resident #152 was free of the misappropriation of her narcotic medication, *Oxycodone (Percocet).
Resident #152 was admitted to the nursing facility on [DATE] for short-term rehabilitation. She had diagnoses that included UT not limited to intervertebral disc disorders with radiculopathy in the lumbar region. The resident was discharged on [DATE].
The admission Minimum Data Set (MDS) assessment dated [DATE] coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 10 out of a possible score of 15 which indicated the resident was moderately impaired in the skills needed for daily decision making.
Resident #152's care plan dated [DATE] identified the resident was at risk for pain related to intervertebral disc disorders with radiculopathy in the lumbar region. The goal set by the staff was that she would maintain an adequate level of comfort as evidenced by no signs or symptoms of unrelieved pain or distress and verbalized satisfaction with level of comfort through the next review. One of the interventions to accomplish this goal included administer her pain medication as ordered by the physician.
The previous Director of Nursing (DON) conducted a random narcotic count on [DATE] and discovered that Resident #152's as needed (PRN) Oxycodone that was ordered PRN 6 hours for pain had been discontinued on [DATE] by Licensed Practical Nurse (LPN) #12. The facility's investigation summary dated [DATE] indicated LPN #12 said the narcotic was discontinued by the resident's attending physician for lack of use. It was discovered by the DON that the whole card of Oxycodone tablets and the Controlled Narcotic sheet was missing and never found. The investigation indicated that the DON confirmed with the physician that he did not discontinue the narcotic. The pharmacy manifest indicated that 90 tablets of Oxycodone was sent to the facility on [DATE] and only one tablet was signed off as administered on [DATE] which would have left 89 tablets. The LPN that wrote the order to discontinue the narcotic was confronted about the discontinuing the the narcotic without a valid physician's order. The other nurses were interviewed and none of them saw the Oxycodone tablets or the Controlled Narcotic sheet. LPN #12's drug test proved positive for Oxycodone. The LPN was removed from the schedule, the local police department notified. The physician reordered Oxycodone for Resident #152.
2. The facility staff failed to ensure Resident #151 was free of the misappropriation of his narcotic medication, *Marinol (Dronabinol).
Resident #151 was admitted to the nursing facility on [DATE] with diagnoses that included palliative care, swallowing problems and Alzheimer's disease. The resident expired in the facility on [DATE].
Resident #151's most recent Minimum Data Set (MDS) assessment was dated [DATE] and coded severely impaired in long and short term memory.
The care plan dated [DATE] identified the resident was at risk for imbalanced nutrition. The goal set by the staff for this problems was that the resident would maintain adequate nutritional status. Some of the approaches to accomplish this goal included monitor intake every meal, dietician assess as needed and medications as ordered by the physician.
The resident had physician's orders dated [DATE] for Marinol 5 milligrams (mg), one capsule every day for weight loss to increase appetite.
On During a random narcotic count conducted by the previous DON on [DATE], it was discovered through an investigation that Resident #151's Marinol was found in LPN#12's personal bag. The facility was unable to determine when the resident's Marinol was confiscated from him due to the medication was signed out as administered daily and the resident did not exhibit any negative consequences as a result of the medication diversion. Three Controlled Records were in the facility's investigation packet for a total of 30 tablets of Marinol without obvious errors in administration based on the signatures of the licensed nurses. LPN #12 was no longer employed by the facility.
3. The facility staff failed to ensure Resident #30 was free of the misappropriation of his narcotic medication, *Klonopin (Clonazepam).
Resident #30 was admitted to the nursing facility on [DATE] with diagnoses that included but not limited to Huntington's disease, major depression and anxiety disorder. Resident #30 was a current resident in the facility.
Resident #30's most recent Minimum Data Set (MDS) assessment was a quarterly dated [DATE] and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 9 out of a possible score of 15 which indicated the resident was moderately impaired in the skills needed for daily decision making.
The care plan dated [DATE] identified the resident had a diagnosis of anxiety. The goal set by the staff for the resident was that his psychosocial well-being would be minimized through the next review. One of the interventions to accomplish this goal included to administer his medications as ordered.
The resident had physician's orders dated [DATE] for Klonopin 1 mg for anxiety disorder every day at bedtime.
On During a random narcotic count conducted by the previous DON on [DATE], it was discovered through an investigation that Resident #30's Klonopin was found in LPN#12's personal bag. The facility was unable to determine when the resident's Klonopin was confiscated from him due to the medication was signed out as administered daily and the resident did not exhibit any negative consequences as a result of the medication diversion. One Controlled Record that reflected the timeframe [DATE] through [DATE] was in the facility's investigation packet for a total of 30 tablets of Klonopin without obvious errors in administration based on the signatures of the licensed nurses. LPN #12 was no longer employed by the facility.
4. The facility staff failed to ensure Resident #43 was free of the misappropriation of her narcotic medication, *Oxycodone (Percocet).
Resident #43 was admitted to the nursing facility on 7//2/18 with diagnoses that included but not limited to chronic pain.
Resident #43's most recent Minimum Data Set (MDS) assessment was a quarterly dated [DATE] and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 12 out of a possible score of 15 which indicated the resident was moderately impaired in the skills needed for daily decision making.
The care plan dated [DATE] and [DATE] identified the resident had a diagnosis of chronic back pain due to neuropathy and chronic back pain. The goal set by the staff for the resident was that she would maintain adequate levels of comfort as evidenced by no signs and symptoms of unrelieved pain of distress through the next review. Some of the interventions to accomplish this goal included to administer pain medication as ordered by the physician.
The resident had physician's orders dated [DATE] for Oxycodone, one tablet as needed (PRN) every 8 hours for pain.
During a random narcotic count conducted by the previous DON on [DATE], it was discovered through an investigation that Resident #43's Oxycodone was found in LPN#12's personal bag. The facility was unable to determine when the resident's Oxycodone was confiscated from her due to the medication was signed out as administered PRN and the resident did not exhibit any negative consequences as a result of the medication diversion. Resident #43's Controlled Narcotic sheets for the Oxycodone during this timeframe were not in the facility's investigation packet and could not be located to be presented during the survey. LPN #12 was no longer employed by the facility.
On [DATE] at 7:00 p.m. narcotic counts were observed by this surveyor (#2) for the facility's 2 medication carts, 100 and 200/300. All narcotics were accounted for in a affixed compartment on the locked medication cart except a discovered Morphine Sulfate 20 milligrams (mg)/1 milliliters (ml), give .5 ml (10 mg) every 4 hours by mouth (po) for a resident that was admitted for respite care (Resident #146), located in the bottom drawer of the medication cart 200/300. The Morphine Sulfate was found in a bag with several of Resident #146's personal non-narcotic medications. Licensed practical Nurse (LPN #4) said she knew it was there, but there should have been a Controlled Record narcotic flow sheet for the resident's narcotic medication and counted along with the other narcotics, 18 milliliters (ml) recorded as the count for Resident #146's Morphine Sulfate. It was also determined that the Morphine Sulfate was not maintained in the separate affixed compartment in the medication cart as the other resident's narcotics. It was also observed that the narcotic shift counts were not consistently co-signed with another licensed nurse.
On [DATE] at 10:00 a.m., this surveyor (#2) requested to review 6 months of narcotic count sheets. After review of the sheets, it was discovered too numerous to count missing licensed nurse co-signatures and some shifts with no signatures.
On [DATE] at 10:30 a.m., the Director of Nursing (DON) said per their policy and the standard of practice, it was expected that licensed nurses co-sign with two signatures, oncoming and off going to ensure the counts were accurate for the resident's narcotics and medications that had the potential for abuse. He stated Resident #146's narcotic medication brought from home should have been locked in the narcotic box with a slip and counted along with the other narcotics until picked up by the family or in the aforementioned case, picked up by hospice. He took this surveyor (#2) to demonstrate that the medication for resident's Morphine Sulfate narcotic was transferred behind a double lock and counted along with the other narcotics. The amount of Morphine Sulfate was as observed on [DATE], 18 ml remained. This resident was discharged home on [DATE].
On [DATE] at 12:12 p.m., this surveyor (#2) asked the Administrator to provide any investigation that may have taken place for the aforementioned misappropriation of narcotics and or drug diversion. He stated he did not know where the info was because he had been Interim Administrator for one day. Upon further search, he located the investigation packet. It was also requested if the facility addressed the issue during a Quality Assurance and Performance Improvement (QAPI) committee meeting at the time of the incident. The Administrator located a large binder and pulled from a large QA binder an AD HOC meeting minutes dated [DATE] with training titled Allegations of Abuse, Not Reported Per Policy. He stated that misappropriation of narcotics would be under abuse. Upon review of the AD HOC minutes and sign in sheet indicated the only training that was conducted regarded Reporting Abuse and no reference to misappropriation of narcotics or drug diversion.
On [DATE] at 11:30 a.m., the Administrator presented another AD HOC meeting minutes with no date or time, but in a box labeled issues was written Drug Diversion. He said that Registered Nurse (RN) #3 located the packet in the previous DON's office. The Administrator stated he was concerned that there was no date as to when the AD HOC meeting took place. Upon review, this surveyor (#2) stated the presented information was the same information in the investigation packet, except it indicated that 100% of all nursing staff would be educated on the facility's narcotic policy, nurse managers will review all discharge orders in morning meeting, nurse management will audit narcotic sheets 5 times a week for 4 weeks for accuracy, DON will perform random narcotic audits to ensure residents are receiving medications and to review in QAPI.
Based on the review of the above undated AD HOC, only 3 nurses out of 10 staff (remaining 7 staff were non-nursing) signed in as receiving the education on the facility's narcotic policy. As a matter of record, there was no information provided to the survey team that represented how many nursing staff (licensed and certified) were employed at the time of the discovery of the misappropriation of the resident's narcotics. There was no evidence provided that nurse managers reviewed discharge orders in the morning meetings, audited 5 times a week for 4 weeks for accuracy, random narcotic audits to ensure residents are receiving medications or that any of the results were reviewed in QAPI. Review of the current staffing sheets reviewed from [DATE] through [DATE] revealed there were at least 46 licensed and certified nurses employed which may have estimated the number of nurses that should have signed in as received the education on the facility's narcotic policy.
During the above interview on [DATE] at 11:30 a.m., the Administrator stated they could not locate any additional nurse inservices or audits to support a monitored corrective action plan for drug diversion. In addition, there was clear evidence that the destruction/waste of narcotics was consistently signed by the current DON along with another licensed nurse, but inconsistencies in 2020. It was stated that the Controlled Drug Record should be kept in the resident's medical records, but many of them could not be located for 2020. The pharmacy shipping manifests for the delivery of narcotics for Resident #152, #151, #30 and #43 were requested for 2020 to current. When they were presented to this surveyor (#2), for any of there was difficulty finding many of the aforementioned resident's Controlled Drug Records for 2020. There was no evidence that this was a part of the monitoring to ensure the narcotic drug records matched the shipping manifests.
On [DATE] at 5:59 p.m., a debriefing was conducted with the Administrator, the Director of Nursing (DON) and the Regional Director of Clinical Services. There aforementioned issues were re-reviewed and the DON and Administrator reiterated their expectations of the licensed nurses. There was no further documents or added information presented prior to survey's remote exit on [DATE].
The facility's policy and procedures titled Ordering and Receiving Controlled Medications dated 2007 indicated that medications included in the Drug Enforcement Administration (DEA) classification as controlled substances, and medications classified as controlled substances by stat law, are subject to special ordering, receipt, and record keeping requirements in the nursing care center, in accordance with federal and state laws and regulations. The nursing care center obtains and keeps current on file any permits required by state agencies.
The facility's policy and procedures titled Controlled Substances dated 2007 indicated that Controlled Substances are substances that have an accepted medical use (DEA drug enforcement schedules II-V), those with the potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence. These medications are subject to special handling, storage, disposal, and record keeping at the nursing care center, in accordance with federal and state laws and regulations.
*Oxycodone is a Semi-synthetic opioid drug prescribed for pain as Tylox®, Percodan®, Oxycontin®. Derived from the poppy plant, has high potential for abuse (retrieved on [DATE] from source https://www.dea.gov/factsheets/oxycodone).
*Marinol is a Schedule III drug under the Controlled Substances Act. Syndros is an oral Dronabinol (THC) solution that is used for the treatment of anorexia associated with weight loss in patients who have failed to respond adequately to conventional antiemetic treatments (Retrieved on [DATE] from source https://www.dea.gov/sites/default/files/2020-06/Marijuana-Cannabis-2020.pdf).
*Klonopin is a Schedule IV drug, Klonopin's medical benefits are recognized, as is its relatively low potential for abuse; however, its dangers and risk for abuse require federal oversight and regulation. As a result, Clonazepam/Klonopin is officially a controlled substance in the United States (Retrieved on [DATE] https://www.deadiversion.usdoj.gov/schedules).
*Oxycodone is a Semi-synthetic opioid drug prescribed for pain as Tylox®, Percodan®, Oxycontin®. Derived from the poppy plant, has high potential for abuse (retrieved on [DATE] from source https://www.dea.gov/factsheets/Oxycodone).
COMPLAINT DEFICIENCY
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, clinical record review and facility document review, the facility staff failed to ensure...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, clinical record review and facility document review, the facility staff failed to ensure the baseline care plan summary was completed for 3 out of 34 residents (Resident #346, Resident #347 and Resident #147) in the survey sample.
The findings included:
1. The facility staff failed to complete a newly admitted resident, (Resident #346), a baseline care plan summary. The summary must include the initial goals for the resident, a list of current medications, dietary instructions, services and treatments to be administered by the facility.
The resident's Minimum Data Set (MDS) assessment was not due. Review of Resident #346's admission assessment dated [DATE] documented the residents was independent in decisions regarding task of daily life, indicating no cognitive impairment.
The review of Resident #346's admission Order for May 2021, included but not limited to the following medications, dietary instructions and treatment:
Medications include but not limited to:
-Oxycodone 5 mg by mouth every 4 hours as needed for pain
-Lantus - 15 units subcutaneous daily in the morning and 10 units daily at bedtime for Type II diabetes
-Lovenox 30 mg - inject 1 syringe subcutaneous daily
Treatment include but not limited to:
-Dialysis every Tuesday, Thursday and Saturday
-Sacrum wound - apply to sacrum every day - cleanse wound with Dakins - apply Sanyl to moist Dakins roll gauze pack and apply abd pad, secure with tape.
-Colostomy care every shift
Dietary instructions:
Consistent Carb Diet (CCD) 2 gram sodium diet, regular texture.
2. The facility staff failed to complete a newly admitted resident, (Resident #347), a baseline care plan summary. The summary must include the initial goals for the resident, a list of current medications, dietary instructions, services and treatments to be administered by the facility.
The resident's Minimum Data Set (MDS) assessment was not due. Review of Resident #347's admission assessment dated [DATE] documented the residents was independent in decisions regarding task of daily life, indicating no cognitive impairment.
The review of Resident #347's admission Order for April 2021, included but not limited to the following medications, dietary instructions and treatment:
Medications include but not limited to:
Aspirin 325 mg - give 1 tablet by mouth daily for Atrial Flutter.
Norvasc 5 mg - give 1 tablet by mouth daily for Hypertension.
Zyprexa 2.5 mg - give 1 tablet by mouth daily at bedtime for Vascular Dementia with Behavioral Disturbances.
Coreg 6.25 mg - give 1 tablet by mouth twice a day for Hypertension.
Treatment instructions include but not limited to:
Oxygen 2 liters via nasal cannula (n/c) as needed for SOB starting on 05/01/21.
Therapy instructions include but not limited to:
Occupational Therapy (OT) and treat as indicated starting on 04/30/21.
Speech Therapy (ST) and treat as indicated starting on 04/30/21.
Physical Therapy (PT) and treat as indicated starting on 04/30/21.
Dietary instructions:
Heart Healthy diet, regular texture.
3. The facility staff failed to complete a newly admitted resident, (Resident #147), a baseline care plan summary. The summary must include the initial goals for the resident, a list of current medications, dietary instructions, services and treatments to be administered by the facility.
Resident #147 was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus, chronic diabetic wounds of right and left foot with status post bilateral transmetatarsal amputations and skin graft infections, end stage renal disease with dependence on renal dialysis.
The 5-day Minimum Data Set (MDS) assessment was dated 4/30/21 and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible score of 15 which indicated the resident had the necessary cognitive skills for daily decision making. The resident had no problems understanding the staff and was understood. The resident was assessed without mood or behavioral problems. Resident #147 required extensive assistance from 2 staff for bed mobility and toilet use. He was not assessed to be able to ambulate (walk in and out of room). He had bilateral lower extremity impairment in range of motion. The wheelchair was the resident's primary mode of transportation. The resident was coded with surgical wounds and infection of feet. The assessment was signed by the MDS Coordinator as completed on 5/10/21.
There was no care plan to include a baseline 48-hour care plan or interim care plan available to this surveyor during the time of the survey.
Resident #147 had complicated wound care procedures, was on hemodialysis, Intravenous (IV) antibiotics via a central line (internal jugular), dietary recommendations and oxygen therapy. None of these areas were represented through care planning to meet professional standards of care.
A phone interview was conducted with the Director of Nursing (DON) on 05/06/21 at approximately 11:09 a.m. The DON stated that baseline care plans should have been completed 48 hours after admission.
On 05/10/21 at approximately 4:10 p.m., phone interview was conducted with the Administrator and (DON.) When asked who is responsible for developing the 48 hour baseline care plan, the DON stated, The admitting nurse and if she runs out of time; the next nurse coming should completed the care plan; they only have 48 hours to complete the baseline care plan.
A pre-exit conference was conducted with the Administrator, Director of Nursing and Cooperate Nurse on 05/10/21 at approximately 6:30 p.m. No further information was provided prior to exit.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility's staff failed to follow a physician's orders for obtaining labs and administering medications for Resident #22....
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility's staff failed to follow a physician's orders for obtaining labs and administering medications for Resident #22.
Resident #22 was originally admitted to the facility 05/13/2019 and readmitted [DATE] after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; End Stage Renal Disease and Aphasia.
The significant change, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 01/31/2021 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #22 cognitive abilities for daily decision making were moderately impaired.
In sectionG(Physical functioning) the resident was coded as requiring extensive assistance of two persons with bed mobility, transfers, locomotion, toileting, personal hygiene, extensive assistance of one person with dressing, supervision after set-up help with eating and requires total dependence with bathing.
The care plan dated 1/12/21 reads that resident has Urinary Tract Infections, potential due to: Use of indwelling catheter-18F 10cc balloon-has dx of obstructive and reflux uropathy. Resident performs own catheter care (resolved) The goals for resident #22 are: Resident is at risk for UTI related to Foley catheter use, will be minimized through next review. The Interventions are: Catheter care q shift and as needed. Observe and report s/s of UTI: changes in color, odor, or consistency of urine, dysuria, fever, pain. Offer fluids frequently throughout the day. Urology consult as needed.
A review of the MAR (Medication Administration Record) Reads: May obtain UA/C&S (Urinalysis/Culture and Sensitivity) in the evening for side pain/bloody urine for 1 day. Order Date: 3/03/21. Time: 1846 (6:46 PM). The MAR show's no evidence of labs being obtained for this order.
A review of progress note reveals the following concerning the UC&S (Urine Culture and Sensitivity): On 3/3/2021 18:02 (6:02 PM) General Note: Received call from dialysis that foley was bloody urine temp taken 98.9 resident c/o side pain. resident returned from dialysis and temp taken 99.5 ax but that was with coat and blanket on. taken orally after 15 minutes temp was 99.0 vitals 104/74 96hr 20rr 98%02. foley flushed and urine returned light pink then yellow. On-call notified and new order from NP (Nurse Practitioner) for UA/C&S and place in book for in NP in morning. resident tolerated all medications and food this shift. will continue to assess as needed and on-coming shift informed of status.
A review of the MAR reads: Azireonam Solution Reconstituted 1 GM. Inject 1 Gram intramuscularly every 12 hours for UTI (Urinary Tract Infection) until 3/22/21 2359 (11:59 PM). Order Date: 3/15/21. Time: 1602 (4:02 PM). Resident #22 received all doses of his prescribed antibiotic at 0900 (9:00 AM) March 16th through March 22, 2021. Resident #22 received all doses of his prescribed antibiotic at 2100 (9:00 PM) from March 15th through March 22, 2021 except on March 16th. (no initials were present on the MAR indicating Resident #22 received his antibiotic).
An interview was conducted with the ADON on 5/11/21 at approximately 4:00 PM concerning the above issues. He stated, I'll look into it. The surveyor also informed the ADON that she was not able to review the POS (Physicians Order Summary) for March 2021 in PCC (Point Click Care). He stated, I'll email it to you.
The ADON was contacted several times concerning the POS for March 2021. Document not received.
On 5/11/21 at approximately 9:30 AM the above findings were shared with the Administrator and The Acting Director of Nursing (ADON) An opportunity was offered to the facility's staff to present additional information but no additional information was provided. The ADON stated, We should have gotten an order for the UC&S. No documentation was found. Nurses should have identified the physician order prior to. Vital signs should have been monitored for the effectiveness of the antibiotics.
Based on resident interview, staff interviews, clinical record review and facility documentation review, the facility staff failed to follow professional standards of nursing for 2 of 34 residents (Resident #346 and Resident #22) in the survey sample.
The findings included:
1. The facility staff failed to follow a physician's orders for wound vac treatment of an abdominal surgical incision for Resident #346.
Resident #346 was admitted to the facility on [DATE]. Diagnosis for Resident #346 included but not limited to surgical aftercare of an Exploratory Laparotomy.
The resident's Minimum Data Set (MDS) assessment was not due. Review of Resident #346's admission assessment dated [DATE] documented the residents was independent in decisions regarding task of daily life, indicating no cognitive impairment. In addition, the admission Assessment was coded for having an abdominal surgical wound requiring surgical wound care (wound vac.) The admission Assessment under skin was coded for having an abdominal surgical wound - area measured 2.8 cm x 3.8 cm x 1.1 cm.
Resident #346's record did not reveal a 48 hour baseline care or an interim care plan.
Review of Resident's #346 discharge summary 05/03/21 read in part: Instructions for follow-up (Routine wound vac changes to midline abdomen surgical wound.)
On 05/06/21 at approximately 7:50 p.m., surveyor #2 observed wound care with License Practical Nurse (LPN) #13 and LPN #14. As they entered the room, a foul odor was observed. It was said by LPN #13 that she thought the colostomy bag had opened and stool had seeped toward the center of the resident's body due to large amount of brown material visible through the dressing. Once the dressing was removed, an approximated amount of drainage was observed and described by LPN #13 to be a cup full of brown foul smelling drainage. LPN #14 stated she was going to call the physician for some orders. She did not return and stated at 8:45 p.m. that she got busy with other issues. LPN #13 cleansed the wound with normal saline and several ABD pads were applied secured with paper tape.
A phone interview was conducted with the Director of Nursing (DON) on 05/05/21 at approximately 1:26 p.m. The
DON stated, If the wound vac was not available then the physician should have been notified for alternative order until the wound vac arrived.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected multiple residents
Based on staff interviews and facility documentation, the facility staff failed to staff a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week.
The findings included:
A review...
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Based on staff interviews and facility documentation, the facility staff failed to staff a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week.
The findings included:
A review of the facility as-worked staffing documentation during a 30-day lookback revealed that there were no RN coverage within a 24-hour period on the following days in April 2021: 04/11/21, 04/24/21 and 04/25/21.
On 05/10/21 at approximately 4:10 p.m., a phone interview was conducted with the Administrator and Director of Nursing (DON.) When asked about the facility not having 8 hours of RN coverage on 04/11/21, 04/24/21 and 04/25/21, they replied, We are not able to provide evidence that there was RN coverage on the days mentioned.
A pre-exit conference was conducted with the Administrator, Director of Nursing (DON) and Cooperate Nurse on 05/10/21 at approximately 6:30 p.m. No further information was provided prior to exit.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0741
(Tag F0741)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff and resident interviews and facility documentation, the facility staff fail...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff and resident interviews and facility documentation, the facility staff failed to assure the 5 agencies were sufficiently oriented to the facility's operational systems necessary to provide care and services.
The findings include:
The following examples demonstrated the agency staff's expression of the lack of orientation to the facility which directly affected the care and services rendered to the residents:
1. On 5/4/21 at 11:00 a.m., during the orientation tour, through 5/6/21 at 2:00 p.m., the biohazard receptacles were overflowing with trash and soiled linen in the resident's bathroom in room [ROOM NUMBER] and 207 on the quarantine unit. These rooms also had a foul odor upon entry.
On 5/4/21 at 1:05 p.m., a foul order was apparent upon entering Resident #147's room, who resided on the quarantine unit, and it was discovered the biohazard (red bags) trash and linen receptacles in the bathroom were full, overflowing and soiled items of trash and linen piled on top of the receptacles. This also remained until inquiry by Surveyor #2 on 5/6/21.
On 5/6/21 at approximately 2:00 p.m., the Administrator donned full PPE and was shown the condition of the resident's rooms and the overflowing trash and soiled linen in the biohazard receptacles in the resident's bathroom, as well as blood, trash, feces and other debris identified on the floor. The Administrator requested the housekeeper to assist to empty the biohazard receptacles and clean the room. The Housekeeping Director stated it was the responsibility of the nursing staff to empty the biohazard bags in the biohazard containers in the dirty utility room, but that they were able to retrieve those bags from her department.
On 5/6/21 at approximately 2:10 p.m., Certified Nursing Assistant (CNA #6), who was one of the CNA's assigned to the quarantine unit, said she was new and had not been oriented to the quarantine unit that used the red bags, but stated housekeeping emptied all trash that included the red bags.
2. On 5/4/21 at 2:10 p.m., the assigned Certified Nursing Assistant (CNA) # 6 was outside Resident #147's room, donning her Personal Protective Equipment (PPE). The CNA entered the room, proceeded to pick up the resident's tray when it was asked if she get get the resident another meal. She said, It is late and I don't think I can get a meal now. I am not sure how that works in this building. The resident told her he had to eat something. She stated she would try but could not promise he would get a meal. CNA also stated that she did not see the call light over and it was difficult to view through the plastic partition. She also stated the call light did not light up and she did not think it sounded at the nurse's station. She added that she was relatively new to the facility and had not been oriented to the resident's on the quarantine unit.
3. On 5/5/21 at 9:30 a.m., Resident #147 arrived from dialysis. LPN #1 hung the resident's IV antibiotic at around 10:00 a.m. She stated, I am agency staff and yesterday was my first day. I did not know anything about this building or the residents and I got behind in passing my medications. That's why his 9:00 a.m. IV antibiotic was hung at 1:00 p.m. I was not sure if he was getting this antibiotic through a midline or a central line because it was in his neck and I wanted to flush it correctly.
4. On 5/6/21 at 7:50 p.m., LPN #13 and #14 proceeded to perform wound care for Resident #346. They both stated it was their first time in the building and had no idea where supplies were located for the wound care. Both nurse's scrambled in and out of the medication room searching for wound care supplies. They told this surveyor (#2) there were 12 hours in their shift and it would take them all of 12 hours to learn what to do. They stated that, Practically all of us and agency staff and maybe there is one here that is regular staff. When asked if they received any information from the facility through their respective agency about the facility or where to access information about resident care or procedures, she stated, Only the nurse's report from the previous shift, but I feel stressed. They called us and said they needed nurse's and that was it. So, here we are!
On 5/10/21 at 8:00 p.m., the Administrator was asked if there was any form of orientation for the agency staff, as well as how many nursing agencies they used. He presented an email that indicated they used licensed and certified staff from 5 separate agencies. He stated he just found out there was an orientation binder at the nurse's station. This binder was retrieved from a mix of multiple binders and reviewed by this surveyor (#2). In the front of the binder, it indicated that if it was the nurse's first time in the facility, they were to come in 30 minutes early to read the binder and sign the agency attestation sheet. The Administrator stated that the binder was the extent of agency orientation and information was not forwarded to the agencies. He was shown that only one CNA signed the attestation sheet on 5/9/21. There was no additional signed sheets provided prior to survey's remote exit on 5/11/21.
No additional information was provided prior to survey exit.
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 observations, clinical record review, staff interviews and review of facility documentation, the facility staff failed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and review of facility documentation, the facility staff failed to ensure the system and disposition of all controlled drugs was in place and implemented to enable accurate reconciliation for 1 out of 34 residents (#146), as well as during the facility's physical inventory of their stored controlled medications at each shift change AND The facility staff failed to provide routine pharmacy services for Resident #20.
The findings included:
1. Resident #146 was admitted on [DATE] to receive respite/palliative care. He was discharged home on 5/5/21.
There was no completed Minimum Data Set (MDS) assessment due to the resident's short-stay.
The History and Physical (H&P) dated 5/3/21 indicated that the resident was in the facility under the care of hospice for respite. He was alert and responsive. No Intravenous fluids to be given or laboratory specimens obtained.
Resident #146 was ordered Morphine Sulfate 20 mg/ml, give 0.5 ml by mouth every 4 hours as needed for pain or shortness of breath.
On 5/4/21 at 7:00 p.m. narcotic counts were observed by this surveyor (#2) for the facility's 2 medication carts, 100 and 200/300. Morphine Sulfate 20 milligrams (mg)/1 milliliters (mg) 18 ml was found in a bag with several of Resident #146's personal non-narcotic medications. The bag was in the bottom drawer of the medication cart 200/300. Licensed practical Nurse (LPN #4) said she knew it was there, but there should have been a Controlled Record narcotic flow sheet for the resident's narcotic medication and counted along with the other narcotics.
On 5/5/21 at 10:00 a.m., this surveyor (#2) requested to review 6 months of narcotic count sheets. After review of the sheets, it was discovered too numerous to count, missing licensed nurse co-signatures and some shifts with no signatures.
On 5/6/21 at 10:30 a.m., the Director of Nursing (DON) said per their policy and the standard of practice, it was expected that licensed nurses co-sign with two signatures, oncoming and off going to ensure the counts were accurate for the resident's narcotics and medications that had the potential for abuse. He stated Resident #146's narcotic medication brought from home should have been locked in the narcotic box with a slip and counted along with the other narcotics until picked up by the family or in the aforementioned case, picked up by hospice. The amount of Morphine Sulfate was as observed on 5/4/21, 18 ml remained. This resident was discharged home on 5/5/21.
On 5/10/21 at 5:59 p.m., a debriefing was conducted with the Administrator, the Director of Nursing (DON) and the Regional Director of Clinical Services. There aforementioned issues were re-reviewed and the DON and Administrator reiterated their expectations of the licensed nurses. There was no further documents or added information presented prior to survey's remote exit on 5/11/21.
The facility's policy and procedures titled Controlled Substances dated 2007 indicated controlled medication accountability records (Resident Controlled Narcotic Sheet) and audit records are kept by the nursing center. When completed these audit and accountability records are kept on file according to state and federal regulations. At each shift change, a physical inventory of controlled medications, as defined by state regulation, is conducted by two licensed clinicians and is documented on an audit record.
COMPLAINT DEFICIENCY
2. Resident #20 was admitted to the facility on [DATE] with diagnoses which included atherosclerotic heart disease, angina, hypertension, hyperlipidemia, reflux, Hospice, vascular dementia and anxiety. The facility staff failed to provide physician ordered medications for Resident #20.
Resident #20 had a Quarterly Minimum Data Set (MDS) dated [DATE]. Resident #20 was noted to be cognitively impaired as documented on the MDS.
A Care Plan dated 12/28/20 indicated the following: Focus- Resident #20 is at risk for imbalanced nutrition due to Dementia, hypertention, hyperlipidemia, TIA, Cerebral Infarction, insomnia, and history of vitamin deficiency. Goals-Maintain nutritional status and body weight through next review. Interventions- Medication as ordered.
Focus- Sometimes I have behaviors which include confusion. She lost her dentures twice, and these were found by staff. She was complaining of chest pain, vital signs stable. later states she is fine. She occasionally refuses to shower, she doesn't want to mess her hair up. Resident can't make up her mind whether she likes eggs or not. Resident was hitting / kicking at care giver. Goal- I will calm down with staff intervention when behaviors occur through next review date. Interventions- Make sure I am not in pain or uncomfortable. Give me my medications as my doctor has ordered.
Focus- Resident #20 needs pain management and monitoring related to: Chronic Back Pain aggravated by Osteorthritis and end of life care. Goal- Resident #15 will maintain adequate level of comfort as evidenced by no s/sx of unrelieved pain or distress, or verbalizing satisfaction with level of comfort through next review. Goal- Administer Pain medication as ordered. Evaluate need to provide medications prior to treatment or therapy.
Resident #20 had a physician's order for the following medication: Decadron Tablet 4 (mg) milligrams give 1 tablet by mouth in the morning for pain.
Resident #20 had a physician's order for the following medication: hydroxyzine HCI tablet 25 mg give 1 tablet by mouth at bedtime for insomnia.
Resident #20 had a physician order for the following medication: Metoprolol Succinate ER tablet Extended Release 24 hour 25 mg give 12.5 mg by mouth one time a day for 12.5 mg total.
A review of the clinical record (Nursing Notes) dated 12/25/20 and Medication Administration Record (MAR) Notes, Indicated: Rosuvastain Calcium tablet 20 mg give 1 tablet by mouth at bedtime for Hyperlipeidemia not available medication being ordered.
A review of the clinical record (Nursing Notes) dated 12/27/20 and MAR Notes, Indicated: Rosuvastain Calcium tablet 20 mg - give 1 tablet by mouth at bedtime for Hyperlipidemia awaiting arrival from pharmacy.
A review of the clinical record (Nursing Notes) dated 12/28/20 and MAR Notes, Indicated: Rosurvastain Calcium tablet 20 mg - give 1 table by mouth at bedtime for Hyperlipidemia medication on order.
A review of the clinical record (Nursing Notes) dated 01/06/21 and MAR Notes, Indicated: Decadron tablet 4 mg give 1 tablet by mouth in the morning for pain, medication unavailable, awaiting delivery from pharmacy.
A review of the clinical record (Nursing Notes) dated 01/05/21 and MAR Notes, Indicated: Decadron tablet 4 mg give 1 tablet by mouth in the morning for pain. Medication on order, awaiting delivery.
A review of the clinical record (Nursing Notes) dated 01/02/21 and MAR Notes, Indicated: Decadron tablet 4 mg give 1 tablet by mouth in the morning for pain. Medication on order.
A review of the clinical record (Nursing Notes) dated 03/22/21 and MAR Notes, Indicated: HydrOxyzine HCI tablet 25 mg give 1 tablet by mouth at bedtime for insomnia, unavailable.
A review of the clinical record (Nursing Notes) dated 4/13/21 and MAR Notes, Indicated: Metoprolol Succcinate ER tab 12.5 mg one time a day, Not available.
A review of the Facility's Pharmacy Policy indicated:
Policy- The facility must make every effort to ensure that a medication ordered for the resident is available to meet their needs.
Procedures:
1.- The pharmacy staff shall:
A.- Call and/or provide written notification to the nursing staff that the physician ordered product(s) is/are unavailable.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, the facility staff failed to ensure 2 of 34 resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, the facility staff failed to ensure 2 of 34 residents (Resident #347 and Resident #147) in the survey sample were free of significant medication errors.
The findings included:
1. The facility staff failed to follow physician orders to decrease Aspirin 325 mg to 81 mg.
Resident #347's Minimum Data Set (MDS-an assessment protocol) a 5-day assessment with an Assessment Reference Date of 05/05/21 coded the resident with a 00 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. In addition, the MDS coded Resident #347 total dependent of two with bathing, personal hygiene and toilet use, extensive assistance of two with bed mobility, transfer and dressing and supervisor with one assist with eating.
Resident #347's care plan dated 05/06/21 documented resident at risk for complications related to anticoagulant or antiplatelet medications due to Atrial Fibrillation. The goal: will remain without complications from bleeding or injury. One intervention/approaches to manage goal included: monitor medication regimen.
During the review of Resident #347's Medication Administration Record (MAR) for May 2021 revealed the following 2 (two) antiplatelet medications and 1 (one) anticoagulation medication order:
Aspirin 325 mg tablet - give 1 tablet by mouth daily for Cerebral Infarction starting on 04/30/21.
Aspirin EC 81 mg - give 1 tablet by mouth daily for Atrial Flutter starting on 05/04/21.
Eliquis 2.5 mg tablet - give 1 tablet twice a day for Atrial Fibrillation starting on 05/04/21.
The review of Resident #347's Eliquis order included the following Drug-to-Drug Interaction Details read:
The use of Eliquis tablet 2.5 mg and Aspirin 325 mg may increase the risk of bleeding.
Review of the physician's progress note dated 05/03/21 read in part under assessment: I have decreased Aspirin from 325 mg down to 81 mg by mouth daily.
Further review of Resident #347's MAR for May 2021 revealed the following medications were administered:
Aspirin 325 mg tablet given at 9:00 a.m., on 05/04/21 and 05/05/21.
Aspirin EC 81 mg tablet given at 9:00 a.m., on 05/04/21 and 05/05/21.
Eliquis 2.5 mg tablet given at 9:00 a.m., and 5:00 p.m., on 05/04/21 and 05/05/21.
A phone interview was conducted with the Director of Nursing (DON) on 05/05/21 at approximately 1:26 p.m. The DON reviewed Resident #347's physician orders and stated, The nurses should have notified the physician for clarification due to Resident #347 taking 2 (two) different doses of Aspirin at the same time (Aspirin 81 mg and Aspirin 325 mg.) On the same day at approximately 3:44 p.m., a new order was written to discontinue the Aspirin 325 mg tablet.
A phone interview was conducted with the Administrator and Director of Nursing (DON) on 05/10/21 at approximately 4:10 p.m. No further information was provided.
A pre-exit conference was conducted with the Administrator, Director of Nursing (DON) and Cooperate Nurse on 05/10/21 at approximately 6:30 p.m. No further information was provided prior to exit.
Definition:
Atrial Fibrillation is a problem with the speed or rhythm of the heartbeat (https://medlineplus.gov/atrialfibrillation.html.)
2. Resident #147 was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus, chronic diabetic wounds of right and left foot with status post bilateral transmetatarsal amputations and skin graft infections, end stage renal disease with dependence on hemodialysis.
The 5-day Minimum Data Set (MDS) assessment was dated 4/30/21 and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible score of 15 which indicated the resident had the necessary cognitive skills for daily decision making. The resident had no problems understanding the staff and was understood. The resident was assessed without mood or behavioral problems. Resident #147 required extensive assistance from 2 staff for bed mobility and toilet use. He was not assessed to be able to ambulate (walk in and out of room). He had bilateral lower extremity impairment in range of motion. The wheelchair was the resident's primary mode of transportation. The resident was coded with surgical wounds and infection of feet. The assessment was signed by the MDS Coordinator as completed on 5/10/21.
There was no care plan to include a baseline 48-hour care plan or interim care plan available to this surveyor during the time of the survey.
On 5/4/21 at 1:05 p.m., Resident #147 was observed sitting on the side of the bed. The resident stated that the Licensed Practical Nurse (LPN) #1 came to hang his IV antibiotic around 1:00 p.m. The IV was infusing via the IV pump. The IV infusion pump beeped around 1:40 p.m. and the nurse entered the room at 2:03 p.m. (58 minutes from Surveyor #2's observation). The LPN took down the IV and flushed the central line.
On 5/5/21 at 9:30 a.m., Resident #147 arrived from dialysis. LPN #1 hung the resident's IV antibiotic at around 10:00 a.m. She stated, I am agency staff and yesterday was my first day. I don't know anything about this building or the residents and I got behind in passing my medications. That's why his 9:00 a.m. IV antibiotic was hung at 1:00 p.m. I was not sure if he was getting this antibiotic through a midline or a central line becuase it was in his neck and I wanted to flush it correctly.
Upon review of the clinical record, Resident #147 had admission physician's orders dated 4/30/21 for Cefepime 1 gram in sodium chloride 0.9% 100 ml IVPB every 24 hours. The Medication Administration Record (MAR) indicated that the IV antibiotic was signed off as administered late on 5/4/21 at 1:34 p.m., on 5/7/21 at 6:29 p.m. and 5/9/21 at 12:44 p.m.
On 5/10/21 at 5:59 p.m., a debriefing was conducted with the Administrator, the Director of Nursing (DON) and the Regional Director of Clinical Services. The DON stated and the Administrator concurred that it was an expectation that treatments and medications are to be performed as ordered by the physician.
The facility's policy and procedures titled Medication Administration dated 2007 indicated medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given.
Cefepime Injection should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria. Cefepime Injection should be administered intravenously over approximately 30 minutes. On hemodialysis days, Cefepime Injection should be administered following hemodialysis. Whenever possible, Cefepime Injection should be administered at the same time each day to maintain therapeutic range and to allow for compensation for the slower rate of renal elimination in hemodialysis patients (Retrieved on 5/14/21 from source dated 9/2012 https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/050817s004lbl.pdf).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interviews, and review of facility documents, the facility's staff failed to ens...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interviews, and review of facility documents, the facility's staff failed to ensure residents received foods/drinks which accommodates their preferences for 1 of 34 residents (Resident #7), in the survey sample.
The findings included:
1. Resident #7 was originally admitted to the facility 10/21/20 and has never been discharged from the facility. The current diagnoses included; glaucoma, a seizure disorder, endstage renal disease requiring dialysis, diabetes and coronary artery disease.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 4/28/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #7's cognitive abilities for daily decision making was intact. In sectionG (Physical functioning) the resident was coded as requiring total care of two people with transfers, toileting, and bathing, total care of one with off unit locomotion, extensive assistance of two people with bed mobility and dressing, extensive assistance of one person with personal hygiene and locomotion on unit, and supervision after set-up with eating. On 5/5/21, at approximately 10:35 a.m., Resident #7 stated he didn't understand why dining services continued to serve him milk for breakfast when he doesn't like milk and would rather have coffee. Again on 5/7/21, at approximately 8:35 a.m., Resident #7 stated he received milk instead of coffee. The resident also stated he hasn't received coffee for breakfast since he sustained the coffee burn.
On 5/7/21 at approximately 9:00 a.m., the District Dining Services Manager stated he met with Resident #7 regarding his preferences and stated his tray card was updated to reflect his dislike for milk and added coffee as a preference for breakfast.
An interview was conducted with Certified Nursing Assistant (CNA) #6 on 5/10/21 at approximately 10:00 a.m., CNA #6 stated she as well as most of the CNA staff is aware Resident #7 doesn't drink milk and prefers coffee for breakfast. CNA #6 also stated most breakfast meals Resident #7 received a box of milk and apple juice and it was the CNA staff responsible to get coffee from the service cart to serve the resident. CNA #6 stated they were not instructed not to serve Resident #7 coffee but they were instructed to ensure all coffee cups lids were secure before serving the resident and Resident #7 was sitting up before serving coffee.
On 5/10/21 at approximately 7:00 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Director of Clinical Services. The Director of Nursing stated it was their expectation that the resident received they food/drink preferences in accordance with the ordered diet.
2. The facility staff failed to offer and provide Resident #147 with an alternative or substitute for his lunchmeal.
Resident #147 was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus, chronic diabetic wounds of right and left foot with status post bilateral transmetatarsal amputations and skin graft infections, end stage renal disease with dependence on renal dialysis.
The 5-day Minimum Data Set (MDS) assessment was dated 4/30/21 and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible score of 15 which indicated the resident had the necessary cognitive skills for daily decision making. The resident had no problems understanding the staff and was understood. The resident was assessed without mood or behavioral problems. Resident #147 required extensive assistance from 2 staff for bed mobility and toilet use. He was not assessed to be able to ambulate (walk in and out of room). He had bilateral lower extremity impairment in range of motion. The wheelchair was the resident's primary mode of transportation. The resident was coded with surgical wounds and infection of feet. The assessment was signed by the MDS Coordinator as completed on 5/10/21.
There was no care plan to include a baseline 48-hour care plan or interim care plan available to this surveyor during the time of the survey.
On 5/4/21 at 1:05 p.m., Resident #147 was observed sitting on the side of the bed with a full lunch meal tray, his call light was on. The resident stated when they served him his lunch meal around 12:15 p.m., he took one bite from a pork chop and could not consume it because it was tough with no taste, thus he spit it out. He also stated he wanted coffee and they gave him iced tea with no sugar substitute. He stated he put his call light on around 12:20 p.m. and again at 12:30 and both times no one came in, but when the licensed Practical Nurse (LPN) #1 came to hang my IV antibiotic a few minutes ago that was due at 9:00 a.m., turned off the light, never asked him what he wanted, at which time he stated he told her he had been calling to get someone to send for a different meal, at which time she told him she was behind and did not have time. He stated, So I tried again after she left out because I am so hungry. The IV was infusing via the IV pump. The IV infusion pump beeped around 1:40 p.m. and the nurse entered the room at 2:03 p.m. (58 minutes from Surveyor #2's observation) she hesitated and made eye contact with this surveyor (Surveyor #2), turned off the light, took down the IV, flushed the central line and said, While I am here, what can I do for you. The resident responded, You can get me what I asked for when you came in to hang my IV antibiotic and said you were busy and did not have time. I would like a different meal for my lunch. At approximately 2:10 p.m., the assigned Certified Nursing Assistant (CNA) # 6 was outside the resident's room donning her Personal Protective Equipment (PPE). The CNA entered the room, proceeded to pick up the resident's tray when it was asked if she could get the resident another meal. She said, It is late and I don't think I can get a meal now. I was not told how that works in this building. The resident told her he had to eat something. She stated she would try but could not promise he would get a meal. She added that she was relatively new to the facility and had not been oriented to the resident's on the quarantine unit.
On 5/4/21 at 7:30 p.m., it was determined Resident #147 did not receive anything to eat until 2:30 p.m. He stated he got a hamburger and told the CNA (#6) to make sure it did not take place of his dinner. In addition, the resident said he was told he would recieve double portions, but to date he has not.
On 5/5/21 at 9:30 a.m., Resident #147 arrived from dialysis. LPN #1 stated that 5/4/21 was her first day and she did not know anything about the resident's or the building. The LPN was not able to explain why she could not have had the aide or another nurse to offer and provide the alternate/substitute meal.
On 5/10/21 at 12:15 p.m., this surveyor (#2) and the Food Service District Manager interviewed the resident about the facility's failure to consistently provide his meals especially on his hemodialysis days, Monday, Wednesday and Friday. The Food Service District Manager stated that he knew Resident #147's breakfast was served early in the AM before the resident left on his dialysis days. The resident stated it was inconsistent and somedays received breakfast after he returned from dialysis and he is having to ask repeatedly for the nursing staff to bring his meal. He stated he would prefer the early breakfast meal before dialysis due to his diabetes where he felt his blood sugar drops during the end of his dialysis treatments. This surveyor (#2) was present when the resident returned from dialysis treatment on 5/5/21 at 9:30 a.m. The resident requested his breakfast and did not receive it until 10:45 p.m. He stated he was weak and shaky, but the staff seem to be put upon because he asked to eat. The Food District Manager stated he would make sure his breakfast was prepared and delivered to him no later than 5:30 a.m. Monday, Wednesday and Friday.
On 5/10/21 at 5:59 p.m., a debriefing was conducted with the Administrator, the Director of Nursing (DON) and the Regional Director of Clinical Services. The DON stated and the Administrator indicated that alternates and substitutes are available for every meal and should be offered if the resident did not eat or they requested a different meal. He stated meals are prepared for dialysis residents, and either picked up or delivered to them per their preference before or after dialysis. The Administrator said, Resident's can be given something to eat at anytime.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0865
(Tag F0865)
Could have caused harm · This affected multiple residents
Based record review and staff interview the facility staff failed to ensure the Quality assurance and performance (QAPI) program include monitoring, and measuring performance activities.
The findings ...
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Based record review and staff interview the facility staff failed to ensure the Quality assurance and performance (QAPI) program include monitoring, and measuring performance activities.
The findings included:
1. The facility staff failed to maintain a QAPI plan for correcting quality deficiencies.
During the survey conducted 05/04/21 through 05/12/21 indicated: In the area of (F-881) A review of the antibiotic Infection Control Surveillance Infection report log showed only the months of March, April, and May were available to view.
During an interview on 05/10/21 at 6:00 PM with the Administrator, ADON and RDCS concerning Antibiotic Stewardship Program. They were asked if the ongoing review for antibiotic stewardship prior to the survey was complete. The ADON stated, We need to continue our reviews for February 2021. I don't see any other documentation from what was provided. The RDCS stated, They are working on it. April wasn't completed.
In the area of (F-882) The facility staff failed to designate at least one qualified Infection Preventionist. Received Infection Prevention and Control Certificates of training.
In the area of (F-880) The facility staff failed to ensure infection control practices were followed in 3 resident rooms on the quarantine unit.
In the area of (F-886) The facility staff failed to perform COVID-19 testing on staff.
In the area of (F-761) The facility staff failed to include monitoring and audit performance strategies following the diversion of narcotics. The facility failed to ensure scheduled II medication were secured in a separately permanent affixed compartment.
During an interview on 05/10/21 at 5:00 PM with the Administrator, he was asked about the follow-up investigation of a drug diversion investigation. The Administrator was asked about documentation for monitoring staff to ensure Narcotics were not being diverted. The Administrator stated, He did not have any documentation for monitoring of drug diversion.
In the area of (F-755) The facility staff failed to include monitoring and audit process to ensure an ongoing account of narcotics and other drugs for abuse were implemented'
In the area of (F-686) The facility staff failed to provide an on going surveillance program for weekly pressure sore assessment to prevent wounds at advance stages.
In the area of (F-689) The facility staff failed to have documentation of on going monitoring and audit of newly admitted residents at risk for accidents of hot liquids spills following an incident of a resident receiving a second degree burn.
The facility developed the following Ad Hoc strategies; to in-service Dietary staff on coffee temperatures, In-service all staff on the importance of placing the lids securely for all beverages, especially hot beverages and to assess all residents for hot liquids.
The Dietary staff in-service was completed on 4/30/21, it was titled Temperature Logs, Coffee Logs. The education read; temperature of food and hot liquids should be obtained everyday before leaving the kitchen. There should not be any gaps (blank spaces) in any log. Failure to do the above will result in a write-up, (disciplinary action). All staff wasn't in-serviced, including many of the facility's direct care staff, as well as the Contract staff. The Hot Liquid Safety Evaluation wasn't completed for all residents admitted after the coffee spill. There was no documentation of monitoring to ensure lids were secure on cups distributed to residents.
A review of the QAPI policy and procedures indicated: PIP (Performance Improvement Plan) action plans-
The PIP's are implemented and monitored through:
Staff training and development of changes to protocols
Monitoring and feed back mechanisms
Review and revision of plans of action when needed
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected multiple residents
Based record review and staff interview the facility staff failed to implement corrective action and monitor to ensure the Quality assurance and performance (QAPI) program to ensure performance goals ...
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Based record review and staff interview the facility staff failed to implement corrective action and monitor to ensure the Quality assurance and performance (QAPI) program to ensure performance goals or targets are achieved. activities.
The findings included:
1. The facility staff failed to maintain a QAPI plan for correcting quality deficiencies.
During the survey conducted 05/04/21 through 05/12/21 indicated: In the area of (F-881) A review of the antibiotic Infection Control Surveillance Infection report log showed only the months of March, April, and May were available to view.
During an interview on 05/10/21 at 6:00 PM with the Administrator, ADON and RDCS concerning Antibiotic Stewardship Program. They were asked if the ongoing review for antibiotic stewardship prior to the survey was complete. The ADON stated, We need to continue our reviews for February 2021. I don't see any other documentation from what was provided. The RDCS stated, They are working on it. April wasn't completed.
In the area of (F-882) The facility staff failed to designate at least one qualified Infection Preventionist. Received Infection Prevention and Control Certificates of training.
In the area of (F-880) The facility staff failed to ensure infection control practices were followed in 3 resident rooms on the quarantine unit.
In the area of (F-886) The facility staff failed to perform COVID-19 testing on staff.
In the area of (F-761) The facility staff failed to include monitoring and audit performance strategies following the diversion of narcotics. The facility failed to ensure scheduled II medication were secured in a separately permanent affixed compartment.
During an interview on 05/10/21 at 5:00 PM with the Administrator, he was asked about the follow-up investigation of a drug diversion investigation. The Administrator was asked about documentation for monitoring staff to ensure Narcotics were not being diverted. The Administrator stated, He did not have any documentation for monitoring of drug diversion.
In the area of (F-755) The facility staff failed to include monitoring and audit process to ensure an ongoing account of narcotics and other drugs for abuse were implemented'
On 5/5/21 at 12:12 p.m., surveyor (#2) asked the Administrator to provide any investigation that may have taken place for the aforementioned misappropriation of narcotics and or drug diversion. He stated he did not know where the info was because he had been Interim Administrator for one day. Upon further search, he located the investigation packet. It was also requested if the facility addressed the issue during a Quality Assurance and Performance Improvement (QAPI) committee meeting at the time of the incident. The Administrator located a large binder and pulled from a large QA binder an AD HOC meeting minutes dated 10/26/20 with training titled Allegations of Abuse, Not Reported Per Policy. He stated that misappropriation of narcotics would be under abuse. Upon review of the AD HOC minutes and sign in sheet indicated the only training that was conducted regarded Reporting Abuse and no reference to misappropriation of narcotics or drug diversion.
On 5/6/12 at 11:30 a.m., the Administrator presented another AD HOC meeting minutes with no date or time, but in a box labeled issues was written Drug Diversion. He said that Registered Nurse (RN) #3 located the packet in the previous DON's office. The Administrator stated he was concerned that there was no date as to when the AD HOC meeting took place. Upon review, this surveyor (#2) stated the presented information was the same information in the investigation packet, except it indicated that 100% of all nursing staff would be educated on the facility's narcotic policy, nurse managers will review all discharge orders in morning meeting, nurse management will audit narcotic sheets 5 times a week for 4 weeks for accuracy, DON will perform random narcotic audits to ensure residents are receiving medications and to review in QAPI.
Based on the review of the above undated AD HOC, only 3 nurses out of 10 staff (remaining 7 staff were non-nursing) signed in as receiving the education on the facility's narcotic policy. As a matter of record, there was no information provided to the survey team that represented how many nursing staff (licensed and certified) were employed at the time of the discovery of the misappropriation of the resident's narcotics. There was no evidence provided that nurse managers reviewed discharge orders in the morning meetings, audited 5 times a week for 4 weeks for accuracy, random narcotic audits to ensure residents are receiving medications or that any of the results were reviewed in QAPI. Review of the current staffing sheets reviewed from 4/30/21 through 5/6/21 revealed there were at least 46 licensed and certified nurses employed which may have estimated the number of nurses that should have signed in as received the education on the facility's narcotic policy.
During the above interview on 5/6/21 at 11:30 a.m., the Administrator stated they could not locate any additional nurse inservices or audits to support a monitored corrective action plan for drug diversion. In addition, there was clear evidence that the destruction/waste of narcotics was consistently signed by the current DON along with another licensed nurse, but inconsistencies in 2020. It was stated that the Controlled Drug Record should be kept in the resident's medical records, but many of them could not be located for 2020. The pharmacy shipping manifests for the delivery of narcotics for Resident #152, #151, #30 and #43 were requested for 2020 to current. When they were presented to surveyor (#2), for any of there was difficulty finding many of the aforementioned resident's Controlled Drug Records for 2020. There was no evidence that this was a part of the monitoring to ensure the narcotic drug records matched the shipping manifests.
In the area of (F-686) The facility staff failed to provide an on going surveillance program for weekly pressure sore assessment to prevent wounds at advance stages.
In the area of (F-689) The facility staff failed to have documentation of on going monitoring and audit of newly admitted residents at risk for accidents of hot liquids spills following an incident of a resident receiving a second degree burn.
The facility developed the following Ad Hoc strategies; to in-service Dietary staff on coffee temperatures, In-service all staff on the importance of placing the lids securely for all beverages, especially hot beverages and to assess all residents for hot liquids.
The Dietary staff in-service was completed on 4/30/21, it was titled Temperature Logs, Coffee Logs. The education read; temperature of food and hot liquids should be obtained everyday before leaving the kitchen. There should not be any gaps (blank spaces) in any log. Failure to do the above will result in a write-up, (disciplinary action). All staff wasn't in-serviced, including many of the facility's direct care staff, as well as the Contract staff. The Hot Liquid Safety Evaluation wasn't completed for all residents admitted after the coffee spill. There was no documentation of monitoring to ensure lids were secure on cups distributed to residents.
A review of the QAIP policy and procedures indicated: PIP (Performance Improvement Plan) action plans-
The PIP's are implemented and monitored through:
Staff training and development of changes to protocols
Monitoring and feed back mechanisms
Review and revision of plans of action when needed
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, clinical record review, and review of facility documents, the facilitys staff failed to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, clinical record review, and review of facility documents, the facilitys staff failed to ensure infection control measures and practices were in place in the laundry room and 3 resident rooms on the quarantine unit (Room's 202, 204 and 207), in the survey sample.
1. The facility failed to ensure that all laundry was handled, stored, and processed in a safe and sanitary method.
During the initial of the laundry on 5/4/21 at approximately 1:15 p.m., the following observations were made with the Housekeeping Supervisor present; Multiple Hoyer slings were observed on top of numerous pillows in the corner against the wall beside the washing machines. The Housekeeping supervisor stated they were slings which were no longer used therefore; they needed to be stored someplace and the pillows were there to be washed and returned to service.
Many other Hoyer slings were hanging on the wall facing the washers and they made contact with the floor. The Housekeeping supervisor stated they were the slings currently in service and staff would pick them up when needed.
Directly beside the washers was a red biohazard container and a regular 13 gallon trash container overflowing with clear plastic bags. The Housekeeping supervisor stated the clear plastic bags were there because the laundry aide had just removed the resident's personal clothing from them and put them in the large laundry basket which was storing the soiled resident clothing.
To the left of the washers was a large laundry type basket on wheels with dirty resident personal laundry climbing the wall, just a few inches from the ceiling. To the left of the sink was a shelf which housed open disinfectant bottles. The Housekeeping supervisor stated she left the opened containers there and she would put them away.
In front of the sink before you get to the dryers was 4 yellow mop pails, one contained brown water which covered the bottom of the pail. The Housekeeping supervisor stated the housekeeping staff shared that area with the laundry but; she wasn't sure why one bucket contained the water.
Beneath the laundry detergents and on the floor were many pillows. The Housekeeping supervisor stated they were pillows which were removed from service and due to be discarded.
Near the dryer was a container of clean resident clothing which needed to be hung and distributed to the residents. Another container was also present, it contained resident clothing items which had no identifiable information, preventing them from being returned to the rightful owner.
Directly across from the dryers were 2 three tier carts of socks, slippers, and mop heads and other miscellaneous things. Finally in front of the clean laundry exit door was another cart full of unfolded personal clothing. The Housekeeping aid stated the items on the three tier carts were items the previous housekeeping staff had held on to.
On 5/5/21 at approximately 11:20 a.m., observations were again made of the laundry room. The slings and pillows in the corner next to the washers had been removed. The soiled resident's clothing was no longer present, the disinfectant bottles had been put away and the pillows due to be discarded were no longer there.
On 5/10/21 at approximately 7:00 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Director of Clinical Services. An opportunity was afforded the facility's staff to provide additional information but they did not.
2. The facility staff failed to ensure infection control measures and practices were followed for 3 resident rooms on the quarantine unit, room [ROOM NUMBER] (A&B), #204 (B) and #207 (A).
On 5/4/21 at 11:00 a.m., during the orientation tour, through 5/6/21 at 2:00 p.m., the biohazard receptacles were the over flowing trash and soiled linen in the resident's bathroom in room [ROOM NUMBER] and 207 as well as trash and other debris on the floors. Blood stains, trash, feces and other debris were identified on the floor in room [ROOM NUMBER].
Resident #147 who resided in room [ROOM NUMBER], unlike the residents in room [ROOM NUMBER] and 207, was able to express his discontent with the condition of his room. This resident was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus, chronic diabetic wounds of right and left foot with status post bilateral transmetatarsal amputations and skin graft infections, end stage renal disease with dependence on renal dialysis.
The 5-day Minimum Data Set (MDS) assessment was dated 4/30/21 and coded the resident on the Brief Interview for Mental Status (BIMS) with a score of 15 out of a possible score of 15 which indicated the resident had the necessary cognitive skills for daily decision making. The resident had no problems understanding the staff and was understood. The resident was assessed without mood or behavioral problems. The assessment was signed by the MDS Coordinator as completed on 5/10/21.
On 5/4/21 at 1:05 p.m., Resident #147 was observed sitting on the side of the bed with a full lunch meal tray, his call light was on. The call light over his door was visibly operational and could be heard from the nurse's station. The left and right foot dressing exhibited serous bloody drainage which was also visible on the floor where the resident placed his feet. The Kling wrap on the left foot was unraveled and intertwined itself around the wheels of his over bed table. The resident stated that his dressing had been in that condition all night and he had been asking someone to change his dressings. The foot of his bed exhibited the same drainage on his sheets at the foot of the bed. There was also brown chunked material on the floor between the two beds along with trash, debris, alcohol wipes, chuck pad and accumulated dried blood that remained until inquired by Surveyor #2 on 5/6/21. The resident also stated he ask for someone to clean his floor of the blood from his foot wounds and pick up the fecal material. A foul order was apparent upon entering the room and it was discovered the biohazard trash and linen receptacles in the bathroom were full, over flowing and soiled items of trash and linen pilled on top of the receptacles. This also remained until inquiry by Surveyor #2 on 5/6/21.
On 5/6/21 at approximately 2:00 p.m., the Administrator donned full PPE and was shown the condition of the resident's rooms and the over flowing trash and soiled linen in the biohazard bags in the resident's bathrooms, as well as blood, trash, feces and other debris identified on the floor. The Administrator requested the housekeeper to assist to empty the biohazard receptacles and clean the rooms. The Housekeeping Director stated it was the job of the nursing staff to empty the biohazard bags in the biohazard containers in the dirty utility room, but that they were able to retrieve those bags from her department.
On 5/10/21 at 5:59 p.m., a debriefing was conducted with the Administrator, the Director of Nursing (DON) and the Regional Director of Clinical Services. The DON stated Administrator concurred that it was an expectation that rooms are maintained clean and biohazard bags disposed of in the specified containers in the dirty utility rooms.
The facility's policy and procedures titled Biohazardous waste dated 2/2017 indicated that disposable items that contain soiling with liquid ore semi-liquid blood or other potentially infectious material, that if compressed are capable of releasing these materials during handling. The policy did not specify which employees were responsible to transfer the biohazard bags to the dirty utility room to be placed in the biohazard receptacles.
Aug 2019
12 deficiencies
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 staff interview, facility document review and clinical record review, it was determined that facility staff failed for ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined that facility staff failed for 1 of 35 residents in the survey sample, to ensure that the assessment accurately reflected Resident #22's status.
The findings included:
Resident #22 was admitted to the facility on [DATE]. Diagnosis included but were not limited to, Cognitive Communication Deficit and Type 2 Diabetes Mellitus. Resident #22's Quarterly Minimum Data Set (MDS an assessment protocol) with an Assessment Reference Date of 06/10/2019 was coded with a BIMS (Brief Interview for Mental Status) score of 11 indicating moderate cognitive impairment. In addition, the Minimum Data Set coded Resident #22 as requiring extensive assistance of 1 with dressing and personal hygiene and extensive assistance of 2 with bed mobility, transfer and toilet use.
On 08/15/2019 review of Resident #22's Quarterly MDS, Section P- Restraints, revealed that the resident was coded as using Bed Rails less than daily.
On 08/15/2019 Resident #22's Physician Order Summary was reviewed and failed to evidence that the resident had orders for Bed Rails. Resident #22's Comprehensive Care Plan was reviewed and failed to evidence that the resident had a care plan for Bed Rails.
On 08/15/2019 at approximately 4:00 p.m., Resident #22 was asked, Do you use Bed Rails? Resident #22 stated, No.
On 08/15/2019 at approximately 5:00 p.m. a copy of Resident #22's Quarterly MDS for 06/10/2019 and the Comprehensive Care Plan was requested.
On 08/16/2019 at approximately 10:00 a.m. a modified copy of the Quarterly MDS for 06/10/2019 attached to a CMS (Centers for Medicare & Medicaid Services) Submission Report for modification with a submission date of 08/15/2019 at 6:29 p.m. and a processing completion date of 08/15/2019 at 6:33 p.m. was received.
An interview was conducted with the Director of Nursing (DON) on 08/16/2019 at approximately 10:30 a.m. and she was asked, Can you explain the submission report to CMS? The DON stated, Resident #22 has never used Bed Rails. There was an error in coding on the MDS.
On 08/16/2019 at approximately 11:10 a.m., an interview was conducted with the MDS Coordinator and she was asked, Did Resident #22 use bed rails, less than daily, as coded on the Quarterly MDS dated [DATE]? The MDS Coordinator stated, No, (residents name) never used bed rails. That was an error in coding. Sometimes I enter information too fast. From now on I am going to make a point to go back and check to make sure before I lock and sign the MDS that it is correct. The MDS Coordinator was asked, When did you identify that you incorrectly coded the MDS for bed rails? The MDS Coordinator stated, After you requested information.
On 08/16/2019 a copy of the facility policy on MDS Assessments was requested. The facility provided a copy of Centers for Medicare & Medicaid Services' Long Term Care Facility Resident Assessment Instrument (RAI) User's Manual MDS 3.0 User's Manual Version 1.16 updated October 2018.
On 08/16/2019 at approximately 6:30 p.m., at the pre-exit meeting the Administrator and the Director of Nursing was informed of the finding. The facility did not present any further information about the finding.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review and facility document review the facility staff failed to implemen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review and facility document review the facility staff failed to implement an approach listed in the residents Comprehensive Person-Centered Plan of Care for 2 of 35 residents in the survey sample (Resident # 154 & #10). The facility failed to implement an indwelling catheter securement device for Resident #154 and failed to administer medications for seizure disorder and Parkinson's Disease for Resident #10.
The findings include:
1. Resident #154 was admitted to the facility on [DATE] with an indwelling Foley catheter for diagnoses of BPH (benign prostatic hyperplasia-an enlarged prostate gland that can cause urination difficulty) and UTI (urinary tract infection). The current MDS (Minimum Data Set) an admission with an assessment reference date of 7/22/19 coded the resident as having long and short term memory deficits and severely impaired daily decision making skills. The resident was coded as having an indwelling catheter (a plastic tube inserted into the bladder to drain urine).
The Comprehensive Person-Centered Plan of Care dated 7/16/19 identified that the resident had a potential for Urinary Tract Infection due to the presence of an indwelling catheter. The goal was the resident's risk for UTI will be minimized through the next review. One of the interventions listed to achieve the goal was to secure the catheter and tubing appropriately.
On 8/15/19 at 1:08 p.m., the resident was observed lying in bed, the Foley catheter bag was observed making contact with the floor mat. Registered Nurse #1 was asked to show the surveyor Resident #154's Foley catheter securement device (anchor). The RN palpated for the securing device through the resident's sweat pants and could not feel one. He lowered the resident's pants and observed that there was no securement device. The RN then went and obtained an anchor and secured the catheter. Further assessment of the catheter tubing entrance evidenced the resident had an elongated cleaved non open area. The bed was lowered after application of the anchor and the drainage bag was left making contact with the floor mat. A request for the facility's indwelling catheter management policy was made at this time.
The nurse practitioners note dated 8/15/19 read, in part as follows: .(resident description) being seen per staff request in regards to urethral erosion. Due to an indwelling Foley catheter. Upon assessment there was a well healed site from a previous catheter related wound .
The facility did not have a policy or procedure on the management of an indwelling catheter. A copy of Lippincott Nursing Procedures eighth edition was provided to this surveyor by the Infection Control Nurse on 8/16/19 at 4:46 p.m., who stated, We use this for our policy. Page 392 read, in part: Secure the catheter using a catheter securement device. If a securement device is not available, tape the catheter to the patient's abdomen or thigh to prevent pressure on the urethra.
The above findings was shared with the Administrator and the Director of Nursing during a pre-exit meeting on 8/16/19.
2. Resident #10 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, muscle weakness, Parkinson's Disease, Convulsions, shortness of breath and dysphagia. A review of the clinical records indicated Resident #10 was not provided physician ordered Keppra (a medication used for the treatment of seizure disorder) and Carbidopa-Levodopa (a medication used for the treatment of Parkinson's Disease symptoms).
A Quarterly Minimum Data Set (MDS) dated [DATE] assessed this resident as having unclear speech and not able to make herself understood. This resident rarely understood and rarely understood others. This resident's vision was highly impaired. In the area of Activities of Daily Living this resident was assessed as requiring extensive assistance in the area of transfer, dressing, eating, toilet use and required two person physical assist. Resident #10 was coded in the area of Neurological as having Seizure disorder or Epilepsy.
A review of Resident #10's Care Plan dated 6/10/19 indicated Resident #10 was at risk for falls due to poor sense of safety awareness related to diagnoses of Alzheimer's disease and diagnose of Seizures. Goal- Risk for falls will be minimized through next review. Interventions- Administer medication as ordered and monitor for sedation.
A review of the clinical record dated 2/3/19 included: Resident did not receive scheduled Keppra MD aware. A review of the Medication Administration Record (MAR) dated February 2019 indicated: Keppra Solution 500 MG/5 ML, give 5 ml via G-tube every 12 hours for seizures. The MAR indicated Keppra was to be administered at 0900 and 2100 (9 PM). The 9:00 AM hour for February 3 was noted with a (7) which indicated other see nurses note.
Further review of the clinical records indicated that physician order Carbidopa-Labodopa tablet 10-100 mg give one tablet via Peg Tube every 8 hours related to Parkinson Disease was not administered during the 6 AM hour as ordered by the physician on February 19, 2019.
During an interview on 08/15/19 at 3:15 PM with the Director of Nursing (DON) she was asked was the medication available for Resident #10 and if Resident #10 received the medication. The DON stated, Resident #10 did not received the ordered medication nor were the medication available.
A facility Medication Administration policy and procedure indicated: Policy- Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication.
Medication Administration:
1. Medications are administered in accordance with writer orders of the Prescriber.
No further information was provided by the facility staff.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record review and facility documentation review, the facility staff failed to revise two of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record review and facility documentation review, the facility staff failed to revise two of 35 residents (Resident #30 and #39) comprehensive person-centered care plans in the survey sample.
The findings included:
1. The facility staff failed to revise Resident #30's comprehensive person-centered care plan to include the use of an indwelling Foley catheter. Resident #30 was originally admitted to the facility on [DATE]. Current diagnosis included but not limited to pressure ulcer of sacral region, stage IV.
Resident #30's Minimum Data Set (MDS-an assessment protocol), a significant change MDS with an Assessment Reference Date of 06/21/19 coded the resident with a 13 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. In addition, the MDS coded Resident #30 as total dependence of two with bathing, extensive assistance of two with bed mobility, transfer, dressing, toilet use and personal hygiene for Activities of Daily Living (ADL). The MDS also coded the resident for being always incontinent of bladder and frequently incontinent of bowel.
During the initial tour on 08/14/19 at approximately 2:38 p.m., an indwelling *Foley catheter was observed to bedside drainage.
The physician Order Sheet (POS) for August 2019 included the following orders:
-06/24/19-Insert Foley catheter for wound healing.
Resident #30's comprehensive person-centered care plan did not include the use of an indwelling Foley catheter.
An interview was conducted with the Director of Nursing (DON) on 08/16/19 at approximately 3:50 p.m. When asked Who is responsible for updating/revision of the resident's person-centered care plans, she replied, The nurses, Unit Manager (UM), MDS Coordinator as well as myself is responsible to updating/revising care plans. When asked, Should the use of Resident #30's Foley catheter be care planned, she replied, Absolutely.
On 08/16/19 at approximately 5:05 p.m., the following care plan was provided to the surveyor with a revision date of 08/16/19:
-Focus: Alteration in elimination of bladder (Indwelling Urinary Catheter).
-Goal: will no have complications from use of my indwelling catheter such as pain, infection or obstructions.
-Intervention to manage goals include but not limited to anchor catheter, avoid excessive tugging on the catheter during transfer and delivery care, check catheter tubing for proper drainage and position, irrigate catheter as ordered and keep drainage bag of catheter below the level of the bladder at all times and off the floor.
The Administrator and Director of Nursing (DON) was informed of the finding during a briefing on 08/16/19 at approximately 6:15 p.m. The facility did not present any further information about the findings.
Definitions:
-Foley catheter is a tube placed in the body to drain and collect urine from the bladder (https://medlineplus.gov/druginfo/meds/a682514.html).
2. The facility staff failed to revise Resident #39's comprehensive person-centered care plan to include the history of Urinary Tract Infections (UTI's) who is receiving a scheduled antibiotic, *Doxycycline 100 milligrams, daily for prophylaxis.
Resident #39's Minimum Data Set (MDS), a quarterly with an Assessment Reference Date (ARD) of 07/05/19 coded Resident #39 Brief Interview for Mental Status (BIMS) score of 11 out of a possible score of 15 indicating moderate cognitive impairment. In addition, the MDS coded Resident #39 with total dependence of two with toilet use and transfer, total dependence of one with bathing, extensive assistance of one with bed mobility, dressing and personal hygiene for Activities of Daily Living care. The MDS also coded the resident for being frequently incontinent of bladder and always incontinent of bowel.
Resident #39's comprehensive person-centered care plan did not include the history of UTI's, who is receiving an antibiotic (Doxycycline 100 mg) daily prophylactically.
An interview was conducted with the Director of Nursing (DON) on 08/16/19 at approximately 9:43 a.m. When asked Who is responsible for updating/revision of the resident's person-centered care plans, she replied, The nurse, Unit Manager (UM), MDS Coordinator as well as myself is responsible to updating/revising care plans.
On 08/16/19 at approximately 10:17 a.m., an interview was conducted with the MDS Coordinator. The surveyor asked, Should Resident #39's person-centered care plan include the use of a scheduled antibiotic (Doxycycline 100 mg) daily for (UTI) prophylaxis? The MDS Coordinator reviewed Resident #39's physician orders and the person-centered care plan. After the review, she stated, I do not see it on the care plan. She said the UTI should be care planned because Resident #39 is receiving scheduled antibiotics; there should be a specific care plan for the use of her antibiotic. The MDS Coordinator said I do not know how I overlooked, I just did not capture it, it just was not care planned.
On 08/16/19 at approximately 10:30 a.m., the following care plan was provided to the surveyor with a revision date of 08/16/19:
-Focus: Resident #39 has history of Urinary Tract Infections (UTI) - potential or actual due to history chronic urinary tract infection.
-Goal: At risk for UTI's will be minimized through next review (10/08/19).
-Interventions: Administer antibiotics as ordered and observe and report signs and symptoms of UTI.
The Administrator and Director of Nursing (DON) was informed of the finding during a briefing on 08/16/19 at approximately 6:15 p.m. The facility did not present any further information about the findings.
Definition:
-Doxycycline is used to treat bacterial infections; it works by preventing the growth and spread of bacteria (https://medlineplus.gov/druginfo/meds/a682514.html).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility staff failed to provide one resident (Resident #10) in the survey sampl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility staff failed to provide one resident (Resident #10) in the survey sample of 35 residents, with physician ordered medications.
The findings included:
Resident #10 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, muscle weakness, Parkinson's Disease, Convulsions, shortness of breath and dysphagia. A review of the clinical records indicated Resident #10 was not provided physician ordered Keppra (a medication used for the treatment of seizure disorder) and Carbidopa-Levodopa (a medication used for the treatment of Parkinson's Disease symptoms).
A Quarterly Minimum Data Set (MDS) dated [DATE] assessed this resident as having unclear speech and not able to make herself understood. This resident rarely understood and rarely understood others. This resident's vision was highly impaired. In the area of Activities of Daily Living this resident was assessed as requiring extensive assistance in the area of transfer, dressing, eating, toilet use and required two person physical assist. Resident #10 was coded in the area of Neurological as having Seizure disorder or Epilepsy.
A review of Resident #10's Care Plan dated 6/10/19 indicated Resident #10 was at risk for falls due to poor sense of safety awareness related to diagnoses of Alzheimer's disease and diagnose of Seizures. Goal- Risk for falls will be minimized through next review. Interventions- Administer medication as ordered and monitor for sedation.
A review of the clinical record dated 2/3/19 included: Resident did not receive scheduled Keppra MD aware. A review of the Medication Administration Record (MAR) dated February 2019 indicated: Keppra Solution 500 MG/5 ML, give 5 ml via G-tube every 12 hours for seizures. The MAR indicated Keppra was to be administered at 0900 and 2100 (9 PM). The 9:00 AM hour for February 3 was noted with a (7) which indicated other see nurses note.
Further review of the clinical records indicated that physician order Carbidopa-Labodopa tablet 10-100 mg give one tablet via Peg Tube every 8 hours related to Parkinson Disease was not administered during the 6 AM hour as ordered by the physician on February 19, 2019.
During an interview on 08/15/19 at 3:15 PM with the Director of Nursing (DON) she was asked was the medication available for Resident #10 and if Resident #10 received the medication. The DON stated, Resident #10 did not received the ordered medication nor were the medication available.
A facility Medication Administration policy and procedure indicated: Policy- Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication.
Medication Administration:
1. Medications are administered in accordance with writer orders of the Prescriber.
No further information was provided by the facility staff.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review and facility document review the facility staff failed to ensure 1...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review and facility document review the facility staff failed to ensure 1 of 35 residents in the survey sample received appropriate care and services to prevent complications from an indwelling Foley catheter, Resident # 154.
The findings include:
Resident #154 was admitted to the facility on [DATE] with an indwelling Foley catheter for diagnoses of BPH (benign prostatic hyperplasia-an enlarged prostate gland that can cause urination difficulty) and UTI (urinary tract infection). The current MDS (Minimum Data Set) an admission with an assessment reference date of 7/22/19 coded the resident as having both long and short term memory deficits and severely impaired daily decision making skills. The resident was coded as having an indwelling catheter (a plastic tube inserted into the bladder to drain urine).
The Comprehensive Person-Centered Plan of Care dated 7/16/19 identified that the resident had a potential for Urinary Tract Infection due to the presence of an indwelling catheter. The goal was the resident's risk for UTI will be minimized through the next review. Two of the interventions listed to achieve the goal was to provide indwelling catheter care every shift and as needed, and secure catheter and tubing appropriately.
The physician order dated 7/15/19 was to administer Cipro (an antibiotic) 500 milligrams one tab twice a day for 14 days for the treatment of a UTI.
On 8/14/19 on initial tour at approximately 11:45 a.m., the resident was observed in bed with a towel over his head. The bed was in the lowest position, the catheter tubing and drainage bag were making contact with the fall mat on the floor.
On 08/15/19 10:56 a.m., the resident was in the low bed, the catheter drainage bag was observed making contact with the floor.
On 08/15/19 at 1:08 p.m., the resident was lying in bed, the Foley catheter bag was observed making contact with the floor mat. Registered Nurse #1 was asked to show the surveyor Resident #154's Foley catheter securement (anchor) device. The RN palpated for the securing device through the resident's sweat pants and could not feel one. He lowered the resident's pants and observed that there was no securement device. The RN then went and obtained an anchor and secured the catheter. Further assessment of the catheter tubing entrance evidenced the resident had an elongated cleaved non open area. The bed was lowered after application of the anchor and the drainage bag was left making contact with the floor mat. A request for the facility's indwelling catheter management policy was made at this time.
The nurse practitioners note dated 8/15/19 read, in part as follows: .(resident description) being seen per staff request in regards to urethral erosion. Due to an indwelling Foley catheter. Upon assessment there was a well healed site from a previous catheter related wound .
On 08/16/19 9:53 a.m., observed the resident in bed, the bed was in the low position with the Foley drainage bag making contact on the floor. The unit manager was then asked to escort this surveyor into the room. The drainage bag position was pointed out to the unit manager. She stated the bag is on the floor, when asked why the bag should not be on the floor she stated, Infection Control. A second request for the facility's policy on indwelling catheter management was made.
The facility did not have a policy or procedure on the management of an Indwelling Catheter. A copy of Lippincott Nursing Procedures eighth edition was provided to this surveyor by the Infection Control Nurse on 8/16/19 at 4:46 p.m., who stated, We use this for our policy. Page 392 read, in part: Secure the catheter using a catheter securement device. If a securement device is not available, tape the catheter to the patient's abdomen or thigh to prevent pressure on the urethra .Don't place the drainage bag on the floor.
The above findings was shared with the Administrator and the Director of Nursing during a pre-exit meeting on 8/16/19.
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 observations, clinical record review and staff interview the facility staff failed to ensure 1 of 35 residents in the survey sample respiratory care equipment was maintained in a manner to en...
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Based on observations, clinical record review and staff interview the facility staff failed to ensure 1 of 35 residents in the survey sample respiratory care equipment was maintained in a manner to ensure optimal functioning, Resident #49. The fixtures on both sides of the oxygen concentrator cabinet that hold the external air filters in place were missing.
The findings include:
Resident #49 had a re-admission date of 7/3/19 with diagnoses to include, but not limited to: chronic respiratory failure, sleep apnea and chronic obstructive pulmonary disease (COPD). The resident was coded as scoring a 15 out of a possible 15 on the Brief Interview for Mental Status indicating the resident's cognition was intact.
The admission physician's orders dated 7/4/19 included an order to administer oxygen at 2 liters as needed for shortness of breath.
The Comprehensive Person-Centered Plan of Care dated 7/4/19 identified the resident was at risk for sleep pattern disturbance. The goals listed were that the resident would not exhibit any sleep related behavioral symptoms and will express feelings of being well rested. One of the approaches listed was to administer oxygen (O2) as needed.
On 8/15/19 at 4:42 p.m., and during the initial tour of the facility on 8/14/19, the resident's oxygen concentrator located at the bedside was observed to be missing the plates on both sides of the cabinet that hold the external filters. These spaces were open allowing dust and other particulates to enter inside the concentrator cabinet. The Maintenance Director was asked to accompany this surveyor into the residents room to check the O2 concentrator. Upon observation of the missing parts he stated, That should have a filter, it keeps the dust and whatever else down to a minimum from going into the system so it can continue to pump out fresh air. The sticker on the upper left corner of the cabinet indicated this concentrator had received it's annual maintenance and calibration check from the contracted oxygen supplier recently, on 8/8/2019.
On 8/15/19 prior to the resident getting up for ADL (activities of daily living) care she was asked if she uses the concentrator, she stated Yes, I used it last night. The nurses notes dated 8/15/19 entered at 9:25 p.m., and 00:35 a.m., evidenced the resident was receiving oxygen at 2 liters via the nasal cannula.
08/15/19 at 4:45 p.m., the Maintenance Director came into the conference room and stated, I got another one ( oxygen concentrator) to replace it.
The above findings was shared with the Administrator and the Director of Nursing during the pre-exit meeting conducted on 8/15/19. No additional information was provided to the survey team for Resident # 49 prior to exit.
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 record review and staff interview the facility staff failed to provide pharmacy services to one resident (Resident #10)...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility staff failed to provide pharmacy services to one resident (Resident #10) in the survey sample of 35 residents. Resident #10 was not provided physician ordered Keppra (a medication used for the treatment of seizure disorder) due to the medication not being available.
The findings included:
The facility staff failed to ensure medications were available in accordance with physician orders.
Resident #10 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, muscle weakness, Parkinson's Disease, Convulsions, shortness of breath and dysphagia.
A Quarterly Minimum Data Set (MDS) dated [DATE] assessed this resident as having unclear speech and not able to make herself understood. This resident rarely understood and rarely understood others. This residents vision was highly impaired. This resident was not assessed in the area of Brief Interview of Mental Status (BIMS). In the area of Activities of Daily Living this resident was assessed as requiring extensive assistance in the area of transfer, dressing, eating, toilet use and required two person physical assist. Resident #10 was coded in the area of Neurological as having Seizure disorder or Epilepsy.
A review of Resident #10's Care Plan dated 6/10/19 indicated Resident #10 was at risk for falls due to poor sense of safety awareness related to diagnoses of Alzheimer's disease and diagnose of Seizures. Goal-Risk for falls will be minimized through next review. Interventions-Administer medication as ordered and monitor for sedation.
A review of the clinical records dated 2/3/19 indicated: Resident did not receive scheduled Keppra MD aware. Called pharmacy and refill will be delivered tonight. A review of the Medication Administration Record (MAR) dated February 2019 indicated: Keppra Solution 500 MG/5 ML (milligrams/milliliters), give 5 ml via G-tube every 12 hours for seizures. The MAR indicated Keppra was to be administered at 0900 (9 AM) and 2100 (9 PM). The 9:00 AM hour for February 3 was noted with a (7) which indicated other see nurses note.
During an interview on 08/15/19 at 3:15 PM with the Director of Nursing (DON) she was asked was the medication available for Resident #10 and if Resident #10 received the medication. The DON stated, Resident #10 did not received the ordered medication nor was the medication available.
A facility Medication Administration policy and procedure indicated: Policy Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication.
Medication Administration:
1. Medications are administered in accordance with writer orders of the Prescriber.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on clinical record review, staff interview and facility documentation, the facility staff failed to ensure a PRN (as needed) psychotropic medication (Xanax-anxiety medication) was limited to 14 ...
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Based on clinical record review, staff interview and facility documentation, the facility staff failed to ensure a PRN (as needed) psychotropic medication (Xanax-anxiety medication) was limited to 14 days for 1 out of 35 residents (Resident #27) in the survey sample who was receiving a PRN (as needed) psychotropic medication.
The findings included:
The physician did not do an evaluation of Resident #27 to extend the psychotropic medication past 14 days nor document the rational and duration in the resident's medical record.
Resident #27 was originally admitted to the facility 02/28/19. Diagnosis for Resident #27 included but not limited to *Dementia without behavioral disturbances and Anxiety. Resident #27's MDS, a significant change with an Assessment Reference Date (ARD) of 06/18/19 coded resident with a BIMS score of 08 out of a possible 15 moderate cognitive impairment.
In addition, the MDS with an ARD of 06/18/19, under section E (Behaviors), coded Resident #27 for exhibiting verbal behaviors directed towards others 1-3 days each week.
Resident #27's comprehensive care plan documented resident for potential for drug related complications associated with use of psychotropic medications related to Anti-anxiety medication usage. Some of the goals set for the resident included not but not limited to: drug complications will be minimized through the next review (09/25/19). Some of the intervention to manage the resident's goal include provide medication as ordered by physician and evaluate for effectiveness and monitor for side effects and report to physician.
Review of physician orders included the following order:
07/01/19: Xanax 1 mg-give 1 tablet by mouth every 8 hours as needed for anxiety monitoring for behaviors including crying, resisting care and yelling.
The July 2019 Medication Administration Records (MAR's) evidenced documentation that the resident was administered the (PRN) Xanax 1 mg by mouth on the following days: 07/01, 07/02, 07/04, 07/05, 07/06, 07/07, 07/09, 07/10, 07/11, 07/13, 07/14, 07/16, 07/17, 07/19, 07/20, 07/21, 07/22, 07/23, 07/24, 07/25, 07/28, 07/29, 07/30 and 07/31/19.
The August 2019 Medication Administration Records (MAR's) evidenced documentation that the resident was administered the (PRN) Xanax 1 mg by mouth on the following days: 08/01, 08/02, 08/03, 08/04, 08/05, 08/06, 08/07, 08/08, 08/10, 08/13, 08/14, 08/15 and 08/16/19.
Review of Resident #27's clinical record for July and August 2019 did not show evidence the physician did an evaluation to extend the psychotropic medication past 14 days nor document the rational and duration in the resident's medical record.
An interview was conducted with the Director of Nursing (DON) on 08/16/19 at approximately 3:50 p.m. The DON stated, I was focused on PRN antipsychotic medication. I was not aware the 14 days also included the psychotropic. The DON stated, We were unable to locate documentation in the resident clinical record that Resident #27 was evaluated to continue the use of the (PRN) Xanax to be extended past the 14 days.
The Administrator and Director of Nursing was informed of the finding during a briefing on 08/16/19 at approximately 6:15 p.m. The facility did not present any further information about the findings.
The facility present the following policy titled Nursing Care Center Pharmacy - Medication Monitoring - Medication Management (Revision date: November 2017).
-Based on comprehensive assessment of a resident, the facility must ensure: PRN orders for psychotropic drugs are limited to 14 days. Exception: If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rational in the resident's medical record and indicate the duration for the PRN order.
Definitions:
-Dementia is the name for a group of symptoms caused by disorders that affect the brain. People with dementia may not be able to think well enough to do normal activities, such as getting dressed or eating. They may lose their ability to solve problems or control their emotions. Their personalities may change. They may become agitated or see things that are not there (https://medlineplus.gov/ency/article/007365.htm).
-Anxiety disorder is a mental condition in which you are frequently worried or anxious about many things. Even when there is no clear cause, you are still not able to control your anxiety (https://medlineplus.gov/ency/patientinstructions/000685.htm).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0773
(Tag F0773)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and facility documentation the facility staff failed to notify the physician an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and facility documentation the facility staff failed to notify the physician and/or his designee of laboratory results for 1 of 35 resident (Resident #24) in the survey sample.
The findings included:
The facility staff failed to report to the physician Resident #24's abnormal lab results of a high Hemoglobin A1C (HgbA1C), resulting in a delay in medical treatment. Resident #24 was originally admitted to the facility on [DATE]. Diagnoses for Resident #24 included but not limited to, Type 2 Diabetes Mellitus (DM.)
Resident #24's Minimum Data Set (MDS), quarterly assessment with an Assessment Reference Date of 06/12/19 coded the Brief Interview for Mental Status (BIMS) score an 03 out of a possible 15 indicating severe cognitive impairment. Resident is extensive assistance of one with bed mobility and bathing, limited assistance of one with dressing and personal hygiene and supervision with transfer and toilet use for Activities of Daily Living (ADL).
Resident #24's comprehensive care plan documented resident has alteration in blood glucose due to diagnosis of insulin dependent diabetes mellitus. Some of the goals set for the resident included not but not limited to: at risk for complications from diabetes will be minimized through the next review (11/11/19). Some of the intervention to manage the resident's goal include administer medication a ordered and labs per physician order and PRN for change in condition/manifestation of clinical signs or symptoms.
The clinical record revealed the following Medication Regimen Review (MMR) written on 06/19/19 to include the following current medication orders:
-Glipizide 10 mg by mouth twice daily and Humalog sliding scale insulin.
-The MMR for 06/19/19 also included - Please consider: HgbA1C to monitor this residents diabetic therapy. The Physician/Prescriber Responded to please draw HgbA1C, signed on 06/26/19.
During the review of Resident #24's medical record, the surveyor was unable to locate the lab results for the HgbA1C ordered on 06/26/19.
On 08/15/19 at approximately 9:45 a.m., the surveyor requested the HgbA1C lab results from the Director of Nursing (DON). On the same day at approximately 11:30 a.m., the DON stated, The lab results were obtained but the physician was never informed of the results. She said the Nurse Practitioner (NP) is reviewing the lab results now. The surveyor was given a copy of the HgbA1C labs results that were obtained on 06/28/19 with the following results:
-Results @ 8.1 (High). Normal range for HgbA1c (4.0-6.0).
On 08/15/19, the surveyor was presented a progress note written by the NP on 08/15/19 to include the following new orders on Resident #24:
-Start ACTOS 30 mg daily for DM.
-Check BMP for Renal Function.
-In 7 days after starting ACTOS-will decrease Glipizide to 5 mg twice daily for DM.
An interview was conducted with the NP on 08/16/19 at approximately 2:55 p.m. The surveyor asked, What is the purpose of a HgbA1C she replied, It gives a baseline on how well we are controlling the resident blood sugars and if they are being complaint with their diet. The surveyor asked, If labs are ordered, when do you expect for the facility to inform of the results? The NP stated, I would expect the lab results in a few days but a least within a week. The resident did not experience any negative effects related to the lab result.
The Administrator and Director of Nursing (DON) was informed of the finding during a briefing on 08/16/19 at approximately 6:15 p.m. The facility did not present any further information about the findings.
Definitions:
-Hemoglobin A1C is a blood test for type 2 diabetes and prediabetes. It measures your average blood glucose, or blood sugar, level over the past 3 months (https://medlineplus.gov/ency/article/007365.htm).
-Diabetes Mellitus Type II is a lifelong (chronic) disease in which there is a high level of sugar (glucose) in the blood (https://medlineplus.gov/ency/article/007365.htm).
-Glipizide is used to treat type 2 diabetes - a condition in which the body does not use insulin normally and, therefore, cannot control the amount of sugar in the blood (https://medlineplus.gov/ency/article/007365.htm).
-Humalog insulin is also used to treat people with type 2 diabetes (condition in which the body does not use insulin normally and therefore cannot control the amount of sugar in the blood) who need insulin to control their diabetes (https://medlineplus.gov/ency/article/007365.htm).
-ACTOS is an oral diabetes medicine that helps control blood sugar levels
(https://medlineplus.gov/ency/article/007365.htm).
-Basic metabolic panel (BMP) is used to check the status of a person's kidneys and their electrolyte and acid/base balance, as well as their blood glucose level-all of which are related to a person's metabolism.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0712
(Tag F0712)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interview, the facility staff failed to ensure 1 of 35 Residents (#39) in th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interview, the facility staff failed to ensure 1 of 35 Residents (#39) in the survey sample was seen by a physician or his/her designee at least every 60 days.
Findings included:
Resident #39 was originally admitted to the facility on [DATE]. Diagnosis included but were not limited to *Chronic Pulmonary Edema and *Depression.
Resident #39's Minimum Data Set (MDS), a quarterly with an Assessment Reference Date (ARD) of 07/05/19 coded Resident #39 Brief Interview for Mental Status (BIMS) score of 11 out of a possible score of 15 indicating moderate cognitive impairment. In addition, the MDS coded Resident #39 total dependence of two with toilet use and transfer, total dependence of one with bathing, extensive assistance of one with bed mobility, dressing and personal hygiene for Activities of Daily Living care.
Review of the clinical record revealed Physician's progress notes only for 09/18/18 and 6/20/19.
An interview was conducted with the Director of Nursing (DON) on 08/16/19 at approximately 3:50 p.m., who stated, We were in the process of changing physician, and Resident #39 was missed. The DON said Medical Records is responsible for notifying the physician when a resident requires re-certification. She said when a resident is admitted to the facility; they are to be seen every 30 days x 3 months then every 60 days after.
On 08/16/19 at approximately 4:09 p.m., an interview was conducted with Medical Records. The surveyor asked how often should a resident be seen by the physician or his designee. She said every 30 days for the first 90 days then every 60 days after. She said the physician was made aware when Resident #39 needed to be seen but he just did not see her; I cannot explain why the physician did not see Resident #39.
The Administrator and Director of Nursing was informed of the finding during a briefing on 08/16/19 at approximately 6:15 p.m. The facility did not present any further information about the findings.
The facility does not have a policy for physician visits but follows the Center for Medicare & Medicaid (CMS) regulations. The following document was presented to the surveyor:
(CMS Manual System) Titled: Frequency of physician visits (Effective November 28, 2017).
-The residents must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least every 60 thereafter.
Definitions:
*Pulmonary Edema is a condition caused by excess fluid in the flung. This fluid collects in the numerous air sacs in the lungs, making it difficult to breathe.
* Depression disorder is a chronic (ongoing) type of depression in which a person's moods are regularly low (Mosby's Dictionary Medicine, Nursing & Health Professions 7th edition).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations, staff interviews and facility documentation the facility staff failed to ensure that opened food products were properly dated, labeled, and stored in accordance with professiona...
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Based on observations, staff interviews and facility documentation the facility staff failed to ensure that opened food products were properly dated, labeled, and stored in accordance with professional standards for food service safety.
The findings included:
On 08/14/2019 at 11:15 a.m., during the initial tour of the kitchen with the Dietary Manager an open carton of *Med Plus 2.0 Vanilla (a fortified nutritional shake) and an opened carton of Thickened Orange Juice was observed in the reach in refrigerator. They were not dated with an opened date or use by date. The Dietary Manager was asked, Should the staff date the cartons when they open them and date them with a use by date? The Dietary Manager stated, Yes, the staff should have dated them. They just forgot to date them. The Dietary Manager stated, I will throw them away. At approximately 11:25 a.m., walked into the walk in freezer accompanied by the Dietary Manager and noted a cardboard box sitting on the shelf. The Dietary Manager was asked, What is inside the cardboard box? The Dietary Manager took the box down off the shelf and inside the box was an open plastic bag. The Surveyor asked the Dietary Manager to pick the plastic bag up out of the box to show the surveyor what was inside the bag. The surveyor noted that the bag was open and not dated or labeled. The Surveyor asked the Dietary Manager, What is inside the bag? The Dietary Manager stated, Breaded Chicken Patties. The Dietary Manager was asked, Should the bag be closed, sealed tightly? The Dietary Manager stated, Yes, someone forgot to close the bag.
At 3:40 p.m. on 08/15/2019, the Surveyor revisited the kitchen and the Dietary Manager stated that he was in the process of inservicing the Dietary Staff on proper Dating and Labeling of items.
On 08/16/2019 at approximately 3:00 p.m., the Dietary Manager provided a copy of the inservice training information and the sign in sheet to the Surveyor.
On 08/16/2019 at approximately 6:30 p.m., at the pre-exit meeting the Administrator and the Director of Nursing was informed of the finding. The facility did not present any further information about the finding.
* Guidance from: https://www.hormelhealthlabs.com/resources/for-healthcare-professionals/product-protocols/med-pass-fortified-nutritional-shake-medication-pass-program/
IV. Implementation of MED PASS®* Program
Procedure:
5. MED PASS® 2.0/MED PASS® NSA needs to be kept at refrigerated temperature (34-40 degrees F) once opened. If kept at this temperature range, product is good for 4 days from the time opened. If product is opened and not refrigerated, product should be discarded after 4 hours.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and facility document review the facility staff failed to perform hand hygiene practices...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and facility document review the facility staff failed to perform hand hygiene practices to provide a safe, sanitary environment and to help prevent the development and transmission of disease and infections; and failed for one of 35 residents, Resident #154's, Foley catheter tubing and bag in a manner in accordance with infection control standards and practices to help prevent associated urinary tract infections.
The findings included:
1. On 08/15/2019 during a follow up visit in the kitchen, the following observations were made:
At approximately 11:50 a.m., [NAME] #3 was observed washing her hands with soap and water for 5 seconds.
At approximately 12:00 p.m., [NAME] #2 was observed washing his hands with soap and water for 5 seconds.
At approximately 12:10 p.m., the Dietary Manager was observed washing his hands with soap and water for 5 seconds.
On 08/15/2019 at 1:00 p.m. the surveyor reviewed hand washing observations with the Dietary Manager. The Dietary Manager was asked, When the staff wash their hands, how long do you expect them to wash them? The Dietary Manager stated, They should wash their hands for 20 seconds, sing Happy Birthday.
At 3:40 p.m. on 08/15/2019, the Surveyor revisited the kitchen and the Dietary Manager stated that he was in the process of inservicing the Dietary Staff on proper handwashing.
On 08/15/2019 at 3:45 p.m., an interview was conducted with [NAME] #2 and reviewed observing him wash his hands for 5 seconds. [NAME] #2 was asked, When you wash your hands, how long should you wash them for? [NAME] #2 stated, I've been inserviced before and I should wash them for 20 seconds.
On 08/16/2019 at approximately 3:00 p.m., the Dietary Manager provided a copy of the inservice training information and the sign in sheet to the Surveyor.
On 08/16/2019 at approximately 3:00 p.m., a copy of the facility policy and procedure on Hand Washing Technique (Refer to [NAME]) with an effective date of 2/17 was provided to the Surveyor. Review of the policy and procedure revealed under Procedure #3 - Apply soap to hands. Using friction, wash all parts of hands, between fingers, knuckles and wrists for 10 to 15 seconds.
On 08/16/2019 at approximately 6:30 p.m., at the pre-exit meeting the Administrator and the Director of Nursing was informed of the finding. The facility did not present any further information about the finding.
2. The facility staff failed to handle Resident #154's Foley catheter tubing and bag in a manner in accordance with infection control standards and practices to prevent catheter associated urinary tract infections.
Resident #154 was admitted to the facility on [DATE] with an indwelling Foley catheter for diagnoses of BPH (benign prostatic hyperplasia-an enlarged prostate gland that can cause urination difficulty) and UTI (urinary tract infection). The admission MDS (Minimum Data Set) with an assessment reference date of 7/22/19 coded the resident as having both long and short term memory deficits and severely impaired daily decision making skills. The resident was coded as having an indwelling catheter (a plastic tube inserted into the bladder to drain urine) and having received an antibiotic for 7 of 7 days of the look back period.
The physician order dated 7/15/19 was to administer Cipro (an antibiotic) 500 milligrams one tab twice a day for 14 days for the treatment of a UTI.
The Comprehensive Person-Centered Plan of Care dated 7/16/19 identified the resident had a potential for Urinary Tract Infection due to the presence of an indwelling catheter. The goal was the resident's risk for UTI will be minimized through the next review. Two of the interventions listed to achieve the goal was to provide indwelling catheter care every shift and as needed, and secure catheter and tubing appropriately.
On 8/14/19 on initial tour at approximately 11:45 a.m., the resident was observed in bed with a towel over his head. The bed was in the lowest position, the catheter tubing and drainage bag were making contact with the fall mat on the floor.
On 08/15/19 10:56 a.m., the resident was in the low bed, the catheter drainage bag was observed making contact with the floor.
On 08/15/19 at 1:08 p.m., the resident was lying in bed, the Foley catheter bag was observed making contact with the floor mat. Registered Nurse #1 was asked to show the surveyor Resident #154's Foley catheter securement device. The RN palpated for the securing device through the resident's sweat pants and could not feel one. He lowered the resident's pants and observed that there was no securement device. The RN then went and obtained an anchor and secured the catheter. Further assessment of the catheter tubing entrance evidenced the resident had an elongated cleaved non open area. The bed was lowered after application of the anchor and the drainage bag was left making contact with the floor mat. A request for the facility's Indwelling Catheter management policy was made at this time.
The nurse practitioners note dated 8/15/19 read, in part as follows: .(resident description) being seen per staff request in regards to urethral erosion. Due to an indwelling Foley catheter. Upon assessment there was a well healed site from a previous catheter related wound .
08/16/19 9:53 a.m., observed the resident in bed, the bed was in the low position with the Foley drainage bag making contact on the floor. The unit manager was then asked to escort this surveyor into the room. The drainage bag position was pointed out to the unit manager. She stated the bag is on the floor, when asked why the bag should not be on the floor she stated, Infection Control. A second request for the facility's policy on Indwelling Catheter management was made. The unit manager was also the facility's Infection Control Nurse.
The facility did not have a policy or procedure on the management of an Indwelling Catheter. A copy of Lippincott Nursing Procedures eighth edition was provided to this surveyor by the Infection Control Nurse on 8/16/19 at 4:46 p.m., who stated, We use this for our policy. Page 392 read, in part: Secure the catheter using a catheter securement device. If a securement device is not available, tape the catheter to the patient's abdomen or thigh to prevent pressure on the urethra .Don't place the drainage bag on the floor.
The above findings was shared with the Administrator and the Director of Nursing during a pre-exit meeting on 8/16/19.
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
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Virginia facilities.
Concerns
- • 71 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • Grade F (25/100). Below average facility with significant concerns.
- • 96% turnover. Very high, 48 points above average. Constant new faces learning your loved one's needs.
Bottom line: Trust Score of 25/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Bayside Of Poquoson Health And Rehab's CMS Rating?
CMS assigns BAYSIDE OF POQUOSON HEALTH AND REHAB 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 Bayside Of Poquoson Health And Rehab Staffed?
CMS rates BAYSIDE OF POQUOSON HEALTH AND REHAB's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 96%, which is 49 percentage points above the Virginia average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 67%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Bayside Of Poquoson Health And Rehab?
State health inspectors documented 71 deficiencies at BAYSIDE OF POQUOSON HEALTH AND REHAB during 2019 to 2025. These included: 1 that caused actual resident harm and 70 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Bayside Of Poquoson Health And Rehab?
BAYSIDE OF POQUOSON HEALTH AND REHAB 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 TRIO HEALTHCARE, a chain that manages multiple nursing homes. With 60 certified beds and approximately 54 residents (about 90% occupancy), it is a smaller facility located in POQUOSON, Virginia.
How Does Bayside Of Poquoson Health And Rehab Compare to Other Virginia Nursing Homes?
Compared to the 100 nursing homes in Virginia, BAYSIDE OF POQUOSON HEALTH AND REHAB's overall rating (1 stars) is below the state average of 3.0, staff turnover (96%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Bayside Of Poquoson Health And Rehab?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.
Is Bayside Of Poquoson Health And Rehab Safe?
Based on CMS inspection data, BAYSIDE OF POQUOSON HEALTH AND REHAB has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Virginia. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Bayside Of Poquoson Health And Rehab Stick Around?
Staff turnover at BAYSIDE OF POQUOSON HEALTH AND REHAB is high. At 96%, the facility is 49 percentage points above the Virginia average of 46%. Registered Nurse turnover is particularly concerning at 67%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Bayside Of Poquoson Health And Rehab Ever Fined?
BAYSIDE OF POQUOSON HEALTH AND REHAB 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 Bayside Of Poquoson Health And Rehab on Any Federal Watch List?
BAYSIDE OF POQUOSON HEALTH AND REHAB 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.