FOREST HILL HEALTH & REHABILITATION
For profit - Limited Liability company
174 Beds
HILL VALLEY HEALTHCARE
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
0/100
#251 of 285 in VA
Photo by Tamika Williams
Photo by Tia Coleman
Photo by Lisa Coyner (The Groutsmith)
1 / 5 photos
Last Inspection: February 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Forest Hill Health & Rehabilitation has received a Trust Grade of F, indicating significant concerns and a very poor overall standing. Ranking #251 out of 285 facilities in Virginia places it in the bottom half, and #5 out of 6 in Richmond City County shows there is only one local option of lower quality. The facility is worsening, with the number of issues increasing from 16 in 2024 to 37 in 2025. Staffing is a major concern, with a low rating of 1 out of 5 stars and a 70% turnover rate, which is much higher than the state average. Additionally, the facility has incurred $80,132 in fines, indicating repeated compliance issues. While the facility does have higher RN coverage than 75% of Virginia facilities, which is a positive aspect, there are serious problems as well. For example, staff failed to supervise residents with known substance abuse issues, leading to dangerous incidents, including overdoses. Another critical finding involved a resident creating sharp weapons from dining cutlery, highlighting a lack of safety measures. Overall, while there are some strengths, the numerous and severe deficiencies make this facility concerning for families seeking care for their loved ones.
- Trust Score
- F
- In Virginia
- #251/285
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 70% turnover. Very high, 22 points above average. Constant new faces learning your loved one's needs.
- Penalties ○ Average
- $80,132 in fines. Higher than 63% of Virginia facilities. Some compliance issues.
- Skilled Nurses ○ Average
- Each resident gets 36 minutes of Registered Nurse (RN) attention daily — about average for Virginia. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 96 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 12%
Review needed
16 → 37 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 16 issues
2025: 37 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: 70%
24pts above Virginia avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $80,132
Well above median ($33,413)
Moderate penalties - review what triggered them
Chain: HILL VALLEY HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is very high (70%)
22 points above Virginia average of 48%
The Ugly 96 deficiencies on record
2 life-threatening 1 actual harm
Feb 2025
37 deficiencies
2 IJ (2 affecting multiple)
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, Resident interview, staff interview, clinical record review, and facility document review, the facility st...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, Resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to maintain an environment that was free from hazards, that each Resident received supervision, and that ongoing monitoring was implemented to prevent accidents and hazards for four (4) Residents (#'s 42, 106, 124, and 130) in a survey sample of 63 Residents, which resulted in Immediate Jeopardy.
The findings included:
The facility staff admitted Resident #42, #106, #124, and #130 with known substance abuse histories. They continued to use illicit drugs and alcohol, returning to the facility after a leave of absence under the influence of illegal drugs and or/alcohol. There was no evidence that the facility implemented ongoing monitoring or effective interventions to address the ongoing substance abuse.
Resident # 42 was sent to the emergency room on more than one occasion for alcohol and drug overdose; Resident #106 was found with alcohol on more than one occasion, sent to the ER for alcohol and drug use, and was also found to have made weapons out of cutlery from his dinner tray; Resident #124 was found under the influence of illicit drugs admitted to being high however when EMS arrived he refused to go to the hospital on the first drug overdose, but was transferred via EMS with the second overdose incident; Resident #130 was found to be under the influence of an illicit substance and admitted to staff that he was high. However, when EMS arrived, he refused hospital transport.
1. Resident # 42 was sent to the emergency room on more than one occasion for alcohol and drug overdose. There was no evidence that the facility implemented ongoing monitoring or effective interventions to address the ongoing substance abuse.
Resident #42 was admitted to the facility with diagnoses that included but were not limited to COPD (Chronic Obstructive Pulmonary Disease), bipolar disorder, sleep apnea, hypertension, fusion of cervical spine, heart failure, major depressive disorder, history of venous thrombosis, (blood clot), anxiety disorder and viral hepatitis C.
On [DATE] at approximately 1:47 pm, an interview was conducted with Resident #42, who stated that he was given a 30-day notice and had nowhere to go. When asked why he was given the 30-day notice, he stated that someone saw him smoking something at the bus stop (Please note the bus stop is at the end of the driveway to the facility). When asked what he was smoking, Resident #42 stated that he was smoking weed. Resident #42 then added, I did not do it on the property, and I didn't bring it into the facility. When asked if the facility Social Worker was attempting to find his placement elsewhere, he stated that they were.
On [DATE] at approximately 10:00 a.m., an interview was conducted with Resident #42, who was asked if he had been taken to the hospital for overdose in the past, and he stated that he had. When asked what substance he uses, he stated, marijuana, cocaine, and sometimes heroin. When asked if he drinks alcohol, he answered that he did. When asked where he gets the substances, he stated, I go out of the facility to get it. When asked if he brought the substances into the facility, he denied using any drugs or alcohol on the property.
A review of the clinical record revealed the following excerpts related to non-compliant behaviors with smoking, drugs, and alcohol use:
[DATE] 2:43 am-Nurse's Note Text: Resident has smoke vape in room fire alarm was going off panel stated, room [ROOM NUMBER], writer and staff went into room smoke alarm over resident bed was red, resident had a smoke vape in bed and one on the table writer educated about smoking in facility resident stated, He understood.
[DATE] 10:49 am - Nurse's Note Text: [Resident #42 name redacted] today to discuss his oxycodone capsules that he gets. We have been opening them up to give them to him. He would like to have another attempt at taking the capsule whole. I am ok with this. He understands that If nursing has any further concerns he will be switched to liquid oxycodone. We also discussed a referral to the pain specialist to ensure he is getting the correct dose.
[DATE] 2:13 pm-Nurse's Note Text: I see [Resident #42 name redacted] today due to a report that he may not be swallowing his oxycodone capsule. I am going to switch him to liquid, and he is still awaiting pain management appt.
[DATE] 11:31 pm-Nurse's Note Text: Resident is on mouth checks after taking oxycodone. Resident did not complying [sic] with swallowing the pill. Resident held it in his mouth and was told to swallow the pill. Resident then proceed to fake swallow the pill again. NP [Nurse Practitioner] made aware of this behavior order oxycodone HCl Oral Solution 5 MG/5ML.
Physician note: [DATE] 9:41 am - I saw [Resident #42 name Redacted] after he was taken to the ER for intoxication. He was found outside of the facility intoxicated and taken to the ER to be evaluated. He eloped from the ED and came back here. He is at baseline, no evidence of alcohol abuse at this time. Unable to obtain drug testing at the ED. All records reviewed; staff notified.
Physician Note: [DATE] 1:37 pm -In to see [Resident #42 name redacted] today due to reports of possibly not taking his oxycodone. I am going to change his meds to liquid to avoid any confusion and eliminate the ability for him to cheek or not take the meds.
[DATE] 12:45 am- Nurse's Note Text: 6:15 p.m. Writer was notified [sic] that resident was sweating profusely and not really able to hold self-up while sitting on the bed. Writer assessed resident. Resident was sweaty profusely (beads of sweat coming off their head and face). BUE sweaty. Resident could not answer any of the writer's questions. Resident alert, nonverbal. Resident continues to stare off into the distance focusing on the wall in front of them. BP:73/59 P:121 R:16 T:98.8 O2:96% BS:84. 1822 Writer contacted 911. 1821 Supervisor [name redacted] notified. 1823 Supervisor notified NP [Nurse Practitioner name redacted] 1834 EMT arrives at facility. 1844 EMT leaves w/resident. 1939 Resident calls the facility asking how did they get to the hospital? And why is they [sic] at the hospital? Resident also requested that someone looks in there [sic] rm. to see if they left their phone and wallet because they didn't have it on them. Writer put resident on hold. While searching for resident phone and wallet, Writer found a cigarette box (Brand name redacted) that contained a lighter, glass pipe (ends of pipe burned and white residue stained the middle of the [NAME] [sic] pipe), one whole and half of a cigarette that has been lit at some point. Supervisor notified.
Physician Note: [DATE] 9:28 a.m. - I see [Resident #42 name redacted] today after him being sent to the ED yesterday for substance abuse and AMS [Altered Mental Status]. He would not admit to what he used to us but in the ED notes he admitted to heroin. I have asked him to provide urine for a drug screen for us if he would like for me to continue to prescribe his oxycodone. This is safety issue. He adamantly refused the drug screen.
Physician Note: [DATE] -Patient is a [AGE] year-old male with bipolar disorder, anxiety and polysubstance abuse on Cymbalta Trazodone and most recent Suboxone. He is here for LTC. He is being seen today at the staff request d/t suspected ongoing drug use. Per the DON, patient was on LOA on [DATE] and taken to the hospital because he overdosed on heroin. A review of ED record states that patient admitted to snorting heroin and bystanders called EMS. He was given Narcan and responded immediately. Patient had another ED visit on 11.8.24. EMS found him sitting on the floor at the bus stop and appeared intoxicated and couldn't walk. He was taken to the ED although he resisted, and he refused having any labs done once in the ED and eloped from the ED. He is found in bed asleep and is easily awakened. He says he left the facility and went to see a friend with whom he smoked heroin and was drinking alcohol. He says he doesn't remember when he passed out but remembers being awakened by the EMS. He says he has never used any drugs or used or brought or distributed any alcohol on these premises. He reports h/o personal and family polysubstance use. Polysubstance abuse: very recent use of alcohol and heroin. Couseling [sic] provided against substance use. Patient has continued to refuse any drug testing even here at the facility. Risk of drug use and associated negative impact remains if this patient has access to drugs. Maintain close monitoring. Patient understand that he signed a discharge notice.
On [DATE] at 1:00 pm, an interview was conducted with LPN A, who stated that they are aware of the Residents going out on LOA (Leave of Absence) and coming back high, but they could not always be with them and cannot stop them from leaving the facility. When asked what is done if they catch them smoking, drinking, or using drugs in the facility, she stated, We document in the chart, notify the supervisor, and educate them. That is all we can really do. When asked if the care plan should reflect the behaviors and interventions, she stated it should.
A review of the care plan revealed the first time the behaviors were addressed were as follows:
BEHAVIORS: the resident has admitted behaviors of drug and alcohol abuse when leaving the facility.
Date Initiated: [DATE].
INTERVENTION: Notify MD as indicated Date Initiated: [DATE]
Referral to inpatient drug abuse recovery center. Date Initiated: [DATE] Revision on: [DATE]
2. Resident #106 was found with alcohol on more than one occasion, sent to the ER for alcohol and drug use, and was also found to have made weapons out of cutlery from his dinner tray. There was no evidence that the facility implemented ongoing monitoring or effective interventions to address the ongoing substance abuse or the formulation of handmade weapons.
Resident #106 was admitted to the facility on [DATE] with diagnoses that included but were not limited to a history of multiple medical problems, including a gunshot wound to the head with stroke secondary to injury, hemiplegia, moderate recurrent major depression disorder, seizure disorder, late effect of traumatic brain injury, insomnia, and muscle spasms.
On [DATE] at approximately 3:00 pm, an interview was conducted with Resident #106, who stated that he did get caught with beer in the facility. He stated that he goes out of the facility with his girlfriend, and that is when he gets the beer. When asked about being taken to the hospital, he stated that he did go to the hospital a couple of times because of drug and/or alcohol use. Resident #106 stated that the facility offered to try and get him into inpatient treatment, but there were no beds available.
A review of the clinical record revealed the following excerpts about illicit drug and or alcohol use by Resident #106:
[DATE] 4:30 pm - Nurse's Note Text: Resident found in the shower room on the floor on his left side. Resident stated he fell trying to get on the toilet. This writer with the help of another nurse assist resident from the floor. Resident denied hitting his head. Resident refused neuro checks. Resident alert and oriented x4. Resident had a bottle of beer that this writer took from resident and reported beer to the DON, approximately 3 minutes before fall resident was verbally inappropriate to this writer stating I am hard and I want some pussy, give me some pussy. This writer redirect resident. Resident also stated he is ready to go to the [NAME].NP notified and gave orders for resident to be transferred to ER for evaluation. Change of condition completed, risk management and transfer summer [sic]. NP/RP notified.
[DATE] 10:27 pm - Nurse's Note Text: Resident returned from hospital at approximately 4:00 pm via stretcher. Resident was seen for depression, alcohol intoxication, and polysubstance abuse (resident overdosed on [DATE]). No new orders at this time. Resident needs to f/u with MD. Resident s/p fall day 1/3, no c/o pain or discomfort noted. Continues to be safety checks for suicidal or homicidal ideations.
[DATE] Physician Progress Note: Per staff, resident fell in the shower room and hit his head; he appears to have altered mental status. Staff assisted him back to his chair and a can of beer rolled out of his chair. Pt insisted on drinking this beer, but staff prevented him from doing so. Pt then left the unit and was found in the middle of the road in his w/c. Staff assisted him back to the facility. He appeared altered, speech was slurred and there a facial droop. Again, another can of beer was found in his chair and patient open the can in an attempt to drink it. Staff intervened. Patient admitted having stolen the beer from the gas station convenience store. He also admitted to have consummed [sic] alcohol, marijuana and cocaine. Per staff he was making inappropriate sexual comments in both incidents. Per staff, drug paraphenalia [sic] (pipe) was found in his possession and taken by staff; he denied feeling suicidal. He was sent to the ED where he tested positive for all substances above. immediately left the unit.
[DATE] 4:39 pm -Nurse's Note Text: Writer observed this resident sitting in his wheelchair next to the service elevator sleeping. Writer was able to easily arouse resident but noted slurred speech and a strong odor while speaking with him. Resident was assisted back to his room. Vitals- BP107/68, P: 88, 02: 95% room air. R:10. While writer and another nurse were speaking with this resident, he reported that he consumed Suboxone and alcohol. Notified NP and advised to closely monitor resident for any changes in level of consciousness, respiratory rate and 02 sats and to notify NP/MD immediately. Charge nurse made aware. DON made aware.
[DATE] 10:48 am - Nurse's Note Text: He admitted to drinking during the day and then consuming Suboxone. He reports that he got this off the street. Narcan is at bedside, staff aware of frequent checks. Patient then left the building again and did not return until hours later. I educated him on the dangers of this. He is on no other controlled substances that I can discontinue.
[DATE] 10:00 am -Nurse's Note Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Abnormal vital signs (low/high BP, heart rate, respiratory rate, weight change) Altered mental status Seems different than usual Talks/Communicates Less Tired, Weak, Confused, or Drowsy Nursing observations, evaluation, and recommendations are: Resident noted in wheelchair, leaning forward onto bed with poor trunk control, blue in the face, excessive drooling, heavy sweating, not easily aroused but responded to sternal rub, resident presented with lethargy stable vitals with the exception of HR and O2sat. when asked what happened, resident was unable to provide a clear answer, NP [NAME] made aware and gave orders to send to ER to eval and treat.
[DATE] 8:13 a.m.-Nurse's Note Text: Late entry [DATE] resident returned to the facility with no report given or paperwork. Writer attempted to call hospital, but nurse was busy with another patient. Resident refused vital signs.
[DATE] 3:09 pm-Nurse's Note Text: Please describe the behavior demonstrated: Writer was notified by therapy that this resident was seen in his wheelchair around wing 2 with an alcoholic beverage on his person. Staff was able to confiscate an opened alcoholic beverage from him. How often did this behavior occur/last: first occurrence. Describe any interventions attempted: educated on appropriate behavior in a skilled nursing facility setting. placed on one-on-one monitoring & 5-day d/c to be given to resident per facilities RDO (Regional Director of Operations).
[DATE] 1:36 pm-Nurse's Note Text: CNA came to nursing station and reported burning smell in residents room. This writer iddmeditely [sic] got up to assess sitatuon [sic]. As walking in resident room, this writer smelt burning smell. This writer asked resident what is the smell? Resident denined [sic] the smell. This writer asked resident asgain[sic] what was he do, and what's burning. Residnent[sic] deined[sic] smelling anything burning and then stated he wasnt doing anything. This writer oserved [sic] a burnt fork with only one tines. Resident took the rest of the tines off the fork pervisuosly[sic] before this incident. This writer called another nurse to assess the satiation. Once nurse arrived this writer went to find The Supervisor on shift. Supervisor confiscated the fork And stated restident [sic] needs to go back on 1:1. Once supervisor left. Resident then immediately transferred to bed out of sight of This writer and other staff. This writer then re-enters the room from standing outside the residents room to observer resident with another fork and lighter on bed and with a weed pipe in his hands. When asked to hand it over resident tried to hid weed pip within his fanny pack. This writer then asked resident to hand over fanny pack. Resident took weed pipe out then then tried to hid weed pipe around his back. Resident was asked to put weed pipe in the fanny pack after placing it in fanny pack this write Confiscated it. Resident was then asked to exit the room to be physical in sight of staff till a sitter was avail Describe any interventions attempted: Confiscated fanny pack with lighter, weedpipe [sic], and fork with only one tines. Resident palaced [sic] on 1:1. Resident siting with sitter no more attmps [sic] to use lighter, weed pipe, or fork it's in supervisor [sic] possession.
A review of the care plan revealed the first time the behaviors were addressed were as follows:
BEHAVIORS: the resident has drug and alcohol behaviors when leaving the facility and has been caught with alcohol while in the facility. Date Initiated: [DATE]
GOAL: the resident's behaviors will cause them less distress through the review period Date Initiated: [DATE]
Target Date: [DATE]
The resident's behaviors will not cause them or other resident's distress through the review period Date Initiated: [DATE] Target Date: [DATE].
INTERVENTIONS: Referred to inpatient recovery for drug and alcohol abuse. Date Initiated: [DATE]
1:1 activities as needed Date Initiated: [DATE]
Explain all procedures to the resident before starting and allow the resident time to adjust to changes Date Initiated: [DATE]
Physician review of medications as needed Date Initiated: [DATE]
3. Resident #124 was found under the influence of illicit drugs and admitted to being high; however, when EMS arrived, he refused to go to the hospital on the first drug overdose but was transferred via EMS with the second overdose incident. There was no evidence that the facility implemented ongoing monitoring or effective interventions to address the ongoing substance abuse.
Resident #124 was admitted to the facility on [DATE] with diagnoses of acute osteomyelitis, type diabetes, chronic viral hepatitis, hypertension, complications of skin graft, major depressive disorder, chronic kidney disease, and diabetic foot ulcer.
On [DATE] at approximately 3:00 pm, an interview was conducted with Resident #124, who stated that he had been unfairly treated by staff due to another Resident stating that he was using drugs. He noted that the facility had no proof of this, and he was being given a discharge notice. When asked if the facility had explained why he was being given the notice, he said they had. When asked if he had been using drugs or alcohol while in the facility, he stated that he had not.
A review of the clinical record revealed the following progress notes:
[DATE] 4:02 pm - Nurses Note Text: Resident left facility at 7 AM. Resident did not return to facility until 11 AM. on resident arrival he reported to this writer and stated he was having chest pains, stomach pains, and that he could not breathe and that he wanted to go to the hospital. This writer resident signs. Bp 164/78, temp 98.3, p83, R18, O2 99. NP [Nurse Practitioner] was notified. Came to see resident. Resident insisted on calling 911. Resident and proceeds to call 911. When EMS arrived on the scene. Resident stated he wanted to go to [Hospital name redacted], EMS told resident There is a [appears words were left out] at [hospital name redacted]. Resident refused to go to the hospital. The NP in this writer went to speak with resident. Resident Then admitted to snorting and unknown substance within his nose, and that he believes it was laced with fentanyl. NP asked resident to do a drugs test. Resident then refused. NP ordered Mucinex, relief and acetaminophen. Resident Took meds. This writer informed oncoming nurse.
Medical Doctor (MD) Note: [DATE] 12:29 pm -CHIEF COMPLAINT - Patient seen at the request of nursing for congestion, feeling like he is withdrawing from something He reports feeling congested and has not slept in 3 days. He reports snorting something 3 days ago and that is when he started not being able to sleep. He is unsure the substance. He also reports that she snorted a little something again this morning while outside of the building, he reports not having any of this substance on his person at this time. I have notified the staff to use Narcan if at any point they find the patient difficult to arouse. Start Mucinex and Tylenol for the congestion and aches.
MD Note: [DATE] 3:15 pm Primary Chief Complaint: GI: Nausea -History Present Illness: Patient with partner history of alcohol dependence drinks six pack four times a week and heroin dependence uses four times a week who has been without both for the past t3 days due to restrictions on leaving the facility. Patient is actively complaining of nausea, diarrhea, body aches, chills, and headaches. Patient appears to be actively withdrawing actively in withdrawal from combination of alcohol and opiates. High risk of adverse outcome in current setting requires active and frequent monitoring with frequent interventions. Therefore, we will transfer patient to the emergency department - Opioid dependence with withdrawal.
[DATE] 5:21 pm - Nurse's Note Text: Resident has been going though alcohol and opioids withdrawal. Resident stated the last day he used both was 3 days ago. Resident Has been getting chills, headache, tremors, Nausea, Prickling and tingling in body, and body aches. BP 164/90, Temp 98.2, p 92. Resident has revived PRN Ativan, PRN Tylenol, PRN Zofran. Resident stated pain medication was not helping. This writer decided to call [On call physician name redacted]. Spoke with [Physician name redacted] MD Spoke with Resident. MD decided to send resident to hospital. Resident being transported to [Hospital name redacted].
[DATE] 7:45 pm -Nurse's Note Text: Nurse from the ER called and stated that the resident will be discharged back to the facility. Basic labs were completed and showing increase in his sugar, but no abnormal findings noted. Withdrawal medication offered to the resident however the resident did refuse stating that he will follow up with receiving methadone. ER nurse stated transportation was being set up by the social worker.
[DATE] 3:17 pm-Nurse's Note Text: Res prescription for Suboxone still needed. Unit manager notified of whom contacted NP to get order prescription to be faxed to facility pharmacy, order faxed, and writer called for order to be sent STAT. Pharmacy will send order STAT.
(Suboxone is a medication used by drug treatment facilities for heroin/opiate withdrawal)
A review of the clinical record revealed the following care plan entry with regard to the use of illicit drugs and or alcohol:
FOCUS: Hx of drug use. The resident is at risk for complications due to a history of illicit drugs use Date Initiated: [DATE]
GOAL: The resident will not have any adverse reactions related to alcoholism thru review period Date Initiated: [DATE]
INTERVENTIONS: Observe resident for any signs and symptoms of intoxication or withdrawal from drugs such as tremors, nausea/vomiting(severe), sweating and notify MD as indicated Date Initiated: [DATE]
Administer medication as ordered Date Initiated: [DATE]
Vitals as needed Date Initiated: [DATE]
4. Resident #130 was found to be under the influence of an illicit substance and admitted to staff that he was high. However, when EMS arrived, he refused hospital transport.
Resident #130 was admitted to the facility on [DATE] with diagnoses included but were not limited to sepsis due to methicillin-susceptible staph, major depressive disorder, anxiety disorder, acquired hypertension, acute kidney failure, type 2 diabetes, nicotine dependence, protein-calorie malnutrition, and history of infectious parasitic disease.
[DATE] 6:43 am - Nurse's Note Text: Resident room noted with a strong odor of weeds [sic] by CNA, nurse and CNA went in to ask resident, resident confirmed he has been smoking weed, we asked him to turn it over, he declined, resident educated about the implication of that, he was told his action will be reported to management. Describe any interventions attempted: Resident told he will be reported to management. Effectiveness of Interventions: Resident will continue to be monitored.
[DATE] 7:24 a.m.- Nurse's Note Text: 4:10 Writer notified of patient lethargic in dining room. Writer into dining room, patient seen with his head behind wheelchair, lethargic and hard to arouse. Obtained vitals at 413 65/40, 56, 16, 100RA, BS 140. Called residents several times, he responded and said, I'm high as a bitch. Writer asked resident several times what he had taken, he refused to say. 911 called made per his nurse. 911 into building. Assessed patient, resident remained with a low BP and heart rate. EMTs encouraged resident to go to hospital. Resident refused. Educated the resident on the importance of going to the hospital to monitor low BP and heart rate, resident continued to refuse. Multiple nurses from units educated the patient on the importance of his health. Encouraged resident to go with EMT to be seen at hospital. Resident then became aggressive saying he wasn't going to the hospital because there was nothing wrong with him. EMTs left building. Writer and nurse attempted to take resident to his room, he refused. Resident remained in dining room area.
Medical Doctor (MD) note - [DATE] - [Resident #130 name redacted] was found asleep in in his wheelchair. He reported that he was high. He was difficult to arouse, BPs were in the 60-70s systolic. EMS was called. Upon arrival his BP was still low, but he refused to go the hospital. He is at baseline this morning when I see him. All reports reviewed and spoke with staff about the incident. I am holding his BP meds over the weekend. No reports of fever, chills, chest pain, shortness of breath, nausea, vomiting, or diarrhea. '
[DATE] - 10:22 p.m. Nurse's Note Text: Nurse went to resident door, there was strong smell of weed in room, coming right to the hallway. Nurse supervisor notified.
A review of the clinical record revealed the following care plan entry concerning the use of illicit drugs and or alcohol:
A review of the care plan revealed the following entry about the use of illicit drugs and/or alcohol:
FOCUS: Resident has behavior in using drugs and alcohol while on premise. Drugs have been confiscated from the resident's room. Revision on: [DATE]
GOAL: The resident's behaviors will cause them less distress through the review period Date Initiated: [DATE]
Target Date: [DATE]
INTERVENTIONS: Approach with a calm quiet voice, divert attention, and remove from the situation and take to an alternative assure the resident they are safe and being cared for if they become distressed Date Initiated: [DATE]
Explain all procedures to the resident before starting and allow the resident time to adjust to changes Date Initiated: [DATE]
Monitor behavior episodes and attempt to determine the underlying cause. Consider location, time of day, persons involved and situations. Date Initiated: [DATE] Notify MD as indicated Date Initiated: [DATE]
On [DATE] at 1:00 pm, an interview was conducted with LPN A, who stated that they are aware of the Residents going out on LOA (Leave of Absence) and coming back high, but they cannot always be with them and cannot stop them leaving the facility. When asked what is done if they catch them smoking, drinking, or using drugs in the facility, she stated, We document in the chart, notify the supervisor, and educate them. That is all we can really do. When asked if the care plan should reflect the behaviors and interventions, she stated it should.
A review of the admission Contract signed by all Residents revealed the following statement:
Pg 3, #2. C. Alcohol and Controlled Substances: The Facility will not permit, without Facility's permission and a physician order, the possession of alcohol or any controlled substance on its premises or in violation of any law. Any resident who, while on Facility premises, engages in the sale, consumption, and/or unauthorized possession of alcohol or any controlled substance will be subject to discharge. Any violations of law subject the violator to immediate discharge and possible prosecution.
On [DATE], an interview with the interim Administrator was conducted, and she stated that she had only been in the facility less than a week and was unaware of the issues surrounding the drug and alcohol use by residents.
On the morning of [DATE], an interview was conducted with the Director of Nursing (DON), who was asked about Residents #42, 106, 124, and 130 care plans concerning drug and alcohol use. When asked if the care plans had adequately addressed the supervision of Residents after it was discovered they were using illicit drugs and/or alcohol, she said that they did not. When asked what they could have implemented, she stated they could have implemented 1:1 supervision and nursing assessments after LOA (Leave of Absence) from the building.
On the morning of [DATE], an interview was conducted with the Corporate Administrator, who stated that they were trying to find placement for the Residents who are continuing to be non-compliant with the use of drugs and or alcohol. She stated that at first, a couple of the residents wanted drug treatment; however, they have since changed their minds. She said that the Ombudsman was working with her to recommend some facilities and group homes for placement of residents that would be appropriate for those settings. She said she would continue to issue 30-day notices until she could find safe discharges for those involved.
On [DATE] at 11:30 a.m., the survey team notified the facility that it was in immediate jeopardy (IJ) in the area of accident hazard and supervision. It was determined that the facility knew as early as [DATE] that they were not able to provide ongoing monitoring for residents who were addicted to illicit drugs and failed, resulting in the continued use of illegal drugs and alcohol in the facility. Also, there was no evidence that effective care plan interventions that included monitoring and supervision of the identified residents were implemented. The residents were leaving the facility seeking illegal drugs and alcohol, returned under the influence of those substances, and created weapons in the facility, risking the safety of other residents.
The survey team and the State Agency supervisory review accepted the Immediacy Removal Plan on 1/10[TRUNCATED]
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Administration
(Tag F0835)
Someone could have died · This affected multiple residents
Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to administer the building in a manner that uses its resource...
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Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to administer the building in a manner that uses its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for four (4) residents (R#42, #106, #124 and #130) and each Long-Term Care Resident which resulted in Immediate Jeopardy.
The findings included:
For all facility residents, the Administration failed to act on the residents found to be using illicit drugs and alcohol in the building, failed to ensure all residents were protected from those substances being brought into the building, and failed to act on one (1) Resident creating sharp stabbing-like weapons from dining room cutlery.
For Resident #42, the facility failed to act on the following incidents documented in the clinical record:
On 7/15/24, 9/9/24, and 10/3/24, Resident #42 was caught smoking in the facility.
On 10/11/24 - Resident #42 Cheeking PRN Narcotic Pain Meds (storing meds in cheek to avoid swallowing, this is done to hoard medication for later consumption)
On 10/22/24 - Resident #42 was sent to emergency room (ER) for intoxication
On 12/27/24 -Resident #42 was sent to the ER for AMS (Altered Mental Status). The ER notes document that Resident #42 was admitted to the hospital for the use of heroin.
On 12/30/24 - MD notes refer to Resident #42 being on LOA (Leave of Absence) and being sent to the ER (while on LOA, the Resident overdosed on heroin.)
For Resident #106, the facility failed to act on the following incidents documented in the clinical record:
On 7/16/24 - Resident #106 was caught smoking in his room
On 8/21/24 - Resident #106 admitted to taking money from their roommate to buy alcohol and methamphetamine and not doing so and not returning the money.
On 9/9/24 -Resident #106 was found to possess a knife/boxcutter.
On 9/16/24 - Resident #106 was found with alcohol, and the Resident presented with AMS and was sent to the ER, found to be positive for alcohol, marijuana, and cocaine use. Resident overdosed.
On 12/16/24 - Resident #106 admitted to staff obtaining Suboxone and beer and using them both in the facility.
On 12/23/24 - Resident #106 was sent to the ER for AMS and returned without paperwork from the ER.
On 12/31/24 - Resident #106 was found in the facility with alcohol.
On 1/4/25 - Resident #106 was found making weapons in his room with a lighter and fork (removed all but 1 of the tines on two forks found burning them with a lighter, producing a stabbing-like weapon).
For Resident #124, the facility failed to act on the following incidents documented in the clinical record:
On 12/12/24 - Resident #124 was found with chest pain and shortness of breath after going LOA 7-11 am. He admitted to snorting an unknown substance that he believed was laced with fentanyl. NP asked the resident to do a drug test. The resident refused to go to the ER and Refused drug testing.
On 12/13/24 - Sent to the ER - Resident #124 was found sweating profusely and stated, I feel like I'm withdrawing from something. The staff indicated the resident admitted to snorting something starting 3 days ago and did not know what it was and also stated, I snorted a little something this morning.
On 1/4/25 - Sent to the ER for drug withdrawal.
For Resident #130, the facility failed to act on the following incidents documented in the clinical record:
On 9/9/24 - Resident #130 was caught smoking marijuana in the room and refused to give it to staff.
On 12/20/24 - Resident #130 was found by staff at 4:00 a.m. in the dining room with AMS, very lethargic sitting in a wheelchair, stating, I'm high as a bitch. The resident refused to go to the ER.
On 1/3/25 - the staff reported a strong odor of marijuana in Resident #130's room.
A review of the admission Contract signed by all Residents revealed the following statement:
Pg 3, #2. C. Alcohol and Controlled Substances: The Facility will not permit, without Facility's permission and a physician order, the possession of alcohol or any controlled substance on its premises or in violation of any law. Any resident who, while on Facility premises, engages in the sale, consumption, and / or unauthorized possession of alcohol or any controlled substance will be subject to discharge. Any violations of law subject the violator to immediate discharge and possible prosecution.
On the morning of 1/10/25, an interview with the interim Administrator was conducted, and she stated that she had only been in the facility less than a week and was unaware of the issues surrounding the drug and alcohol use by Residents.
A review of the clinical records revealed a lack of, or ineffective interventions implemented to prevent re-occurrences. A review of the care plans for each Resident revealed that the facility failed to address the recent history of substance abuse and subsequent noncompliant behaviors with regard to the alcohol and substance abuse policy.
On 1/10/25 at 11:30 a.m., the survey team notified the facility that it was in immediate jeopardy (IJ) in the area of administration. It was determined that the facility knew as early as 9/16/24 that they were not able to provide a substance abuse program for residents who were addicted to illicit drugs and failed, resulting in the continued use of illicit drugs and alcohol in the facility. Residents were leaving the facility seeking illegal drugs and alcohol, returned under the influence of those substances, and created weapons in the facility, risking the safety of other residents.
The survey team and the State Agency supervisory review accepted the Immediacy Removal Plan on 1/10/25 at 4:35 p.m.
The removal plan read as follows:
Deficiency Statement:
The facility failed to implement effective interventions to address ongoing substance abuse among residents with known substance abuse histories. This failure resulted in overdoses, weapon creation, and possession of illicit substances, which posed a serious risk of harm, injury, or death to all residents.
Immediate corrective action is necessary to mitigate these hazards
Resident Safety Measures: Conducted immediate comprehensive assessments of all residents potentially impacted to evaluate psychosocial and physical harm.
Implemented one-on-one supervision for residents #'s 42, 106, 124, and 130 until further care plans can be established.
Residents #'s 61, 101, 109, 127, do not require enhanced supervision as prior investigation regarding allegation of drug abuse was found to be unsubstantiated.
Secured all entrances and exits to the facility to prevent unauthorized entry or re-entry of residents suspected of leaving the facility to obtain illicit substances.
Prohibited Substance Management: Conducted a full facility sweep to identify and remove illicit drugs, alcohol, and weapons.
Implemented a no-tolerance policy for possession or use of illicit substances and weapons within the facility, communicated to all residents and staff immediately.
Partnered with local law enforcement for ongoing assistance with identifying and preventing the presence of illicit substances and weapons in the facility.
Systemic Changes to Prevent Recurrence:
Measures to Address Psychosocial Harm:
Resident Support: Provided immediate counseling and mental health services for Resident #109, Resident #33, and any other residents expressing fearfulness or experiencing psychosocial harm.
Facilitated group therapy sessions to address concerns related to the recent incidents and restore a sense of safety and community among residents.
Family and Resident Communication: Held meetings with residents and their families to address concerns, outline corrective actions and rebuild trust.
Established a dedicated hotline for residents and families to report ongoing concerns or incidents confidentially.
Discharge Plans for Noncompliant Residents:
Evaluation for discharge: Residents violating the no-tolerance policy for illicit substance use, possession of weapons, or engaging in violent or unsafe behaviors will be evaluated for discharge.
The interdisciplinary team (IDT) will review each case to ensure compliance with federal and state discharge regulations.
On 1/10/25, the survey team verified through observation that Resident #'s 42, 106, 124, and 130 had 1:1 observation while in the facility as outlined in their plan. Security was present in the building, and front desk staff was at the entrance monitoring the visitors and Residents entering and exiting the facility. On 1/14/25, the facility notified the survey team that they had educated those who had worked and were moving forward with educating staff before the start of the shift.
The facility submitted copies of the curriculum used to educate staff, in-service sign-in sheets, and documents signed by each staff member who was educated.
The survey team verified via staff interview that staff education and training on the abovementioned topics was completed. The staff members interviewed were able to correctly answer questions about the substance use/abuse, policy, procedures, leave of absence policy and procedures, and signs and symptoms of substance use and or abuse. All staff interviewed (Nurses, CNAs, and receptionists) verified receiving education and handouts and signed the attestation for the training received document.
The Immediate Jeopardy was removed on 1/14/25 at 12:45 p.m., and the scope and severity were lowered to level 2, patterned.
On 1/14/25, 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
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 Residents...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review and facility documentation the facility staff failed to ensure Residents are cared for in a manner that promotes maintenance or enhancement of his or her quality of life for one (1) Resident (#24) in a survey sample of 63 Residents.
The findings included:
For Resident #24 the facility staff failed to adequately bathe, and groom Resident to ensure he was free from body odors and unkempt appearance and failed to dress him in clothing other than a hospital gown and failed to get him out of bed daily so that he may attend activities and have social interaction with peers.
Resident #24 was admitted to the facility on [DATE] with diagnoses that include but are not limited to paranoid schizophrenia, diabetes, chronic kidney disease, mild intellectual disabilities, hypertension, hypothyroidism, bipolar disorder, major depressive disorder, severe with psychotic features, and anxiety.
The following observations were made of Resident #24.
1/28/25- 2 p.m. observed Resident #24 in bed eyes closed dressed in hospital gown hair greasy and a strong body odor evident.
1/29/25 - 11:30 a.m. Resident #24 in bed watching TV hospital dressed in hospital gown, hair greasy, body odor present.
1/30/25 11:50 a.m. nails long brown substance under nails, in need of shower / bath hair appears greasy Resident has body odor and smells of urine. In bed only in hospital gown and brief.
1/31/25 11:38 AM Resident # 24 in bed dressed in hospital gown nails still appear dirty and hair greasy continues to have body odor.
On 1/31/25 at 11:40 a.m., an interview was conducted with Resident #24. When asked does the staff usually get you up and get you dressed, he responded, No not usually, I can't walk. When asked does the staff get you up and put you in the wheelchair, he responded No not unless I have to go somewhere. When asked does the staff get you up and put you in the shower, he stated that they usually bathe him in bed. When asked when the last time is his hair was washed, he stated that he did not know.
Excerpts from the Resident Preference Evaluation dated 6/21/24 read:
1. How important is it for you to choose what you wear? (2.) Somewhat important
2. How important is it to you to listen to music you like? (2) Somewhat important
5. How important is it to you to do things with groups of people? (2) Somewhat important
6.How important is it to you to do your favorite activities? (1) Very important
7 How important is it to you to go outside to get fresh air when the weather is good? (2) Somewhat important
On 2/5/25 an interview was conducted with CNA B who was asked if Resident #24 has clothing in his room, CNA B answered yes, he has clothing, when asked if they fit him and were in good repair CNA B stated that the clothing was fine and if he did not have clothing the facility would have gotten him some from the clothing drive. When asked why Resident #24 is always wearing a hospital gown instead of his personal clothing CNA B stated he just got out of the shower.
On 2/5/25 at approximately 3:00 p.m. an interview was conducted with the unit manager who stated that it is the expectation of the facility that all Residents are kept clean, odor free, and dressed appropriately in their own personal clothing on a daily basis.
On 2/5/25 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
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, clinical record review and facility documentation review, the facilit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure it was clinically appropriate for the self-administration of medications for one (1) resident (Resident # 83) in survey sample of 64 residents.
Findings included:
For Resident # 83, the facility staff failed to ensure there was a self-administration of medication assessment related to medication found at the bedside.
Resident # 83 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included but were not limited to: Chronic Obstructive Pulmonary Disease, Hypertension, Chronic Kidney Disease, Diabetes, Acute Respiratory Failure and Congestive Heart Failure.
The most recent Minimum Data Set (MDS) was an Annual Assessment with an Assessment Reference Date (ARD) of 12/24/2024. Resident # 83's BIMS (Brief Interview for Mental Status) Score was a 15 out of 15, indicating no cognitive impairment. Resident # 83 required assistance with Activities of Daily Living.
Review of the clinical record was conducted on 1/28/2025 to 1/31/2025 and 2/3/2025 to 2/5/2025.
During the initial tour on 1/28/2025 at approximately 12:10 p.m., a medication bottle was observed on the nightstand by the bed by the window. There were several items cluttered on the nightstand. The resident was lying in bed when the surveyor walked into the room.
The label on the bottle stated the medication was Polyethylene Glycol (a laxative) dated February 9, 2024 with no refills.
Resident # 83 stated the bottle of medication was a prescription she picked up a long time ago before coming to the facility.
On 1/28/2025 at 1:34 p.m., an interview was conducted with Registered Nurse-B who stated medications should not be left at the bedside without self administration assessments and orders from the Physician. Registered Nurse-B stated none of the residents on the unit had assessments with orders for self administration of medications. Registered Nurse-B stated she did not see the medication bottle with on the nightstand when she administered the medications that morning.
On 1/28/2025 at 2:39 p.m., an interview was conducted with the other nurse LPN (Licensed Practical Nurse)-D scheduled to pass medications on the unit that day. Licensed Practical Nurse-D stated bottles of medications should not be left at the bedside without an order from the physician.
Registered Nurse-B removed the bottle of medication from the nightstand after explaining to the resident that medications could not be left at the bedside without an order. Resident # 83 stated she did not remember the medication was there.
Review of the Physicians Orders revealed an active order for the medication Polyethylene Glycol 3350 Oral Powder 17 GM (gram) /Scoop (Polyethylene Glycol 3350) Give 1 scoop by mouth one time a day for constipation.
Review of the January 2025 Medication Administration Record revealed scheduled daily administration of the medication Polyethylene Glycol 3350 Oral Powder 17 GM (gram) /Scoop (Polyethylene Glycol 3350) Give 1 scoop by mouth one time a day for constipation. The documentation revealed the medication was administered as ordered.
During the end of day debriefings on 2/4/2025, the Administrator, Director of Nursing and Regional Nurse Consultants were informed of the findings. They stated medications should not be left at the bedside unless a resident has been assessed for self administration of medications. A copy of the medication administration policy was requested.
Review of the Self-Administration of Medication and Treatments Policy revealed the policy was not dated to indicate when it was implemented or reviewed and revised. The Policy stated Residents have the right to self-administer medications/treatments if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so.
On 2/5/2025 at 2:12 p.m., an interview was conducted with the Director of Nursing who stated medications should never be left at the bedside unless there has been an assessment by the physician and an order for the medications to be left at the bedside. 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 F0567
(Tag F0567)
Could have caused harm · This affected 1 resident
Based on resident interview, staff interview, clinical record review, and review of facility documents, the facility staff failed to allow resident to manage financial affairs for 1 of 38 residents (R...
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Based on resident interview, staff interview, clinical record review, and review of facility documents, the facility staff failed to allow resident to manage financial affairs for 1 of 38 residents (Resident #135), in the survey sample.
The findings included:
Resident #135 was originally admitted to the facility 9/10/24. The current diagnoses included Non-ST-elevation Myocardial Infarction, muscle weakness, type 2 diabetes mellitus with hyperglycemia, and essential hypertension.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/17/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #135's cognitive abilities for daily decision making were intact.
An interview was conducted on 5/21/25 at 1:45 PM with Resident #135. Resident #135 stated, the facility is trying to kick me out because I owe them money. Resident #135 also stated, a payment plan has been set up with the Business Office Manager but they are still trying to make me leave the facility.
A review of a facility document: Form SSA-11-BK (Request To Be Selected As Payee) read that the Business Office Manager applied to have Forest Hill Health and Rehabilitation as the Payee regarding Resident #135's social security benefits.
An interview was conducted on 5/22/25 at 1:30 PM with the Business Office Manager. The Business Office Manager stated that on 4/29/25 the facility applied to have Forest Hill Health and Rehabilitation as the Payee regarding Resident #135's social security benefits using Form SSA-11-BK (Request To Be Selected As Payee). The Business Office Manager also stated that Form SSA-787 (Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits) was completed by the Nurse Practitioner (NP) on 4/25/25. The Business Office Manager further stated that the NP answered that Resident #135 is able to manage funds or direct others how to manage them, as well as being able to manage funds in the future on the Form SSA-787 (Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits).
A review of Form SSA-787 (Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits) dated 4/25/25 read: Do you believe the patient is capable of managing or directing the management of benefits in his or her own best interest? Yes Do you expect the patient to be able to manage funds in the future? Yes
An interview was conducted on 5/22/25 at 2:50 PM with Resident #135. Resident #135 stated he is able to manage his own financial affairs. Resident #135 also stated that he never gave permission to the Business Office Manager or the facility to make a request to the Social Security Administration to be selected as the payee regarding his benefits.
The facility's Business Office/Collection Policy with an effective date of 1/1/25 read: For unpaid Patient Liability balances, the Business Office Manager must notify the resident/POA/Guardian/RP that due to the unpaid balance and refusal to pay we will be filing for Rep Payee. The Business Office Manager must initiate a Rep Payee application to be completed, signed by physician, and submitted to social security before end of month, or must have a signed RFMS agreement authorizing direct deposit.
On 5/22/25 at approximately 7:00 p.m., a final interview was conducted with the Administrator, Director of Nursing, two (2) Corporate Nursing Consultants, Minimum Data Set Consultant, Regional Maintenance Director, and Regional Human Resource Director. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
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 ensure two (2)...
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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 ensure two (2) of 63 residents (Resident #39 and Resident #46) in the survey sample were given the opportunity to formulate an advance directive.
The findings included;
1. The facility staff failed to ensure Resident #39 had an opportunity to develop an advanced directive.
Resident #39 was originally admitted to the facility 11/09/23 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Depression, Unspecified.
The 5-day Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/17/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #39 cognitive abilities for daily decision making were moderately impaired.
In sectionGG(Functional Abilities Goals) the resident was coded as requiring partial/moderate assistance with eating, oral hygiene. Resident coded as dependent in lower body dressing, personal hygiene and rolling left and right.
The care plan dated 11/22/23 read that Resident #39 had an Activities of Daily Living (ADL) self-care performance deficit related to multiple sclerosis, rheumatoid arthritis, spinal stenosis, right foot drop, morbid obesity, osteoarthritis, bilateral hand contractures and personality disorder. The Goal was to have the resident participate in as much of her ADL care as possible. The intervention for the resident requires total dependance by two (2) staff members for toileting and requires max assist to total dependance by two (2) staff members for bed mobility, transfers and one person assist for mobility in wheelchair.
A review of the medical records revealed no advanced directives were available or that the resident had an opportunity to develop one.
A review of the Physicians Order Summary (POS) revealed resident had a Full Code Status as of 11/10/2023.
On 02/03/25 at approximately 2:33 PM., an interview was conducted with Resident #39 concerning an advanced Directive. Resident #39 said that I'm a full code. I don't think that I have an Advance. Directive.
2. The facility staff failed to ensure Resident #46 had an opportunity to formulate an advanced directive.
Resident #46 was originally admitted to the facility 1/04/22 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Chronic Kidney Disease.
The annual, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/28/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #46 cognitive abilities for daily decision making were intact.
In sectionGG(Functional Abilities Goals) the resident was coded as requiring supervision with eating, upper body dressing, requires substantial/maximal assistance with toileting hygiene, showers/bathing, lower body dressing and personal hygiene.
The care plan dated 7/11/23 read that resident has an ADL self-care performance deficit r/t Weakness, Acute Kidney Failure, history of Falling, Epilepsy and Bipolar Disorder, history of falls. The Goal is the resident will improve current level of function in through the review date (11/21/23). The intervention: Monitor/document/report as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function.
The Physicians Order Summary for January 2025 reads that Resident has a Full Code status as of 07/15/2024.
On 2/04/25 at approximately 1:00 PM., an interview was conducted with the Social Services Director (SSD) concerning advanced Directives. The SSD said that no Advanced Directive were done by Social Services or that he had an opportunity to develop one.
On 2/05/25 at approximately 2:30 PM., the nursing staff on unit 4 were asked for the advanced Directive Book but to no book was available.
On 2/05/25 at approximately 1:51 PM., an interview was conducted with RN C concerning the advance directives for the above residents. RN C said that they usually keep them in a red folder on the unit (unit 4), but she can't find the folder.
On 02/05/25 at approximately 2:09 PM., an interview was conducted with Licensed Practical Nurse (LPN) B. LPN B, said that they did not have an advance directive book on Unit four (4).
On 02/05/25 at approximately 2:21 PM., an interview was conducted with the Director of Nursing (DON) concerning the above. The DON also said that upon admission Social Services will complete the advance directive with the resident, family or guardian. The DON also mentioned that on each unit the facility has a code status book.
On 2/05/25 at approximately 7:00 PM., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to complete an Advanced Beneficiary Notice (ABN) for two (2) Residents, (Residents #192 a...
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Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to complete an Advanced Beneficiary Notice (ABN) for two (2) Residents, (Residents #192 and #37) in the four (4) sampled residents.
The findings included:
Residents #192, and #37 were chosen from a list of residents discharged in the previous 6 months. On 2-3-25 at 9:00 AM, the Business Office Manager was asked for a copy of the Advance Beneficiary Notice for 4 Residents. The Director of Nursing (DON) presented 4 forms that she stated were the ABNs.
The forms revealed two (2) of the four (4) sampled Residents received Form CMS-10123 NOMNC (Notice of Medicare Non-Coverage) which were signed by the resident or the authorized representative, and included the estimated date of non-coverage, and appeal information.
The other two (2) of the four (4) sampled Residents (Resident #192, and #37) received form CMS-R-131 forms which revealed no date when insurance coverage would end, did not specify a cost for the Resident should they elect to pay for continued services, and did not give information on the appeal process available to them.
The form for Resident #192 was filled out by an Occupational Therapy Assistant, and documented spoke with (name). Daughter of the Resident. No date, and no time was documented. No letter was sent.
The form for Resident #37 was filled out by an Occupational Therapist, and documented Left voicemail w/RP (responsible party) no name given for that individual, no date, and no time was documented. No letter was sent.
Neither of these two (2) Residents nor their representatives signed the forms, no estimated cost of continued services was documented, nor were letters sent to instruct on appeal should the Resident's wish to continue the services.
An interview was conducted with the newly hired Social Worker who stated she would normally be the person to administer the NOMNC. She stated that she could see the issues with the 2 NOMNC/ABN's received by surveyors, and listed the failures of the documents after reviewing them both. The facility had a history of not having a vetted, acceptable Social worker at times during the past year, and those dates can be found elsewhere in the statement of deficiencies under Federal Tag - 850.
During the end of day debriefing on 2-3-25 the Director of Nursing and Administrator were informed of the findings.
The facility staff stated they had nothing further to present.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, clinical record review and facility documentation review, the facilit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to ensure personal privacy was afforded to three (3) residents (Residents # 123, #2, and # 46) in a survey sample of 63 residents.
1. For Resident # 123, the facility staff failed to provide a curtain to pull around the bed while providing ADL (Activities of Daily Living) Care.
Resident # 123 was admitted to the facility on [DATE] with the diagnoses of, but not limited to: Dementia with Agitation, Diabetes, Hypertension, and Legal blindness.
The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 1/7/2025. Resident # 123's BIMS (Brief Interview for Mental Status) Score was a 13 out of 15, indicating no cognitive impairment.
Review of the clinical record was conducted on 1/28/2025 to 1/31/2025 and 2/3/2025 to 2/5/2025.
On 1/29/2025 at approximate 10:40 a.m., a Certified Nursing Assistant was observed providing care to Resident # 123. The Certified Nursing Assistant was helping Resident # 123 get dressed for the day. Resident # 123 was visible to anyone who came into the room. There was no curtain around the bed. The roommate (Resident # 2) was in the room and could see Resident # 123.
The Certified Nursing Assistant stated she was an agency employee. The Certified Nursing Assistant stated she pulled the curtain around the roommate (Resident # 2) as far as she could and tried to shield Resident #123 while providing care. She stated it was important to provide privacy.
On 2/3/2025 at 3:15 p.m., an interview was conducted with Registered Nurse-B who stated it was important for the residents' to have privacy in their rooms.
On 2/4/2025 during the end of day meeting, the Administrator, Corporate Nurse Consultants and Director of Nursing were made aware of the findings. No further information was provided.
2. Resident # 2, the facility staff failed to have a provide a curtain to pull around the bed while providing Activities of Daily Living (ADL) Care.
Resident # 2 was admitted on [DATE] with diagnoses including but not limited to: Epilepsy, Seizures, Confirmed Physical Abuse, Confirmed Psychological Abuse, Major Depressive Disorder, Anxiety Disorder, and Neoplasm of the Brain.
Resident #2's most recent MDS (Minimum Data Set) was a Quarterly Assessment with an ARD (Assessment Reference Date) of 12/27/2024 coded the Resident as having a BIMS (Brief Interview of Mental Status) score of 13 out of 15 indicating no cognitive impairment.
Review of the clinical record was conducted on 1/28/2025 to 1/31/2025 and 2/3/2025 to 2/5/2025.
Observations were made of there being one quarter panel curtain suspended above Resident # 2's bed. The curtain did not extend around the bed to completely provide visual privacy while ADL care was being provided.
Resident # 2 had a roommate in the room. The roommate (Resident # 123) was in the room while ADL care was being provided for Resident # 2.
The Certified Nursing Assistant stated she was an agency employee. The Certified Nursing Assistant stated she pulled the curtain as far as she could and tried to shield Resident # 2 while providing care. She stated it was important to provide privacy.
On 2/3/2025 at 3:15 p.m., an interview was conducted with Registered Nurse-B who stated it was important for the residents' to have privacy in their rooms.
On 2/4/2025 during the end of day meeting, the Administrator, Corporate Nurse Consultants and Director of Nursing were made aware of the findings. No further information was provided.3. The facility staff failed to ensure privacy while performing incontinence care for Resident #46. Resident #46 was originally admitted to the facility 1/04/22 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Chronic Kidney Disease.
The annual, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/28/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #46 cognitive abilities for daily decision making were intact.
In sectionGG(Functional Abilities Goals) the resident was coded as requiring supervision with eating, upper body dressing, requires substantial/maximal assistance with toileting hygiene, showers/bathing, lower body dressing and personal hygiene.
The care plan dated 7/11/23 read that resident has an ADL self-care performance deficit r/t Weakness, Acute Kidney Failure, history of Falling, Epilepsy and Bipolar Disorder, history of falls. The Goal is the resident will improve current level of function in through the review date (11/21/23). The intervention: Monitor/document/report as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function
On 01/29/25 at approximately 11:30 AM., while rounding in the hallway on unit 4, Resident #46 was heard yelling for his Certified Nurse's Assistant (CNA) B, by her first name several times.
On 01/29/25 at approximately 11:39 AM., CNA B entered Resident #46 room (403B unit 4). The resident had informed her that he had a Bowel Movement (BM). After receiving permission from Resident #46 to observe his care, CNA B began incontinent and ADL care on the resident. There was a partial privacy curtain preventing the resident across from him to seeing the ADL care, the door to room [ROOM NUMBER] B was closed. Visibly from the door the resident could be seen receiving care. A timeline of events: 11:51 AM., there was a knock at the door, two staff quickly entered the room while the resident was exposed, receiving Activities of Daily Living (ADL), incontinent care. 11:54 AM., there was a knock at the door, then quickly, the door opened, entered one staff, resident still exposed, while receiving ADL care. 11:56 AM., there was a knock at the door, the Assistant Director of Nursing (ADON) quickly entered the room and said I'm just rounding. CNA B, said I'm ok.
On 02/05/25 at approximately 1:56 PM., an interview was conducted with CNA F concerning the above incident. CNA F said that She shouldn't have walked into the residents' room while he was receiving care. CNA F also said that months ago that she informed a nurse that some of the rooms didn't have privacy curtains. CNA F also said that if the rooms don't have privacy curtains, she will just make sure the door is closed.
On 2/03/25 at approximately 4:21 PM., an interview was conducted with the Director of Nursing (DON) concerning the privacy curtains. The DON said after knocking on a resident's closed-door staff should wait to hear what the CNA is saying first before entering.
On 02/03/25 at approximately 3:19 PM., an interview was conducted with CNA B concerning Resident #46. CNA B said that no one should walk in the room while care is being provided. CNA B also said that the resident only had a portion of a privacy curtain when care was being rendered.
On 2/05/25 at approximately 7:00 PM., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.
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 F0586
(Tag F0586)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the fac...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff discouraged one Resident from communication with external local entities/police during an abuse allegation, and did not allow evidence from a police report of the abuse situation for 2 Residents (Residents #131, and #130) in a survey sample size of 63 residents.
The findings included:
The facility failures described above resulted in the sexual abuse/harassment of Resident #131 by Resident #130, without police protection.
Resident #131 (victim) was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Traumatic Brain Injury (TBI) after a motor vehicle accident, diplopia, muscle weakness, unsteadiness on feet, abnormal gait and mobility, wheelchair use, and cognitive communication deficit, although there was no communication deficit noted at the time of survey.
Resident #131's most recent Minimum Data Set with an Assessment Reference Date of 1-23-25 was coded as a discharge assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicates no cognitive impairment. The Resident was cognitively intact, and his own responsible party. The Resident required touch assistance from one staff member for transferring and was wheelchair bound at times and was able to stand or walk independently for short distances. He required set up or touch assistance only with hygiene and bathing. The Resident denied complaints against any other staff or Residents since his admission on [DATE]. The Resident was discharged to a group home on 1-23-25 to be closer to family and to the least restrictive environment.
Resident #130 (aggressor of victim #131) was admitted to the facility on [DATE]. Hospital discharge records indicated that the Resident was alert and oriented to person, place and time, and was ambulatory. Diagnoses included but were not limited to: Major depressive disorder, recurrent anxiety, Chronic hepatitis C, type two diabetes, nicotine dependence, fractured left heel with infected wound sepsis due to Methicillin Susceptible Staphylococcus Aureus, enhanced barrier precautions, and history of infectious parasitic disease.
Resident #130's most recent Minimum Data Set with an Assessment Reference Date of 12-17-24 was coded as a significant change assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicated no cognitive impairment. The Resident was his own responsible party. The Resident required partial to moderate assistance from one staff member for hygiene and bathing. Resident #130 was observed during survey as ambulating without assistance or device.
Resident #130 went out of the facility daily using the public city bus transportation and repeatedly returned under the influence of drugs and alcohol. Instances of this were recorded in the nursing progress notes to include the following most recent to survey.
9-19-24 6:43 am Resident room noted with a strong odor of weeds [sic] by (Certified Nursing Assistant) CNA, nurse and CNA went in to ask resident, resident confirmed he has been smoking weed, we asked him to turn it over, he declined, resident educated about the implication of that, he was told his action will be reported to management. Describe any interventions attempted: Resident told he will be reported to management Effectiveness of Interventions: Resident will continue to be monitored.
12-20-24 7:24 a.m. (documentation time). Note Text: 4:10 am (time of actual observation) Writer notified of patient lethargic in dining room. Writer into dining room, patient seen with his head (laid backward supine fashion) behind wheelchair, lethargic and hard to arouse. Obtained vitals at 4:13 am 65/40, 56, 16, 100% RA (oxygen saturation on room air alone), BS 140 (blood sugar). Called resident several times, he responded and said, I'm high as a bitch. Writer asked resident several times what he had taken, he refused to say. 911 called made per his nurse. 911 into building. Assessed patient, resident remained with a low BP and heart rate. EMTs encouraged resident to go to hospital. Resident refused. Educated the resident on the importance of going to the hospital to monitor low BP and heart rate, resident continued to refuse. Multiple nurses from units educated the patient on the importance of his health. Encouraged resident to go with EMT to be seen at hospital. Resident then became aggressive saying he wasn't going to the hospital because there was nothing wrong with him. EMTs left building. Writer and nurse attempted to take resident to his room, he refused. Resident remained in dining room area.
MD (physician) note - 12-20-24 - [Resident #130 name redacted] was found asleep in in his wheelchair. He reported that he was high. He was difficult to arouse, BPs were in the 60-70s systolic. EMS was called. Upon arrival his BP was still low, but he refused to go the hospital. He is at baseline this morning when I see him. All reports reviewed and spoke with staff about the incident. I am holding his BP meds over the weekend. No reports of fever, chills, chest pain, shortness of breath, nausea, vomiting, or diarrhea. '
1-3-25 - 10:22 pm. Note Text: Nurse went to resident door, there was strong smell of weed in room, coming right to the hallway. Nurse supervisor notified.
A review of Resident #130's care plan revealed the following entry regarding the use of illicit drugs and or alcohol:
FOCUS: The Resident is at risk of complications due to a history of illicit drug use. Revision on: 12-16-24.
GOAL: The Resident will not have any adverse reaction to alcoholism thru review period. Date Initiated: 12-16-2024. Target Date: 3-16-25.
INTERVENTIONS: (3)
1. Observe Resident for signs and symptoms of intoxication or withdrawal from drugs such as tremors nausea/vomiting (severe) sweating and notify MD (doctor) as indicated. Date Initiated: 12-16-2024.
2. Administer medication as ordered. Date Initiated: 12-16-2024.
3. Vitals as needed. Date Initiated: 12-16-2024.
On 1-7-25 at 11:14 am nursing progress notes documented Verbal spat with roommate .both parties speaking in elevated tones, no physical contact noted both parties separated.
On 1-7-25 at 12:23 pm Resident #15 agreed to a room change, and his spouse was notified. Adult Protective Services (APS) was called by an anonymous caller at the facility and the incident of sexual abuse was reported to them. The caller stated in the APS report of 1-7-25 that the facility Administration did not notify police, and they (the Administration) stated the reason as that can't happen (because) is that Resident (Resident #131 victim) would be charged with assault for pushing Resident (#130 aggressor) out of the doorway so that Resident (#131) could escape.
This note indicated that there was physical contact known by staff at the time which was denied in the 1-7-25 nursing note.
It was also alleged by the caller to APS that Resident #130 had been making sexual advances toward Resident #131 and wanted to get in his pants. It was also alleged that Resident #131 was asked by facility staff Why can't you just go home? The caller went on to state that Resident #131 had been moved 4 times for different assaults, verbal and such, but this was the only sexual assault. This assertion of frequent moves was found to be true as Resident #131's census in the facility documented those moves.
The APS caller stated that on this day (1-7-25) the situation escalated and Resident #130 blocked the door of the room and told Resident #131 you are going to let me F K you. The caller stated that Resident #130 proceeded to touch, molest, and sexually assault Resident #131 who began yelling and screaming, and pushed Resident #130 out of the doorway into the hallway to escape when staff came to see what the commotion was about. Resident #131 told them immediately what had happened.
On 1-9-25 at 1:00 pm an interview was conducted with LPN A who stated that they are aware of the Residents going out on LOA (Leave of Absence) and coming back high, also stating but we cannot be with them at all times and cannot stop them leaving the facility. When asked what is done if they catch them smoking or drinking or using drugs in the facility, she stated, We document in the chart, notify the supervisor and educate them, that is all we can really do. When asked if the care plan should reflect the behaviors and interventions, she stated that it should.
On 1-9-25 (the second day of survey) at 3:00 pm, Resident #130 was interviewed during an investigation involving Resident drug, alcohol, and weapons abuses that were found to be actively occurring in the facility. This Resident was found to be involved in drug abuse while a Resident. The Resident was asked about an altercation with his roommate which was documented in the nursing progress notes as having occurred on 1-7-25. Resident #130 stated he bought Resident #131 cigarettes and Resident #131 refused to pay him for them. He stated he had indeed used drugs but not in the facility, only outside. This statement was found to be false as staff stated they had removed drugs and drug paraphernalia from his room, and documented that at 4:00 AM on 12-20-24 the Resident was found in the dining room after using drugs in the facility, and was also using in the facility on 9-19-24, and 1-3-25.
On 1-9-25 at 3:30 pm, Resident #131 in person, and his spouse by phone were interviewed. They both stated that Resident #130 had made advances toward Resident #131, however, Resident #131 stated he made it Clear that I am straight, married, and got no interest in no [NAME]. Resident #131 stated he would ask me to dress in front of him to see my chest, and I didn't care about that, because he said he would get me some cigarettes, but when he cornered me in the room and wouldn't let me leave the room and grabbed my D k and said I'm gonna F k you in the A , that was it! I screamed for help and pushed him through the door and the nurses almost got knocked down coming in, they heard it all just ask them. Resident #131 stated the temp agency nurse (name) and the other nurse who works here all the time (name) came. Resident #131 stated He (#130 name) and (Resident #106 name) smoke stuff in the room and have overdosed sometimes. I just want out of here. Resident #131 was asked if he had reported the sexual abuse, and he stated I told the nurses, they saw it happen! I told the Administrator who said I would be arrested for pushing him if I called the police, and I've told everybody, but they just moved me to another room.
On 1-9-25 A copy of all Facility Reported Incidents (FRI's) for the prior 6 months were requested. 9 were provided by the Administrator, and all 9 followed the standardized format and documentation included notification of the state agency the Virginia Department of Health Office of Licensure and Certification (VDH/OLC), the state Long Term Care Ombudsman, and Adult Protective Services (APS). The 9 completed FRI's were all prior to 9-20-24.
On 1-9-25 at 4:00 pm the facility Administrator was asked for any investigation from 1-7-25 involving Residents #130, and #131.
On 1-10-25 at 5:00 pm Resident #130 was interviewed by surveyors and stated I feel as though I'm being targeted by a staff member. The Director of Nursing (DON) she don't like me and wants me out of here. She believes anything anyone tells her. He continued to say, Yes I smoke weed but not on the property and I use heroin sometimes, not a lot. The surveyor asked how do you use it, and he replied, I smoke it. The surveyor asked if he received it from someone in the facility. He replied, No I get it outside. He was asked where do you use it? His response was I use it at the bus stop, I go out almost every day. He was asked if he was caught by staff in the facility with drugs or alcohol, and he replied, No they said I was smoking weed in my room, but I won't. He was questioned about the accusations from his roommate, and he stated, I bought him cigarettes, I didn't touch that [NAME] I didn't ask him for no sex. He didn't give me money for the cigarettes he is a liar. They gave me a notice to leave but I got nowhere to go.
On 1-10-25 The Administrator delivered a 2-page document dated 1-10-25 entitled Facility Reported Incident (FRI), Date reported 1-10-25, and was signed by the current Administrator. The synopsis was a simple typed document on a clean white unlined sheet of copy paper, and did not state that it was an initial FRI, nor a 5 day follow up. The document described a portion of the incident of 1-7-25, and the fact that Resident #131 alleged that his roommate (Resident #130) had made sexual advances to him and had attempted to block the doorway to keep him (Resident #131) from leaving the room. This was the third time that the allegation of abuse was made to someone in the facility, and to others. The first being the day of the occurrence to staff witnesses, the second to APS who reported it to the facility, to police, and the state agency, and the third on this day 1-10-25.
The document reported that Resident #131 had moved Resident #130 out of the way and exited the room. The document included that Resident #131 stated again he was tired of his roommate (Resident #130) making sexual advances at him and he wanted to be out of that room. Resident #131 also stated he wanted to be discharged .
The Administrator documented on 1-10-25 that Resident #130 denied the allegation of sexual abuse, and that the facility had concluded that the allegation was unsubstantiated, and was first reported to them on this day. These assertions are incorrect as staff were aware and present on 1-7-25 when the abuse was alleged to have occurred and was first documented. Further the Resident stated to the Administrator (as written in the above portion of the Administrators document) that he was blocked from leaving by his roommate, he was tired of his roommate (Resident #130) making sexual advances at him and he wanted to be out of that room. Sexual abuse and sexual harassment are both crimes. By the facility staff's documentation, and own admission this was reported repeatedly to them, observed by floor baseline staff when it occurred, reported to APS by a complainant, and they continued to report it as unsubstantiated.
The facility Resident Protections from abuse policy failures included all of the following 4 areas;
1. The facility was expected to complete background checks on all employees to protect the Resident population from abuse, also training was to be conducted annually for staff. (Training)
2. The Abuse policy document also stated that Residents would be protected if an allegation of abuse was made, and the police involved if that allegation alleged that a crime had happened. (Protection)
3. The Abuse policy document also stated that a comprehensive investigation would be conducted. (Investigation)
4. The document further stated that the state agency and other stake holders would be notified within 24 hours of an allegation of abuse, and that the report would occur within 2 hours if injury occurred. Then the initial report would be followed by a five day follow up report which would be sent to the state agency after the facility investigated to reveal their findings. (Reporting)
The facility staff failed to conduct required education for staff, failed to complete background checks in compliance with regulations. The facility staff failed to report the allegation of abuse to the state agency until the state agency reported it to them again 3 days after the allegation was made to, and witnessed by, staff. Police were not called after an allegation that a crime had occurred which was requested by the Resident and his spouse, and a comprehensive investigation was not conducted until the state agency asked for one 3 days after the allegation of abuse was known by staff
The facility Abuse policies were not implemented specifically involving and including the following evidence;
TRAINING failure: Protections from Abuse and other annual training records in the facility were reviewed and revealed that Certified Nursing Assistants (CNA's) 12 hours of required annual training was not completed for 4 of the 6 employees reviewed, and background checks for staff were also found to be deficient.
PROTECTION failure: Resident #131 was not afforded police intervention, he was protected by a room move, however, there were no other Resident interviews to ascertain if any other Residents in the building had ever experienced this abuse, and if from this abuser.
INVESTIGATION failure: None of the staff witnesses of the 1-7-25 incident were interviewed, nor were statements received, and Resident #4's previous and current roommates were not interviewed. The spouse of Resident #131 was not interviewed, and other Residents on the unit were not interviewed.
The FRI document stated that on 1-10-25 the first notification by the Resident was obtained. This was incorrect, as staff witnessed the incident partially, if not fully, and documented it. A witness to the incident called APS on 1-7-25.
The Resident was blockaded from leaving his room which was witnessed by staff, as he was told police would arrest him for pushing his aggressor, proving involuntary seclusion/kidnapping, and he screamed for help which resulted in staff intervention.
Further the Resident wanted a room change because of the allegation which was made by Resident #131 to staff.
The allegation of abuse was alleged by a witness to APS, alleged by the Resident's spouse, alleged by the Resident, and by Administration in their synopsis/FRI (facility reported incident) to the state agency on 1-10-25.
The 1-10-25 initial facility document does not include many of the avenues that were available to the facility for a complete investigation, and thus they were unable to reach a more comprehensive conclusion of events.
Initial REPORTING failure: The 1-10-25 FRI document was the first report by the facility after the allegation of a sexual abuse that facility staff were made aware of on 1-7-25. This document was derived on 1-10-25 only after surveyors requested documentation of it, and 3 days after the abuse occurred.
Any allegation of abuse is mandated to be reported within 24 hours if no serious injury occurred to the state agency (VDH/OLC) Virginia Department of Health/Office of Licensure and Certification. The Department of Social Services office of Adult protective Services (APS) were not notified by the facility, and the police were not called by the facility as was requested by Resident #131 and his spouse on the day of the occurrence.
INVESTIGATION follow up RESULTS failure: The 5-day mandated follow up reporting after a full investigation; The Administrator's synopsis on 1-10-25 alleges that the abuse was unsubstantiated. A review of all the above evidence by the state agency reveals it to be substantiated, in part, or in all. A police investigation would have been appropriate in this case, as both Residents were alert, and oriented to person, place, time, and situation, however, this was not afforded to Resident #131.
On 1-10-25 Two nursing staff members spoke to surveyors on agreement of anonymity as they feared retaliation if it were known that they had spoken to surveyors. The two Nursing staff members worked on the units where Residents #131, and #130 were housed and both agreed that Resident #130 bought cigarettes for Resident #131, however, they stated that they had never known of a problem with that as no one complained about it, and they agreed that Resident #131 always went outside to smoke and had not created an issue. One was an agency nurse who worked in the facility, and one was a facility employee. Both stated they were aware of the incident involving Residents #130, and #131, and stated they wondered when the situation would blow up because Resident #130 was obviously grooming and pursuing Resident #131 (name), with the cigarettes, and Resident #131 (name) was married. The nurses were asked if the Administration was aware and they both stated yeah they knew, we all knew.
During interview on 1-29-25 and review of the clinical record, it was found that the Social Worker had only been there a short time, however, was aware of the incident with Resident's #131, and #130. She stated that Resident #131 (name) had been discharged on 1-23-25 to a group home in (name) closer to family a near by county. She also stated that Resident #130 would be discharging on 1-29-25 to a different group home closer to the facility.
At that time the Administrator was informed that the investigation was incomplete, and no FRI was ever received at the state agency VDH/OLC for the first allegation of abuse. She was further notified they had not implemented their policies on abuse.
The allegations were never reported to the state agency until the day after surveyors asked for an investigation. Residents were not protected from a known abuser. Abuse was not investigated fully, and the facility policy was not implemented for the protections of Residents from abuse. Further, there was never any added staff supervision for Resident #130 to prevent the abuse from continuing with another Resident.
No staff ever reported the suspicion of a crime, and no police report was ever filed. The first alleged report by the Administrator was incomplete and had errors in information giving the appearance of a verbal altercation and that the victim was not touched. APS, was not notified of the alleged abuse by facility Administration, and was instead notified by a complainant resulting in an investigation being opened by the state agency.
On 1-30-25 at approximately 4:00 p.m., the facility Administrator, Corporate Registered Nurse, and DON were notified of the findings. They stated they had no further information or documentation to offer.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the fac...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff failed to protect one Resident from abuse by a room mate with known illicit drug and alcohol abuse in their shared room for 1 Resident (Residents #131) in a survey sample size of 63 residents.
The findings included:
Resident #131 was exposed to, and not protected from alleged sexual harassment and abuse, and facility known illicit drug and alcohol abuse in their shared room by his room mate (Resident #130).
Resident #131 (victim) was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Traumatic Brain Injury (TBI) after a motor vehicle accident, diplopia, muscle weakness, unsteadiness on feet, abnormal gait and mobility, wheelchair use, and cognitive communication deficit, although there was no communication deficit noted at the time of survey.
Resident #131's most recent Minimum Data Set with an Assessment Reference Date of 1-23-25 was coded as a discharge assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicates no cognitive impairment. The Resident was cognitively intact, and his own responsible party. The Resident required touch assistance from one staff member for transferring and was wheelchair bound at times and was able to stand or walk independently for short distances. He required set up or touch assistance only with hygiene and bathing. The Resident denied complaints against any other staff or Residents since his admission on [DATE]. The Resident was discharged to a group home on 1-23-25 to be closer to family and to the least restrictive environment.
Resident #130 (aggressor of victim #131) was admitted to the facility on [DATE]. Hospital discharge records indicated that the Resident was alert and oriented to person, place and time, and was ambulatory. Diagnoses included but were not limited to: Major depressive disorder, recurrent anxiety, Chronic hepatitis C, type two diabetes, nicotine dependence, fractured left heel with infected wound sepsis due to Methicillin Susceptible Staphylococcus Aureus, enhanced barrier precautions, and history of infectious parasitic disease.
Resident #130's most recent Minimum Data Set with an Assessment Reference Date of 12-17-24 was coded as a significant change assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicated no cognitive impairment. The Resident was his own responsible party. The Resident required partial to moderate assistance from one staff member for hygiene and bathing. Resident #130 was observed during survey as ambulating without assistance or device.
Resident #130 went out of the facility daily using the public city bus transportation and repeatedly returned under the influence of drugs and alcohol. Instances of this were recorded in the nursing progress notes to include the following most recent to survey.
9-19-24 6:43 am Resident room noted with a strong odor of weeds [sic] by (Certified Nursing Assistant) CNA, nurse and CNA went in to ask resident, resident confirmed he has been smoking weed, we asked him to turn it over, he declined, resident educated about the implication of that, he was told his action will be reported to management. Describe any interventions attempted: Resident told he will be reported to management Effectiveness of Interventions: Resident will continue to be monitored.
12-20-24 7:24 a.m. (documentation time). Note Text: 4:10 am (time of actual observation) Writer notified of patient lethargic in dining room. Writer into dining room, patient seen with his head (laid backward supine fashion) behind wheelchair, lethargic and hard to arouse. Obtained vitals at 4:13 am 65/40, 56, 16, 100% RA (oxygen saturation on room air alone), BS 140 (blood sugar). Called resident several times, he responded and said, I'm high as a bitch. Writer asked resident several times what he had taken, he refused to say. 911 called made per his nurse. 911 into building. Assessed patient, resident remained with a low BP and heart rate. EMTs encouraged resident to go to hospital. Resident refused. Educated the resident on the importance of going to the hospital to monitor low BP and heart rate, resident continued to refuse. Multiple nurses from units educated the patient on the importance of his health. Encouraged resident to go with EMT to be seen at hospital. Resident then became aggressive saying he wasn't going to the hospital because there was nothing wrong with him. EMTs left building. Writer and nurse attempted to take resident to his room, he refused. Resident remained in dining room area.
MD (physician) note - 12-20-24 - [Resident #130 name redacted] was found asleep in in his wheelchair. He reported that he was high. He was difficult to arouse, BPs were in the 60-70s systolic. EMS was called. Upon arrival his BP was still low, but he refused to go the hospital. He is at baseline this morning when I see him. All reports reviewed and spoke with staff about the incident. I am holding his BP meds over the weekend. No reports of fever, chills, chest pain, shortness of breath, nausea, vomiting, or diarrhea. '
1-3-25 - 10:22 pm. Note Text: Nurse went to resident door, there was strong smell of weed in room, coming right to the hallway. Nurse supervisor notified.
A review of Resident #130's care plan revealed the following entry regarding the use of illicit drugs and or alcohol:
FOCUS: The Resident is at risk of complications due to a history of illicit drug use. Revision on: 12-16-24.
GOAL: The Resident will not have any adverse reaction to alcoholism thru review period. Date Initiated: 12-16-2024. Target Date: 3-16-25.
INTERVENTIONS: (3)
1. Observe Resident for signs and symptoms of intoxication or withdrawal from drugs such as tremors nausea/vomiting (severe) sweating and notify MD (doctor) as indicated. Date Initiated: 12-16-2024.
2. Administer medication as ordered. Date Initiated: 12-16-2024.
3. Vitals as needed. Date Initiated: 12-16-2024.
On 1-7-25 at 11:14 am nursing progress notes documented Verbal spat with roommate .both parties speaking in elevated tones, no physical contact noted both parties separated.
On 1-7-25 at 12:23 pm Resident #15 agreed to a room change, and his spouse was notified. Adult Protective Services (APS) was called by an anonymous caller at the facility and the incident of sexual abuse was reported to them. The caller stated in the APS report of 1-7-25 that the facility Administration did not notify police, and they (the Administration) stated the reason as that can't happen (because) is that Resident (Resident #131 victim) would be charged with assault for pushing Resident (#130 aggressor) out of the doorway so that Resident (#131) could escape.
This note indicated that there was physical contact known by staff at the time which was denied in the 1-7-25 nursing note.
It was also alleged by the caller to APS that Resident #130 had been making sexual advances toward Resident #131 and wanted to get in his pants. It was also alleged that Resident #131 was asked by facility staff Why can't you just go home? The caller went on to state that Resident #131 had been moved 4 times for different assaults, verbal and such, but this was the only sexual assault. This assertion of frequent moves was found to be true as Resident #131's census in the facility documented those moves.
The APS caller stated that on this day (1-7-25) the situation escalated and Resident #130 blocked the door of the room and told Resident #131 you are going to let me F K you. The caller stated that Resident #130 proceeded to touch, molest, and sexually assault Resident #131 who began yelling and screaming, and pushed Resident #130 out of the doorway into the hallway to escape when staff came to see what the commotion was about. Resident #131 told them immediately what had happened.
On 1-9-25 at 1:00 pm an interview was conducted with LPN A who stated that they are aware of the Residents going out on LOA (Leave of Absence) and coming back high, also stating but we cannot be with them at all times and cannot stop them leaving the facility. When asked what is done if they catch them smoking or drinking or using drugs in the facility, she stated, We document in the chart, notify the supervisor and educate them, that is all we can really do. When asked if the care plan should reflect the behaviors and interventions, she stated that it should.
On 1-9-25 (the second day of survey) at 3:00 pm, Resident #130 was interviewed during an investigation involving Resident drug, alcohol, and weapons abuses that were found to be actively occurring in the facility. This Resident was found to be involved in drug abuse while a Resident. The Resident was asked about an altercation with his roommate which was documented in the nursing progress notes as having occurred on 1-7-25. Resident #130 stated he bought Resident #131 cigarettes and Resident #131 refused to pay him for them. He stated he had indeed used drugs but not in the facility, only outside. This statement was found to be false as staff stated they had removed drugs and drug paraphernalia from his room, and documented that at 4:00 AM on 12-20-24 the Resident was found in the dining room after using drugs in the facility, and was also using in the facility on 9-19-24, and 1-3-25.
On 1-9-25 at 3:30 pm, Resident #131 in person, and his spouse by phone were interviewed. They both stated that Resident #130 had made advances toward Resident #131, however, Resident #131 stated he made it Clear that I am straight, married, and got no interest in no [NAME]. Resident #131 stated he would ask me to dress in front of him to see my chest, and I didn't care about that, because he said he would get me some cigarettes, but when he cornered me in the room and wouldn't let me leave the room and grabbed my D k and said I'm gonna F k you in the A , that was it! I screamed for help and pushed him through the door and the nurses almost got knocked down coming in, they heard it all just ask them. Resident #131 stated the temp agency nurse (name) and the other nurse who works here all the time (name) came. Resident #131 stated He (#130 name) and (Resident #106 name) smoke stuff in the room and have overdosed sometimes. I just want out of here. Resident #131 was asked if he had reported the sexual abuse, and he stated I told the nurses, they saw it happen! I told the Administrator who said I would be arrested for pushing him if I called the police, and I've told everybody, but they just moved me to another room.
On 1-9-25 A copy of all Facility Reported Incidents (FRI's) for the prior 6 months were requested. 9 were provided by the Administrator, and all 9 followed the standardized format and documentation included notification of the state agency the Virginia Department of Health Office of Licensure and Certification (VDH/OLC), the state Long Term Care Ombudsman, and Adult Protective Services (APS). The 9 completed FRI's were all prior to 9-20-24.
On 1-9-25 at 4:00 pm the facility Administrator was asked for any investigation from 1-7-25 involving Residents #130, and #131.
On 1-10-25 at 5:00 pm Resident #130 was interviewed by surveyors and stated I feel as though I'm being targeted by a staff member. The Director of Nursing (DON) she don't like me and wants me out of here. She believes anything anyone tells her. He continued to say, Yes I smoke weed but not on the property and I use heroin sometimes, not a lot. The surveyor asked how do you use it, and he replied, I smoke it. The surveyor asked if he received it from someone in the facility. He replied, No I get it outside. He was asked where do you use it? His response was I use it at the bus stop, I go out almost every day. He was asked if he was caught by staff in the facility with drugs or alcohol, and he replied, No they said I was smoking weed in my room, but I won't. He was questioned about the accusations from his roommate, and he stated, I bought him cigarettes, I didn't touch that [NAME] I didn't ask him for no sex. He didn't give me money for the cigarettes he is a liar. They gave me a notice to leave but I got nowhere to go.
On 1-10-25 The Administrator delivered a 2-page document dated 1-10-25 entitled Facility Reported Incident (FRI), Date reported 1-10-25, and was signed by the current Administrator. The synopsis was a simple typed document on a clean white unlined sheet of copy paper, and did not state that it was an initial FRI, nor a 5 day follow up. The document described a portion of the incident of 1-7-25, and the fact that Resident #131 alleged that his roommate (Resident #130) had made sexual advances to him and had attempted to block the doorway to keep him (Resident #131) from leaving the room. This was the third time that the allegation of abuse was made to someone in the facility, and to others. The first being the day of the occurrence to staff witnesses, the second to APS who reported it to the facility, to police, and the state agency, and the third on this day 1-10-25.
The document reported that Resident #131 had moved Resident #130 out of the way and exited the room. The document included that Resident #131 stated again he was tired of his roommate (Resident #130) making sexual advances at him and he wanted to be out of that room. Resident #131 also stated he wanted to be discharged .
The Administrator documented on 1-10-25 that Resident #130 denied the allegation of sexual abuse, and that the facility had concluded that the allegation was unsubstantiated, and was first reported to them on this day. These assertions are incorrect as staff were aware and present on 1-7-25 when the abuse was alleged to have occurred and was first documented. Further the Resident stated to the Administrator (as written in the above portion of the Administrators document) that he was blocked from leaving by his roommate, he was tired of his roommate (Resident #130) making sexual advances at him and he wanted to be out of that room. Sexual abuse and sexual harassment are both crimes. By the facility staff's documentation, and own admission this was reported repeatedly to them, observed by floor baseline staff when it occurred, reported to APS by a complainant, and they continued to report it as unsubstantiated.
The facility Resident Protections from abuse policy failures included all of the following 4 areas;
1. The facility was expected to complete background checks on all employees to protect the Resident population from abuse, also training was to be conducted annually for staff. (Training)
2. The Abuse policy document also stated that Residents would be protected if an allegation of abuse was made, and the police involved if that allegation alleged that a crime had happened. (Protection)
3. The Abuse policy document also stated that a comprehensive investigation would be conducted. (Investigation)
4. The document further stated that the state agency and other stake holders would be notified within 24 hours of an allegation of abuse, and that the report would occur within 2 hours if injury occurred. Then the initial report would be followed by a five day follow up report which would be sent to the state agency after the facility investigated to reveal their findings. (Reporting)
The facility staff failed to conduct required education for staff, failed to complete background checks in compliance with regulations. The facility staff failed to report the allegation of abuse to the state agency until the state agency reported it to them again 3 days after the allegation was made to, and witnessed by, staff. Police were not called after an allegation that a crime had occurred which was requested by the Resident and his spouse, and a comprehensive investigation was not conducted until the state agency asked for one 3 days after the allegation of abuse was known by staff
The facility Abuse policies were not implemented specifically involving and including the following evidence;
TRAINING failure: Protections from Abuse and other annual training records in the facility were reviewed and revealed that Certified Nursing Assistants (CNA's) 12 hours of required annual training was not completed for 4 of the 6 employees reviewed, and background checks for staff were also found to be deficient.
PROTECTION failure: Resident #131 was not afforded police intervention, he was protected by a room move, however, there were no other Resident interviews to ascertain if any other Residents in the building had ever experienced this abuse, and if from this abuser.
INVESTIGATION failure: None of the staff witnesses of the 1-7-25 incident were interviewed, nor were statements received, and Resident #4's previous and current roommates were not interviewed. The spouse of Resident #131 was not interviewed, and other Residents on the unit were not interviewed.
The FRI document stated that on 1-10-25 the first notification by the Resident was obtained. This was incorrect, as staff witnessed the incident partially, if not fully, and documented it. A witness to the incident called APS on 1-7-25.
The Resident was blockaded from leaving his room which was witnessed by staff, as he was told police would arrest him for pushing his aggressor, proving involuntary seclusion/kidnapping, and he screamed for help which resulted in staff intervention.
Further the Resident wanted a room change because of the allegation which was made by Resident #131 to staff.
The allegation of abuse was alleged by a witness to APS, alleged by the Resident's spouse, alleged by the Resident, and by Administration in their synopsis/FRI (facility reported incident) to the state agency on 1-10-25.
The 1-10-25 initial facility document does not include many of the avenues that were available to the facility for a complete investigation, and thus they were unable to reach a more comprehensive conclusion of events.
Initial REPORTING failure: The 1-10-25 FRI document was the first report by the facility after the allegation of a sexual abuse that facility staff were made aware of on 1-7-25. This document was derived on 1-10-25 only after surveyors requested documentation of it, and 3 days after the abuse occurred.
Any allegation of abuse is mandated to be reported within 24 hours if no serious injury occurred to the state agency (VDH/OLC) Virginia Department of Health/Office of Licensure and Certification. The Department of Social Services office of Adult protective Services (APS) were not notified by the facility, and the police were not called by the facility as was requested by Resident #131 and his spouse on the day of the occurrence.
INVESTIGATION follow up RESULTS failure: The 5-day mandated follow up reporting after a full investigation; The Administrator's synopsis on 1-10-25 alleges that the abuse was unsubstantiated. A review of all the above evidence by the state agency reveals it to be substantiated, in part, or in all. A police investigation would have been appropriate in this case, as both Residents were alert, and oriented to person, place, time, and situation, however, this was not afforded to Resident #131.
On 1-10-25 Two nursing staff members spoke to surveyors on agreement of anonymity as they feared retaliation if it were known that they had spoken to surveyors. The two Nursing staff members worked on the units where Residents #131, and #130 were housed and both agreed that Resident #130 bought cigarettes for Resident #131, however, they stated that they had never known of a problem with that as no one complained about it, and they agreed that Resident #131 always went outside to smoke and had not created an issue. One was an agency nurse who worked in the facility, and one was a facility employee. Both stated they were aware of the incident involving Residents #130, and #131, and stated they wondered when the situation would blow up because Resident #130 was obviously grooming and pursuing Resident #131 (name), with the cigarettes, and Resident #131 (name) was married. The nurses were asked if the Administration was aware and they both stated yeah they knew, we all knew.
During interview on 1-29-25 and review of the clinical record, it was found that the Social Worker had only been there a short time, however, was aware of the incident with Resident's #131, and #130. She stated that Resident #131 (name) had been discharged on 1-23-25 to a group home in (name) closer to family a near by county. She also stated that Resident #130 would be discharging on 1-29-25 to a different group home closer to the facility.
At that time the Administrator was informed that the investigation was incomplete, and no FRI was ever received at the state agency VDH/OLC for the first allegation of abuse. She was further notified they had not implemented their policies on abuse.
The allegations were never reported to the state agency until the day after surveyors asked for an investigation. Residents were not protected from a known abuser. Abuse was not investigated fully, and the facility policy was not implemented for the protections of Residents from abuse. Further, there was never any added staff supervision for Resident #130 to prevent the abuse from continuing with another Resident.
No staff ever reported the suspicion of a crime, and no police report was ever filed. The first alleged report by the Administrator was incomplete and had errors in information giving the appearance of a verbal altercation and that the victim was not touched. APS, was not notified of the alleged abuse by facility Administration, and was instead notified by a complainant resulting in an investigation being opened by the state agency.
On 1-30-25 at approximately 4:00 p.m., the facility Administrator, Corporate Registered Nurse, and DON were notified of the findings. They stated they had no further information or documentation to offer.
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
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the fac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff failed to implement their abuse policies to protect Residents, report abuse timely, investigate fully, and allow a police report of the abuse for 4 Residents (Residents #130, #131, #7, and #39) in a survey sample size of 63 residents.
The findings included:
1. The facility failures described above resulted in the sexual abuse/harassment of Resident #131 by Resident #130.
Resident #131 (victim) was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Traumatic Brain Injury (TBI) after a motor vehicle accident, diplopia, muscle weakness, unsteadiness on feet, abnormal gait and mobility, wheelchair use, and cognitive communication deficit, although there was no communication deficit noted at the time of survey.
Resident #131's most recent Minimum Data Set with an Assessment Reference Date of 1-23-25 was coded as a discharge assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicates no cognitive impairment. The Resident was cognitively intact, and his own responsible party. The Resident required touch assistance from one staff member for transferring and was wheelchair bound at times and was able to stand or walk independently for short distances. He required set up or touch assistance only with hygiene and bathing. The Resident denied complaints against any other staff or Residents since his admission on [DATE]. The Resident was discharged to a group home on 1-23-25 to be closer to family and to the least restrictive environment.
Resident #130 (aggressor of victim #131) was admitted to the facility on [DATE]. Hospital discharge records indicated that the Resident was alert and oriented to person, place and time, and was ambulatory. Diagnoses included but were not limited to: Major depressive disorder, recurrent anxiety, Chronic hepatitis C, type two diabetes, nicotine dependence, fractured left heel with infected wound sepsis due to Methicillin Susceptible Staphylococcus Aureus, enhanced barrier precautions, and history of infectious parasitic disease.
Resident #130's most recent Minimum Data Set with an Assessment Reference Date of 12-17-24 was coded as a significant change assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicated no cognitive impairment. The Resident was his own responsible party. The Resident required partial to moderate assistance from one staff member for hygiene and bathing. Resident #130 was observed during survey as ambulating without assistance or device.
Resident #130 went out of the facility daily using the public city bus transportation and repeatedly returned under the influence of drugs and alcohol. Instances of this were recorded in the nursing progress notes to include the following most recent to survey.
9-19-24 6:43 am Resident room noted with a strong odor of weeds [sic] by (Certified Nursing Assistant) CNA, nurse and CNA went in to ask resident, resident confirmed he has been smoking weed, we asked him to turn it over, he declined, resident educated about the implication of that, he was told his action will be reported to management. Describe any interventions attempted: Resident told he will be reported to management Effectiveness of Interventions: Resident will continue to be monitored.
12-20-24 7:24 a.m. (documentation time). Note Text: 4:10 am (time of actual observation) Writer notified of patient lethargic in dining room. Writer into dining room, patient seen with his head (laid backward supine fashion) behind wheelchair, lethargic and hard to arouse. Obtained vitals at 4:13 am 65/40, 56, 16, 100% RA (oxygen saturation on room air alone), BS 140 (blood sugar). Called resident several times, he responded and said, I'm high as a bitch. Writer asked resident several times what he had taken, he refused to say. 911 called made per his nurse. 911 into building. Assessed patient, resident remained with a low BP and heart rate. EMTs encouraged resident to go to hospital. Resident refused. Educated the resident on the importance of going to the hospital to monitor low BP and heart rate, resident continued to refuse. Multiple nurses from units educated the patient on the importance of his health. Encouraged resident to go with EMT to be seen at hospital. Resident then became aggressive saying he wasn't going to the hospital because there was nothing wrong with him. EMTs left building. Writer and nurse attempted to take resident to his room, he refused. Resident remained in dining room area.
MD (physician) note - 12-20-24 - [Resident #130 name redacted] was found asleep in in his wheelchair. He reported that he was high. He was difficult to arouse, BPs were in the 60-70s systolic. EMS was called. Upon arrival his BP was still low, but he refused to go the hospital. He is at baseline this morning when I see him. All reports reviewed and spoke with staff about the incident. I am holding his BP meds over the weekend. No reports of fever, chills, chest pain, shortness of breath, nausea, vomiting, or diarrhea. '
1-3-25 - 10:22 pm. Note Text: Nurse went to resident door, there was strong smell of weed in room, coming right to the hallway. Nurse supervisor notified.
A review of Resident #130's care plan revealed the following entry regarding the use of illicit drugs and or alcohol:
FOCUS: The Resident is at risk of complications due to a history of illicit drug use. Revision on: 12-16-24.
GOAL: The Resident will not have any adverse reaction to alcoholism thru review period. Date Initiated: 12-16-2024. Target Date: 3-16-25.
INTERVENTIONS: (3)
1. Observe Resident for signs and symptoms of intoxication or withdrawal from drugs such as tremors nausea/vomiting (severe) sweating and notify MD (doctor) as indicated. Date Initiated: 12-16-2024.
2. Administer medication as ordered. Date Initiated: 12-16-2024.
3. Vitals as needed. Date Initiated: 12-16-2024.
On 1-7-25 at 11:14 am nursing progress notes documented Verbal spat with roommate .both parties speaking in elevated tones, no physical contact noted both parties separated.
On 1-7-25 at 12:23 pm Resident #15 agreed to a room change, and his spouse was notified. Adult Protective Services (APS) was called by an anonymous caller at the facility and the incident of sexual abuse was reported to them. The caller stated in the APS report of 1-7-25 that the facility Administration did not notify police, and they (the Administration) stated the reason as that can't happen (because) is that Resident (Resident #131 victim) would be charged with assault for pushing Resident (#130 aggressor) out of the doorway so that Resident (#131) could escape.
This note indicated that there was physical contact known by staff at the time which was denied in the 1-7-25 nursing note.
It was also alleged by the caller to APS that Resident #130 had been making sexual advances toward Resident #131 and wanted to get in his pants. It was also alleged that Resident #131 was asked by facility staff Why can't you just go home? The caller went on to state that Resident #131 had been moved 4 times for different assaults, verbal and such, but this was the only sexual assault. This assertion of frequent moves was found to be true as Resident #131's census in the facility documented those moves.
The APS caller stated that on this day (1-7-25) the situation escalated and Resident #130 blocked the door of the room and told Resident #131 you are going to let me F K you. The caller stated that Resident #130 proceeded to touch, molest, and sexually assault Resident #131 who began yelling and screaming, and pushed Resident #130 out of the doorway into the hallway to escape when staff came to see what the commotion was about. Resident #131 told them immediately what had happened.
On 1-9-25 at 1:00 pm an interview was conducted with LPN A who stated that they are aware of the Residents going out on LOA (Leave of Absence) and coming back high, also stating but we cannot be with them at all times and cannot stop them leaving the facility. When asked what is done if they catch them smoking or drinking or using drugs in the facility, she stated, We document in the chart, notify the supervisor and educate them, that is all we can really do. When asked if the care plan should reflect the behaviors and interventions, she stated that it should.
On 1-9-25 (the second day of survey) at 3:00 pm, Resident #130 was interviewed during an investigation involving Resident drug, alcohol, and weapons abuses that were found to be actively occurring in the facility. This Resident was found to be involved in drug abuse while a Resident. The Resident was asked about an altercation with his roommate which was documented in the nursing progress notes as having occurred on 1-7-25. Resident #130 stated he bought Resident #131 cigarettes and Resident #131 refused to pay him for them. He stated he had indeed used drugs but not in the facility, only outside. This statement was found to be false as staff stated they had removed drugs and drug paraphernalia from his room, and documented that at 4:00 AM on 12-20-24 the Resident was found in the dining room after using drugs in the facility, and was also using in the facility on 9-19-24, and 1-3-25.
On 1-9-25 at 3:30 pm, Resident #131 in person, and his spouse by phone were interviewed. They both stated that Resident #130 had made advances toward Resident #131, however, Resident #131 stated he made it Clear that I am straight, married, and got no interest in no [NAME]. Resident #131 stated he would ask me to dress in front of him to see my chest, and I didn't care about that, because he said he would get me some cigarettes, but when he cornered me in the room and wouldn't let me leave the room and grabbed my D k and said I'm gonna F k you in the A , that was it! I screamed for help and pushed him through the door and the nurses almost got knocked down coming in, they heard it all just ask them. Resident #131 stated the temp agency nurse (name) and the other nurse who works here all the time (name) came. Resident #131 stated He (#130 name) and (Resident #106 name) smoke stuff in the room and have overdosed sometimes. I just want out of here. Resident #131 was asked if he had reported the sexual abuse, and he stated I told the nurses, they saw it happen! I told the Administrator who said I would be arrested for pushing him if I called the police, and I've told everybody, but they just moved me to another room.
On 1-9-25 A copy of all Facility Reported Incidents (FRI's) for the prior 6 months were requested. 9 were provided by the Administrator, and all 9 followed the standardized format and documentation included notification of the state agency the Virginia Department of Health Office of Licensure and Certification (VDH/OLC), the state Long Term Care Ombudsman, and Adult Protective Services (APS). The 9 completed FRI's were all prior to 9-20-24.
On 1-9-25 at 4:00 pm the facility Administrator was asked for any investigation from 1-7-25 involving Residents #130, and #131.
On 1-10-25 at 5:00 pm Resident #130 was interviewed by surveyors and stated I feel as though I'm being targeted by a staff member. The Director of Nursing (DON) she don't like me and wants me out of here. She believes anything anyone tells her. He continued to say, Yes I smoke weed but not on the property and I use heroin sometimes, not a lot. The surveyor asked how do you use it, and he replied, I smoke it. The surveyor asked if he received it from someone in the facility. He replied, No I get it outside. He was asked where do you use it? His response was I use it at the bus stop, I go out almost every day. He was asked if he was caught by staff in the facility with drugs or alcohol, and he replied, No they said I was smoking weed in my room, but I won't. He was questioned about the accusations from his roommate, and he stated, I bought him cigarettes, I didn't touch that [NAME] I didn't ask him for no sex. He didn't give me money for the cigarettes he is a liar. They gave me a notice to leave but I got nowhere to go.
On 1-10-25 The Administrator delivered a 2-page document dated 1-10-25 entitled Facility Reported Incident (FRI), Date reported 1-10-25, and was signed by the current Administrator. The synopsis was a simple typed document on a clean white unlined sheet of copy paper, and did not state that it was an initial FRI, nor a 5 day follow up. The document described a portion of the incident of 1-7-25, and the fact that Resident #131 alleged that his roommate (Resident #130) had made sexual advances to him and had attempted to block the doorway to keep him (Resident #131) from leaving the room. This was the third time that the allegation of abuse was made to someone in the facility, and to others. The first being the day of the occurrence to staff witnesses, the second to APS who reported it to the facility, to police, and the state agency, and the third on this day 1-10-25.
The document reported that Resident #131 had moved Resident #130 out of the way and exited the room. The document included that Resident #131 stated again he was tired of his roommate (Resident #130) making sexual advances at him and he wanted to be out of that room. Resident #131 also stated he wanted to be discharged .
The Administrator documented on 1-10-25 that Resident #130 denied the allegation of sexual abuse, and that the facility had concluded that the allegation was unsubstantiated, and was first reported to them on this day. These assertions are incorrect as staff were aware and present on 1-7-25 when the abuse was alleged to have occurred and was first documented. Further the Resident stated to the Administrator (as written in the above portion of the Administrators document) that he was blocked from leaving by his roommate, he was tired of his roommate (Resident #130) making sexual advances at him and he wanted to be out of that room. Sexual abuse and sexual harassment are both crimes. By the facility staff's documentation, and own admission this was reported repeatedly to them, observed by floor baseline staff when it occurred, reported to APS by a complainant, and they continued to report it as unsubstantiated.
The facility Resident Protections from abuse policy failures included all of the following 4 areas;
1. The facility was expected to complete background checks on all employees to protect the Resident population from abuse, also training was to be conducted annually for staff. (Training)
2. The Abuse policy document also stated that Residents would be protected if an allegation of abuse was made, and the police involved if that allegation alleged that a crime had happened. (Protection)
3. The Abuse policy document also stated that a comprehensive investigation would be conducted. (Investigation)
4. The document further stated that the state agency and other stake holders would be notified within 24 hours of an allegation of abuse, and that the report would occur within 2 hours if injury occurred. Then the initial report would be followed by a five day follow up report which would be sent to the state agency after the facility investigated to reveal their findings. (Reporting)
The facility staff failed to conduct required education for staff, failed to complete background checks in compliance with regulations. The facility staff failed to report the allegation of abuse to the state agency until the state agency reported it to them again 3 days after the allegation was made to, and witnessed by, staff. Police were not called after an allegation that a crime had occurred which was requested by the Resident and his spouse, and a comprehensive investigation was not conducted until the state agency asked for one 3 days after the allegation of abuse was known by staff
The facility Abuse policies were not implemented specifically involving and including the following evidence;
TRAINING failure: Protections from Abuse and other annual training records in the facility were reviewed and revealed that Certified Nursing Assistants (CNA's) 12 hours of required annual training was not completed for 4 of the 6 employees reviewed, and background checks for staff were also found to be deficient.
PROTECTION failure: Resident #131 was not afforded police intervention, he was protected by a room move, however, there were no other Resident interviews to ascertain if any other Residents in the building had ever experienced this abuse, and if from this abuser.
INVESTIGATION failure: None of the staff witnesses of the 1-7-25 incident were interviewed, nor were statements received, and Resident #4's previous and current roommates were not interviewed. The spouse of Resident #131 was not interviewed, and other Residents on the unit were not interviewed.
The FRI document stated that on 1-10-25 the first notification by the Resident was obtained. This was incorrect, as staff witnessed the incident partially, if not fully, and documented it. A witness to the incident called APS on 1-7-25.
The Resident was blockaded from leaving his room which was witnessed by staff, as he was told police would arrest him for pushing his aggressor, proving involuntary seclusion/kidnapping, and he screamed for help which resulted in staff intervention.
Further the Resident wanted a room change because of the allegation which was made by Resident #131 to staff.
The allegation of abuse was alleged by a witness to APS, alleged by the Resident's spouse, alleged by the Resident, and by Administration in their synopsis/FRI (facility reported incident) to the state agency on 1-10-25.
The 1-10-25 initial facility document does not include many of the avenues that were available to the facility for a complete investigation, and thus they were unable to reach a more comprehensive conclusion of events.
Initial REPORTING failure: The 1-10-25 FRI document was the first report by the facility after the allegation of a sexual abuse that facility staff were made aware of on 1-7-25. This document was derived on 1-10-25 only after surveyors requested documentation of it, and 3 days after the abuse occurred.
Any allegation of abuse is mandated to be reported within 24 hours if no serious injury occurred to the state agency (VDH/OLC) Virginia Department of Health/Office of Licensure and Certification. The Department of Social Services office of Adult protective Services (APS) were not notified by the facility, and the police were not called by the facility as was requested by Resident #131 and his spouse on the day of the occurrence.
INVESTIGATION follow up RESULTS failure: The 5-day mandated follow up reporting after a full investigation; The Administrator's synopsis on 1-10-25 alleges that the abuse was unsubstantiated. A review of all the above evidence by the state agency reveals it to be substantiated, in part, or in all. A police investigation would have been appropriate in this case, as both Residents were alert, and oriented to person, place, time, and situation, however, this was not afforded to Resident #131.
On 1-10-25 Two nursing staff members spoke to surveyors on agreement of anonymity as they feared retaliation if it were known that they had spoken to surveyors. The two Nursing staff members worked on the units where Residents #131, and #130 were housed and both agreed that Resident #130 bought cigarettes for Resident #131, however, they stated that they had never known of a problem with that as no one complained about it, and they agreed that Resident #131 always went outside to smoke and had not created an issue. One was an agency nurse who worked in the facility, and one was a facility employee. Both stated they were aware of the incident involving Residents #130, and #131, and stated they wondered when the situation would blow up because Resident #130 was obviously grooming and pursuing Resident #131 (name), with the cigarettes, and Resident #131 (name) was married. The nurses were asked if the Administration was aware and they both stated yeah they knew, we all knew.
During interview on 1-29-25 and review of the clinical record, it was found that the Social Worker had only been there a short time, however, was aware of the incident with Resident's #131, and #130. She stated that Resident #131 (name) had been discharged on 1-23-25 to a group home in (name) closer to family a near by county. She also stated that Resident #130 would be discharging on 1-29-25 to a different group home closer to the facility.
At that time the Administrator was informed that the investigation was incomplete, and no FRI was ever received at the state agency VDH/OLC for the first allegation of abuse. She was further notified they had not implemented their policies on abuse.
The allegations were never reported to the state agency until the day after surveyors asked for an investigation. Residents were not protected from a known abuser. Abuse was not investigated fully, and the facility policy was not implemented for the protections of Residents from abuse. Further, there was never any added staff supervision for Resident #130 to prevent the abuse from continuing with another Resident.
No staff ever reported the suspicion of a crime, and no police report was ever filed. The first alleged report by the Administrator was incomplete and had errors in information giving the appearance of a verbal altercation and that the victim was not touched. APS, was not notified of the alleged abuse by facility Administration, and was instead notified by a complainant resulting in an investigation being opened by the state agency.
On 1-30-25 at approximately 4:00 p.m., the facility Administrator, Corporate Registered Nurse, and DON were notified of the findings. They stated they had no further information or documentation to offer.
2. Resident #7 while in psychosis and having suicidal ideation was admitted to the hospital was found to have a switch blade in her bedside table on 1/26/25, on the same day was re-admitted to the facility on [DATE]. The facility staff failed to report the above allegation within the required time frame of 2 hours to the State Survey Agency. Resident #7 was originally admitted to the facility 12/04/23 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Schizoaffective Disorder and Bipolar Disorder Unspecified.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/16/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #7 cognitive abilities for daily decision making were intact.
In sectionG(Functional Status) the resident was coded as requiring supervision of one person with transfers, bed mobility, eating and toileting.
The Care Plan dated 12/05/23 read that Resident #7 has a mood problem related to: schizoaffective disorder, depression, anxiety and bipolar disorder. The resident has a
history of hospitalization through suicidal ideation. The goal for the resident was that the resident will have improved mood state through the next review date. Interventions for the resident are to monitor medications as ordered and Behavioral consults as needed.
During the initial tour an interview was conducted to Resident #7 concerning hospitalizations. Resident #7 said that she went to the hospital recently for having a cough but was recently admitted back to the facility.
A change of condition note dated on 01/26/2025 at 5:34 PM., Resident alerted writer that she was actively SI (Suicidal Ideation) with plan to cut herself. Resident admitted to having switchblade in her bedside drawer. Writer entered residents' room to find carpenter knife in her top drawer on the right-hand side. Resident states the staff put it in her drawer. Writer notified provider on call, resident refused to take any medications at this time, stating I need to go to the hospital if you don't call 911 I will. Writer informed provider of this who advised writer to send her to the ER for further evaluation. 911 called, charge nurse notified, residents POA contacted with no answer, will try to call again. VSS 137/69, 18RR, 97.6T, 70HR, 96%RA. Resident is A&OX3.
An interview was conducted on 02/05/25 at approximately 2:57 PM., with Licensed Practical Nurse (LPN) H. LPN H said that while working the 3-11 shift, Resident #7 said that she was feeling suicidal, wanted to go to the hospital and was going to use the switch blade in top drawer on the right side of her bed. LPN H also said that she grabbed the weapon the knife and the resident told her to hurry up and call the police. LPN H said that the police confiscated the weapon from her.
On 02/05/25 at approximately 2:28 PM., an interview was conducted with LPN J concerning Resident #7. LPN J said that she was called up stairs by the facility staff informing her that Resident #7 had a Swiss knife. LPN J said that once she saw the Swiss knife it looked like something a [NAME] would use to clean fish, it had a wine cork remover, a screwdriver and a nail file attached to it. Once I came upstairs and entered the resident's room, she informed me that it (Swiss knife) was in her drawer, but the nurse had informed me that she took it. resident said that she wanted to kill herself. the resident was sent out for psych eval. she told EMTS that it was in her drawer.
On 2/04/25 at approximately 4:20 PM., an end of day meeting was conducted with Administrator, the Director of Nursing (DON)., the Regional/Corporate staff, Regional Risk Management, the Regional Nurse Consultant and with the [NAME] President of Clinical Services concerning Resident #7. They were asked if an incident report or facility synopsis had been documented concerning the above incident involving a knife. The Administrator said that no facility synopsis had been filed but a soft file should have been completed instead. The administrator also mentioned that witnessed statements were received today as well as staff interviews. The above staff were also asked if death or harm could have been caused if the resident had used the Swiss Knife to cut herself. No comments were made.
Swiss Army knife
The Swiss Army knife is a pocketknife, generally multi-tooled. The term Swiss Army knife was coined by American soldiers after World War II because they had trouble pronouncing the German word Offiziersmesser, meaning officer's knife. The Swiss Army knife generally has a drop-point main blade plus other types of blades and tools, such as a screwdriver, a can opener, a saw blade, a pair of scissors, and many others. These are folded into the handle of the knife through a pivot point mechanism. https://en.wikipedia.org/wiki/Swiss_Army_knife.
3. The facility staff failed to report allegations of abuse in a timely manner to the State Survey Agency after Resident #39 alleged being physically abused by a staff member. Resident #39 was originally admitted to the facility 11/09/23 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Depression, Unspecified.
The 5-day Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/17/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #39 cognitive abilities for daily decision making were moderately impaired.
In sectionGG(Functional Abilities Goals) the resident was coded as requiring partial/moderate assistance with eating, oral hygiene. Resident coded as dependent in lower body dressing, personal hygiene and rolling left and right.
The care plan dated 11/22/23 read that Resident #39 had an Activities of Daily Living (ADL) self-care performance deficit related to multiple sclerosis, rheumatoid arthritis, spinal stenosis, right foot drop, morbid obesity, osteoarthritis, bilateral hand contractures and personality disorder. The Goal was to have the resident participate in as much of her ADL care as possible. The intervention for the resident requires total dependance by 2 staff members for toileting and requires max assist to total dependance by 2 staff members for bed mobility, transfers and one person assist for mobility in wheelchair.
A review of a nursing note dated 2/04/25 at 12:33 PM., read: State surveyors question this writer about concerns that resident stating that there was an incident with a cna handling her roughly during incontinent care, when this writer spoke with resident concerning this incident, resident denied speaking to surveyor about incident, stating it never happened.
Progress note on 2/05/25 at 12 Midnight: Patient with h/o depression, on no psychotropics. She was seen on 9.18.24 and no change was made to her treatment regimen. She is being seen today at the staff request because she reported to the department of health that a CNA was rough with her during care in early 2024. She is found in bed today; she is alert, calm and pleasant. She says she is doing well. She says this incident took place in April 2024. She says a CNA who was caring for her pushed her too far towards the wall. She felt this person was too rough with me. She says she reported this to the unit manager immediately and this individual never cared for her again. She says she also reported this to the VDH because she felt she needed they needed to know. She says she is surprised it took until today for someone from the VDH to come see her. She says she was told this CNA is no longer here but the reason for her living is not related to her incident with her. She says nothing like that happened to her ever again and she feels safe here.
A review of Facility Reported Synopsis dated 2/05/25 read that Resident #39 alleged she was handled roughly by staff during incontinent care. The incident occurred April or May of 2024. The alleged staff member is no longer employed with the facility.
On 01/28/25 at approximately 3:48 PM., during the initial tour Resident #39 alleged that a Certified Nurses Aide was rough with her while turning her onto her side to provide incontinent care.
The Abuse/Neglect/Misappropriation/Crime Policy reads dated 10/17/23 reads: There is zero tolerance for abuse, neglect, misappropriation of property, or any crime against a patient of the Health and Rehabilitation Center. Procedure: Any suspected or witnessed incidents of patient abuse, neglect, theft against a patient should be reported to the administration, an internal investigation conducted, appropriate and timely reporting to the State Survey Agency and other legally designated agencies, as well as staff corrective action, suspension, and/or termination as necessary. Failure for an employee to report any suspected or witnessed incident of mistreatment, abuse, neglect against a patient will result in corrective action. Immediately upon notification of any alleged violations involving, abuse, neglect or exploitation the administrator will immediately report to the state agency, but no later than 2 hours after the allegation is made.
On 2/05/25 at approximately 7:00 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the fac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff failed to report an allegation of abuse to the state agency, police, and other stake holders timely for 4 Residents (Residents #131, #130, #7, and #39) in a survey sample size of 63 residents.
The findings included:
1. The facility failures described above resulted in the sexual abuse/harassment of Resident #131 by Resident #130.
Resident #131 (victim) was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Traumatic Brain Injury (TBI) after a motor vehicle accident, diplopia, muscle weakness, unsteadiness on feet, abnormal gait and mobility, wheelchair use, and cognitive communication deficit, although there was no communication deficit noted at the time of survey.
Resident #131's most recent Minimum Data Set with an Assessment Reference Date of 1-23-25 was coded as a discharge assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicates no cognitive impairment. The Resident was cognitively intact, and his own responsible party. The Resident required touch assistance from one staff member for transferring and was wheelchair bound at times and was able to stand or walk independently for short distances. He required set up or touch assistance only with hygiene and bathing. The Resident denied complaints against any other staff or Residents since his admission on [DATE]. The Resident was discharged to a group home on 1-23-25 to be closer to family and to the least restrictive environment.
Resident #130 (aggressor of victim #131) was admitted to the facility on [DATE]. Hospital discharge records indicated that the Resident was alert and oriented to person, place and time, and was ambulatory. Diagnoses included but were not limited to: Major depressive disorder, recurrent anxiety, Chronic hepatitis C, type two diabetes, nicotine dependence, fractured left heel with infected wound sepsis due to Methicillin Susceptible Staphylococcus Aureus, enhanced barrier precautions, and history of infectious parasitic disease.
Resident #130's most recent Minimum Data Set with an Assessment Reference Date of 12-17-24 was coded as a significant change assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicated no cognitive impairment. The Resident was his own responsible party. The Resident required partial to moderate assistance from one staff member for hygiene and bathing. Resident #130 was observed during survey as ambulating without assistance or device.
Resident #130 went out of the facility daily using the public city bus transportation and repeatedly returned under the influence of drugs and alcohol. Instances of this were recorded in the nursing progress notes to include the following most recent to survey.
9-19-24 6:43 am Resident room noted with a strong odor of weeds [sic] by (Certified Nursing Assistant) CNA, nurse and CNA went in to ask resident, resident confirmed he has been smoking weed, we asked him to turn it over, he declined, resident educated about the implication of that, he was told his action will be reported to management. Describe any interventions attempted: Resident told he will be reported to management Effectiveness of Interventions: Resident will continue to be monitored.
12-20-24 7:24 a.m. (documentation time). Note Text: 4:10 am (time of actual observation) Writer notified of patient lethargic in dining room. Writer into dining room, patient seen with his head (laid backward supine fashion) behind wheelchair, lethargic and hard to arouse. Obtained vitals at 4:13 am 65/40, 56, 16, 100% RA (oxygen saturation on room air alone), BS 140 (blood sugar). Called resident several times, he responded and said, I'm high as a bitch. Writer asked resident several times what he had taken, he refused to say. 911 called made per his nurse. 911 into building. Assessed patient, resident remained with a low BP and heart rate. EMTs encouraged resident to go to hospital. Resident refused. Educated the resident on the importance of going to the hospital to monitor low BP and heart rate, resident continued to refuse. Multiple nurses from units educated the patient on the importance of his health. Encouraged resident to go with EMT to be seen at hospital. Resident then became aggressive saying he wasn't going to the hospital because there was nothing wrong with him. EMTs left building. Writer and nurse attempted to take resident to his room, he refused. Resident remained in dining room area.
MD (physician) note - 12-20-24 - [Resident #130 name redacted] was found asleep in in his wheelchair. He reported that he was high. He was difficult to arouse, BPs were in the 60-70s systolic. EMS was called. Upon arrival his BP was still low, but he refused to go the hospital. He is at baseline this morning when I see him. All reports reviewed and spoke with staff about the incident. I am holding his BP meds over the weekend. No reports of fever, chills, chest pain, shortness of breath, nausea, vomiting, or diarrhea. '
1-3-25 - 10:22 pm. Note Text: Nurse went to resident door, there was strong smell of weed in room, coming right to the hallway. Nurse supervisor notified.
A review of Resident #130's care plan revealed the following entry regarding the use of illicit drugs and or alcohol:
FOCUS: The Resident is at risk of complications due to a history of illicit drug use. Revision on: 12-16-24.
GOAL: The Resident will not have any adverse reaction to alcoholism thru review period. Date Initiated: 12-16-2024. Target Date: 3-16-25.
INTERVENTIONS: (3)
1. Observe Resident for signs and symptoms of intoxication or withdrawal from drugs such as tremors nausea/vomiting (severe) sweating and notify MD (doctor) as indicated. Date Initiated: 12-16-2024.
2. Administer medication as ordered. Date Initiated: 12-16-2024.
3. Vitals as needed. Date Initiated: 12-16-2024.
On 1-7-25 at 11:14 am nursing progress notes documented Verbal spat with roommate .both parties speaking in elevated tones, no physical contact noted both parties separated.
On 1-7-25 at 12:23 pm Resident #15 agreed to a room change, and his spouse was notified. Adult Protective Services (APS) was called by an anonymous caller at the facility and the incident of sexual abuse was reported to them. The caller stated in the APS report of 1-7-25 that the facility Administration did not notify police, and they (the Administration) stated the reason as that can't happen (because) is that Resident (Resident #131 victim) would be charged with assault for pushing Resident (#130 aggressor) out of the doorway so that Resident (#131) could escape.
This note indicated that there was physical contact known by staff at the time which was denied in the 1-7-25 nursing note.
It was also alleged by the caller to APS that Resident #130 had been making sexual advances toward Resident #131 and wanted to get in his pants. It was also alleged that Resident #131 was asked by facility staff Why can't you just go home? The caller went on to state that Resident #131 had been moved 4 times for different assaults, verbal and such, but this was the only sexual assault. This assertion of frequent moves was found to be true as Resident #131's census in the facility documented those moves.
The APS caller stated that on this day (1-7-25) the situation escalated and Resident #130 blocked the door of the room and told Resident #131 you are going to let me F K you. The caller stated that Resident #130 proceeded to touch, molest, and sexually assault Resident #131 who began yelling and screaming, and pushed Resident #130 out of the doorway into the hallway to escape when staff came to see what the commotion was about. Resident #131 told them immediately what had happened.
On 1-9-25 at 1:00 pm, an interview was conducted with LPN A who stated that they are aware of the Residents going out on LOA (Leave of Absence) and coming back high, also stating but we cannot be with them at all times and cannot stop them leaving the facility. When asked what is done if they catch them smoking or drinking or using drugs in the facility, she stated, We document in the chart, notify the supervisor and educate them, that is all we can really do. When asked if the care plan should reflect the behaviors and interventions, she stated that it should.
On 1-9-25 (the second day of survey) at 3:00 pm, Resident #130 was interviewed during an investigation involving Resident drug, alcohol, and weapons abuses that were found to be actively occurring in the facility. This Resident was found to be involved in drug abuse while a Resident. The Resident was asked about an altercation with his roommate which was documented in the nursing progress notes as having occurred on 1-7-25. Resident #130 stated he bought Resident #131 cigarettes and Resident #131 refused to pay him for them. He stated he had indeed used drugs but not in the facility, only outside. This statement was found to be false as staff stated they had removed drugs and drug paraphernalia from his room, and documented that at 4:00 AM on 12-20-24 the Resident was found in the dining room after using drugs in the facility, and was also using in the facility on 9-19-24, and 1-3-25.
On 1-9-25 at 3:30 pm, Resident #131 in person, and his spouse by phone were interviewed. They both stated that Resident #130 had made advances toward Resident #131, however, Resident #131 stated he made it Clear that I am straight, married, and got no interest in no [NAME]. Resident #131 stated he would ask me to dress in front of him to see my chest, and I didn't care about that, because he said he would get me some cigarettes, but when he cornered me in the room and wouldn't let me leave the room and grabbed my D k and said I'm gonna F k you in the A , that was it! I screamed for help and pushed him through the door and the nurses almost got knocked down coming in, they heard it all just ask them. Resident #131 stated the temp agency nurse (name) and the other nurse who works here all the time (name) came. Resident #131 stated He (#130 name) and (Resident #106 name) smoke stuff in the room and have overdosed sometimes. I just want out of here. Resident #131 was asked if he had reported the sexual abuse, and he stated I told the nurses, they saw it happen! I told the Administrator who said I would be arrested for pushing him if I called the police, and I've told everybody, but they just moved me to another room.
On 1-9-25 A copy of all Facility Reported Incidents (FRI's) for the prior 6 months were requested. Nine (9) were provided by the Administrator, and all 9 followed the standardized format and documentation included notification of the state agency the Virginia Department of Health Office of Licensure and Certification (VDH/OLC), the state Long Term Care Ombudsman, and Adult Protective Services (APS). The 9 completed FRI's were all prior to 9-20-24.
On 1-9-25 at 4:00 pm the facility Administrator was asked for any investigation from 1-7-25 involving Residents #130, and #131.
On 1-10-25 at 5:00 pm Resident #130 was interviewed by surveyors and stated I feel as though I'm being targeted by a staff member. The Director of Nursing (DON) she don't like me and wants me out of here. She believes anything anyone tells her. He continued to say, Yes I smoke weed but not on the property and I use heroin sometimes, not a lot. The surveyor asked how do you use it, and he replied, I smoke it. The surveyor asked if he received it from someone in the facility. He replied, No I get it outside. He was asked where do you use it? His response was I use it at the bus stop, I go out almost every day. He was asked if he was caught by staff in the facility with drugs or alcohol, and he replied, No they said I was smoking weed in my room, but I won't. He was questioned about the accusations from his roommate, and he stated, I bought him cigarettes, I didn't touch that [NAME] I didn't ask him for no sex. He didn't give me money for the cigarettes he is a liar. They gave me a notice to leave but I got nowhere to go.
On 1-10-25, the Administrator delivered a 2-page document dated 1-10-25 entitled Facility Reported Incident (FRI), Date reported 1-10-25, and was signed by the current Administrator. The synopsis was a simple typed document on a clean white unlined sheet of copy paper, and did not state that it was an initial FRI, nor a 5 day follow up. The document described a portion of the incident of 1-7-25, and the fact that Resident #131 alleged that his roommate (Resident #130) had made sexual advances to him and had attempted to block the doorway to keep him (Resident #131) from leaving the room. This was the third time that the allegation of abuse was made to someone in the facility, and to others. The first being the day of the occurrence to staff witnesses, the second to APS who reported it to the facility, to police, and the state agency, and the third on this day 1-10-25.
The document reported that Resident #131 had moved Resident #130 out of the way and exited the room. The document included that Resident #131 stated again he was tired of his roommate (Resident #130) making sexual advances at him and he wanted to be out of that room. Resident #131 also stated he wanted to be discharged .
The Administrator documented on 1-10-25 that Resident #130 denied the allegation of sexual abuse, and that the facility had concluded that the allegation was unsubstantiated, and was first reported to them on this day. These assertions are incorrect as staff were aware and present on 1-7-25 when the abuse was alleged to have occurred and was first documented. Further the Resident stated to the Administrator (as written in the above portion of the Administrators document) that he was blocked from leaving by his roommate, he was tired of his roommate (Resident #130) making sexual advances at him and he wanted to be out of that room. Sexual abuse and sexual harassment are both crimes. By the facility staff's documentation, and own admission this was reported repeatedly to them, observed by floor baseline staff when it occurred, reported to APS by a complainant, and they continued to report it as unsubstantiated.
The facility Resident Protections from abuse policy failures included all of the following 4 areas;
1. The facility was expected to complete background checks on all employees to protect the Resident population from abuse, also training was to be conducted annually for staff. (Training)
2. The Abuse policy document also stated that Residents would be protected if an allegation of abuse was made, and the police involved if that allegation alleged that a crime had happened. (Protection)
3. The Abuse policy document also stated that a comprehensive investigation would be conducted. (Investigation)
4. The document further stated that the state agency and other stake holders would be notified within 24 hours of an allegation of abuse, and that the report would occur within 2 hours if injury occurred. Then the initial report would be followed by a five day follow up report which would be sent to the state agency after the facility investigated to reveal their findings. (Reporting)
The facility staff failed to conduct required education for staff, failed to complete background checks in compliance with regulations. The facility staff failed to report the allegation of abuse to the state agency until the state agency reported it to them again 3 days after the allegation was made to, and witnessed by, staff. Police were not called after an allegation that a crime had occurred which was requested by the Resident and his spouse, and a comprehensive investigation was not conducted until the state agency asked for one 3 days after the allegation of abuse was known by staff.
The facility Abuse policies were not implemented specifically involving and including the following evidence;
TRAINING failure: Protections from Abuse and other annual training records in the facility were reviewed and revealed that Certified Nursing Assistants (CNA's) 12 hours of required annual training was not completed for 4 of the 6 employees reviewed, and background checks for staff were also found to be deficient.
PROTECTION failure: Resident #131 was not afforded police intervention, he was protected by a room move, however, there were no other Resident interviews to ascertain if any other Residents in the building had ever experienced this abuse, and if from this abuser.
INVESTIGATION failure: None of the staff witnesses of the 1-7-25 incident were interviewed, nor were statements received, and Resident #4's previous and current roommates were not interviewed. The spouse of Resident #131 was not interviewed, and other Residents on the unit were not interviewed.
The FRI document stated that on 1-10-25 the first notification by the Resident was obtained. This was incorrect, as staff witnessed the incident partially, if not fully, and documented it. A witness to the incident called APS on 1-7-25.
The Resident was blockaded from leaving his room which was witnessed by staff, as he was told police would arrest him for pushing his aggressor, proving involuntary seclusion/kidnapping, and he screamed for help which resulted in staff intervention.
Further the Resident wanted a room change because of the allegation which was made by Resident #131 to staff.
The allegation of abuse was alleged by a witness to APS, alleged by the Resident's spouse, alleged by the Resident, and by Administration in their synopsis/FRI (facility reported incident) to the state agency on 1-10-25.
The 1-10-25 initial facility document does not include many of the avenues that were available to the facility for a complete investigation, and thus they were unable to reach a more comprehensive conclusion of events.
Initial REPORTING failure: The 1-10-25 FRI document was the first report by the facility after the allegation of a sexual abuse that facility staff were made aware of on 1-7-25. This document was derived on 1-10-25 only after surveyors requested documentation of it, and 3 days after the abuse occurred.
Any allegation of abuse is mandated to be reported within 24 hours if no serious injury occurred to the state agency (VDH/OLC) Virginia Department of Health/Office of Licensure and Certification. The Department of Social Services office of Adult protective Services (APS) were not notified by the facility, and the police were not called by the facility as was requested by Resident #131 and his spouse on the day of the occurrence.
INVESTIGATION follow up RESULTS failure: The 5-day mandated follow up reporting after a full investigation; The Administrator's synopsis on 1-10-25 alleges that the abuse was unsubstantiated. A review of all the above evidence by the state agency reveals it to be substantiated, in part, or in all. A police investigation would have been appropriate in this case, as both Residents were alert, and oriented to person, place, time, and situation, however, this was not afforded to Resident #131.
On 1-10-25 Two nursing staff members spoke to surveyors on agreement of anonymity as they feared retaliation if it were known that they had spoken to surveyors. The two Nursing staff members worked on the units where Residents #131, and #130 were housed and both agreed that Resident #130 bought cigarettes for Resident #131, however, they stated that they had never known of a problem with that as no one complained about it, and they agreed that Resident #131 always went outside to smoke and had not created an issue. One was an agency nurse who worked in the facility, and one was a facility employee. Both stated they were aware of the incident involving Residents #130, and #131, and stated they wondered when the situation would blow up because Resident #130 was obviously grooming and pursuing Resident #131 (name), with the cigarettes, and Resident #131 (name) was married. The nurses were asked if the Administration was aware and they both stated yeah they knew, we all knew.
During interview on 1-29-25 and review of the clinical record, it was found that the Social Worker had only been there a short time, however, was aware of the incident with Resident's #131, and #130. She stated that Resident #131 (name) had been discharged on 1-23-25 to a group home in (name) closer to family a near by county. She also stated that Resident #130 would be discharging on 1-29-25 to a different group home closer to the facility.
At that time the Administrator was informed that the investigation was incomplete, and no FRI was ever received at the state agency VDH/OLC for the first allegation of abuse. She was further notified they had not implemented their policies on abuse.
The allegations were never reported to the state agency until the day after surveyors asked for an investigation. Residents were not protected from a known abuser. Abuse was not investigated fully, and the facility policy was not implemented for the protections of Residents from abuse. Further, there was never any added staff supervision for Resident #130 to prevent the abuse from continuing with another Resident.
No staff ever reported the suspicion of a crime, and no police report was ever filed. The first alleged report by the Administrator was incomplete and had errors in information giving the appearance of a verbal altercation and that the victim was not touched. APS, was not notified of the alleged abuse by facility Administration, and was instead notified by a complainant resulting in an investigation being opened by the state agency.
On 1-30-25 at approximately 4:00 p.m., the facility Administrator, Corporate Registered Nurse, and DON were notified of the findings. They stated they had no further information or documentation to offer.
The facility's staff failed to report allegations of abuse or self-harm within a timely manner for Resident #7.
2. Resident #7 while in psychosis and having suicidal ideation was admitted to the hospital was found to have a switch blade in her bedside table on 1/26/25, on the same day was re-admitted to the facility on [DATE]. The facility staff failed to report the above allegation within the required time frame of 2 hours to the State Survey Agency. Resident #7 was originally admitted to the facility 12/04/23 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Schizoaffective Disorder and Bipolar Disorder Unspecified.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/16/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #7 cognitive abilities for daily decision making were intact.
In sectionG(Functional Status) the resident was coded as requiring supervision of one person with transfers, bed mobility, eating and toileting.
The Care Plan dated 12/05/23 read that Resident #7 has a mood problem related to: schizoaffective disorder, depression, anxiety and bipolar disorder. The resident has a
history of hospitalization through suicidal ideation. The goal for the resident was that the resident will have improved mood state through the next review date. Interventions for the resident are to monitor medications as ordered and Behavioral consults as needed.
During the initial tour an interview was conducted to Resident #7 concerning hospitalizations. Resident #7 said that she went to the hospital recently for having a cough but was recently admitted back to the facility.
A change of condition note dated on 01/26/2025 at 5:34 PM., Resident alerted writer that she was actively SI (Suicidal Ideation) with plan to cut herself. Resident admitted to having switchblade in her bedside drawer. Writer entered residents' room to find carpenter knife in her top drawer on the right-hand side. Resident states the staff put it in her drawer. Writer notified provider on call, resident refused to take any medications at this time, stating I need to go to the hospital if you don't call 911 I will. Writer informed provider of this who advised writer to send her to the ER for further evaluation. 911 called, charge nurse notified, residents POA contacted with no answer, will try to call again. VSS 137/69, 18RR, 97.6T, 70HR, 96%RA. Resident is A&OX3.
An interview was conducted on 02/05/25 at approximately 2:57 PM., with Licensed Practical Nurse (LPN) H. LPN H said that while working the 3-11 shift, Resident #7 said that she was feeling suicidal, wanted to go to the hospital and was going to use the switch blade in top drawer on the right side of her bed. LPN H also said that she grabbed the weapon the knife and the resident told her to hurry up and call the police. LPN H said that the police confiscated the weapon from her.
On 02/05/25 at approximately 2:28 PM., an interview was conducted with LPN J concerning Resident #7. LPN J said that she was called up stairs by the facility staff informing her that Resident #7 had a Swiss knife. LPN J said that once she saw the Swiss knife it looked like something a [NAME] would use to clean fish, it had a wine cork remover, a screwdriver and a nail file attached to it. Once I came upstairs and entered the resident's room, she informed me that it (Swiss knife) was in her drawer, but the nurse had informed me that she took it. resident said that she wanted to kill herself. the resident was sent out for psych eval. she told EMTS that it was in her drawer.
On 2/04/25 at approximately 4:20 PM., an end of day meeting was conducted with Administrator, the Director of Nursing (DON)., the Regional/Corporate staff, Regional Risk Management, the Regional Nurse Consultant and with the [NAME] President of Clinical Services concerning Resident #7. They were asked if an incident report or facility synopsis had been documented concerning the above incident involving a knife. The Administrator said that no facility synopsis had been filed but a soft file should have been completed instead. The administrator also mentioned that witnessed statements were received today as well as staff interviews. The above staff were also asked if death or harm could have been caused if the resident had used the Swiss Knife to cut herself. No comments were made.
Swiss Army knife
The Swiss Army knife is a pocketknife, generally multi-tooled. The term Swiss Army knife was coined by American soldiers after World War II because they had trouble pronouncing the German word Offiziersmesser, meaning officer's knife. The Swiss Army knife generally has a drop-point main blade plus other types of blades and tools, such as a screwdriver, a can opener, a saw blade, a pair of scissors, and many others. These are folded into the handle of the knife through a pivot point mechanism. https://en.wikipedia.org/wiki/Swiss_Army_knife.
3. Resident #39. The facility staff failed to report allegations of abuse in a timely manner to the State Survey Agency after resident alleged being physically abused by a staff member. Resident #39 was originally admitted to the facility 11/09/23 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Depression, Unspecified.
The 5-day Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/17/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #39 cognitive abilities for daily decision making were moderately impaired.
In sectionGG(Functional Abilities Goals) the resident was coded as requiring partial/moderate assistance with eating, oral hygiene. Resident coded as dependent in lower body dressing, personal hygiene and rolling left and right.
The care plan dated 11/22/23 read that Resident #39 had an Activities of Daily Living (ADL) self-care performance deficit related to multiple sclerosis, rheumatoid arthritis, spinalstenosis, right foot drop, morbid obesity, osteoarthritis, bilateral hand contractures and personality disorder. The Goal was to have the resident participate in as much of her ADL care as possible. The intervention for the resident requires total dependance by 2 staff members for toileting and requires max assist to total dependance by 2 staff members for bed mobility, transfers and one person assist for mobility in wheelchair.
A review of a nursing note dated 2/04/25 at 12:33 PM., read: State surveyors question this writer about concerns that resident stating that there was an incident with a cna handling her roughly during incontinent care, when this writer spoke with resident concerning this incident, resident denied speaking to surveyor about incident, stating it never happened.
Progress note on 2/05/25 at 12 Midnight: Patient with h/o depression, on no psychotropics. She was seen on 9.18.24 and no change was made to her treatment regimen. She is being seen today at the staff request because she reported to the department of health that a CNA was rough with her during care in early 2024. She is found in bed today; she is alert, calm and pleasant. She says she is doing well. She says this incident took place in April 2024. She says a CNA who was caring for her pushed her too far towards the wall. She felt this person was too rough with me. She says she reported this to the unit manager immediately and this individual never cared for her again. She says she also reported this to the VDH because she felt she needed they needed to know. She says she is surprised it took until today for someone from the VDH to come see her. She says she was told this CNA is no longer here but the reason for her living is not related to her incident with her. She says nothing like that happened to her ever again and she feels safe here.
A review of Facility Reported Synopsis dated 2/05/25 read that Resident #39 alleged she was handled roughly by staff during incontinent care. The incident occurred April or May of 2024. The alleged staff member is no longer employed with the facility.
On 01/28/25 at approximately 3:48 PM., during the initial tour Resident #39 alleged that a Certified Nurses Aide was rough with her while turning her onto her side to provide incontinent care.
On 2/05/25 at approximately 7:00 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant.
The Abuse/Neglect/Misappropriation/Crime Policy reads dated 10/17/23 reads: There is zero tolerance for abuse, neglect, misappropriation of property, or any crime against a patient of the Health and Rehabilitation Center. Procedure: Any suspected or witnessed incidents of patient abuse, neglect, theft against a patient should be reported to the administration, an internal investigation conducted, appropriate and timely reporting to the State Survey Agency and other legally designated agencies, as well as staff corrective action, suspension, and/or termination as necessary. Failure for an employee to report any suspected or witnessed incident of mistreatment, abuse, neglect against a patient will result in corrective action. Immediately upon notification of any alleged violations involving, abuse, neglect or exploitation the administrator will immediately report to the [TRUNCATED]
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the fac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff failed to investigate an allegation of abuse fully for 2 Residents (Residents #131, and #130) in a survey sample size of 63 residents.
The findings included:
1. The facility failures described above resulted in the sexual abuse/harassment of Resident #131 by Resident #130.
Resident #131 (victim) was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Traumatic Brain Injury (TBI) after a motor vehicle accident, diplopia, muscle weakness, unsteadiness on feet, abnormal gait and mobility, wheelchair use, and cognitive communication deficit, although there was no communication deficit noted at the time of survey.
Resident #131's most recent Minimum Data Set with an Assessment Reference Date of 1-23-25 was coded as a discharge assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicates no cognitive impairment. The Resident was cognitively intact, and his own responsible party. The Resident required touch assistance from one staff member for transferring and was wheelchair bound at times and was able to stand or walk independently for short distances. He required set up or touch assistance only with hygiene and bathing. The Resident denied complaints against any other staff or Residents since his admission on [DATE]. The Resident was discharged to a group home on 1-23-25 to be closer to family and to the least restrictive environment.
Resident #130 (aggressor of victim #131) was admitted to the facility on [DATE]. Hospital discharge records indicated that the Resident was alert and oriented to person, place and time, and was ambulatory. Diagnoses included but were not limited to: Major depressive disorder, recurrent anxiety, Chronic hepatitis C, type two diabetes, nicotine dependence, fractured left heel with infected wound sepsis due to Methicillin Susceptible Staphylococcus Aureus, enhanced barrier precautions, and history of infectious parasitic disease.
Resident #130's most recent Minimum Data Set with an Assessment Reference Date of 12-17-24 was coded as a significant change assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicated no cognitive impairment. The Resident was his own responsible party. The Resident required partial to moderate assistance from one staff member for hygiene and bathing. Resident #130 was observed during survey as ambulating without assistance or device.
Resident #130 went out of the facility daily using the public city bus transportation and repeatedly returned under the influence of drugs and alcohol. Instances of this were recorded in the nursing progress notes to include the following most recent to survey.
9-19-24 6:43 am Resident room noted with a strong odor of weeds [sic] by (Certified Nursing Assistant) CNA, nurse and CNA went in to ask resident, resident confirmed he has been smoking weed, we asked him to turn it over, he declined, resident educated about the implication of that, he was told his action will be reported to management. Describe any interventions attempted: Resident told he will be reported to management Effectiveness of Interventions: Resident will continue to be monitored.
12-20-24 7:24 a.m. (documentation time). Note Text: 4:10 am (time of actual observation) Writer notified of patient lethargic in dining room. Writer into dining room, patient seen with his head (laid backward supine fashion) behind wheelchair, lethargic and hard to arouse. Obtained vitals at 4:13 am 65/40, 56, 16, 100% RA (oxygen saturation on room air alone), BS 140 (blood sugar). Called resident several times, he responded and said, I'm high as a bitch. Writer asked resident several times what he had taken, he refused to say. 911 called made per his nurse. 911 into building. Assessed patient, resident remained with a low BP and heart rate. EMTs encouraged resident to go to hospital. Resident refused. Educated the resident on the importance of going to the hospital to monitor low BP and heart rate, resident continued to refuse. Multiple nurses from units educated the patient on the importance of his health. Encouraged resident to go with EMT to be seen at hospital. Resident then became aggressive saying he wasn't going to the hospital because there was nothing wrong with him. EMTs left building. Writer and nurse attempted to take resident to his room, he refused. Resident remained in dining room area.
MD (physician) note - 12-20-24 - [Resident #130 name redacted] was found asleep in in his wheelchair. He reported that he was high. He was difficult to arouse, BPs were in the 60-70s systolic. EMS was called. Upon arrival his BP was still low, but he refused to go the hospital. He is at baseline this morning when I see him. All reports reviewed and spoke with staff about the incident. I am holding his BP meds over the weekend. No reports of fever, chills, chest pain, shortness of breath, nausea, vomiting, or diarrhea. '
1-3-25 - 10:22 pm. Note Text: Nurse went to resident door, there was strong smell of weed in room, coming right to the hallway. Nurse supervisor notified.
A review of Resident #130's care plan revealed the following entry regarding the use of illicit drugs and or alcohol:
FOCUS: The Resident is at risk of complications due to a history of illicit drug use. Revision on: 12-16-24.
GOAL: The Resident will not have any adverse reaction to alcoholism thru review period. Date Initiated: 12-16-2024. Target Date: 3-16-25.
INTERVENTIONS: (3)
1. Observe Resident for signs and symptoms of intoxication or withdrawal from drugs such as tremors nausea/vomiting (severe) sweating and notify MD (doctor) as indicated. Date Initiated: 12-16-2024.
2. Administer medication as ordered. Date Initiated: 12-16-2024.
3. Vitals as needed. Date Initiated: 12-16-2024.
On 1-7-25 at 11:14 am nursing progress notes documented Verbal spat with roommate .both parties speaking in elevated tones, no physical contact noted both parties separated.
On 1-7-25 at 12:23 pm Resident #15 agreed to a room change, and his spouse was notified. Adult Protective Services (APS) was called by an anonymous caller at the facility and the incident of sexual abuse was reported to them. The caller stated in the APS report of 1-7-25 that the facility Administration did not notify police, and they (the Administration) stated the reason as that can't happen (because) is that Resident (Resident #131 victim) would be charged with assault for pushing Resident (#130 aggressor) out of the doorway so that Resident (#131) could escape.
This note indicated that there was physical contact known by staff at the time which was denied in the 1-7-25 nursing note.
It was also alleged by the caller to APS that Resident #130 had been making sexual advances toward Resident #131 and wanted to get in his pants. It was also alleged that Resident #131 was asked by facility staff Why can't you just go home? The caller went on to state that Resident #131 had been moved 4 times for different assaults, verbal and such, but this was the only sexual assault. This assertion of frequent moves was found to be true as Resident #131's census in the facility documented those moves.
The APS caller stated that on this day (1-7-25) the situation escalated and Resident #130 blocked the door of the room and told Resident #131 you are going to let me F K you. The caller stated that Resident #130 proceeded to touch, molest, and sexually assault Resident #131 who began yelling and screaming, and pushed Resident #130 out of the doorway into the hallway to escape when staff came to see what the commotion was about. Resident #131 told them immediately what had happened.
On 1-9-25 at 1:00 pm an interview was conducted with LPN A who stated that they are aware of the Residents going out on LOA (Leave of Absence) and coming back high, also stating but we cannot be with them at all times and cannot stop them leaving the facility. When asked what is done if they catch them smoking or drinking or using drugs in the facility, she stated, We document in the chart, notify the supervisor and educate them, that is all we can really do. When asked if the care plan should reflect the behaviors and interventions, she stated that it should.
On 1-9-25 (the second day of survey) at 3:00 pm, Resident #130 was interviewed during an investigation involving Resident drug, alcohol, and weapons abuses that were found to be actively occurring in the facility. This Resident was found to be involved in drug abuse while a Resident. The Resident was asked about an altercation with his roommate which was documented in the nursing progress notes as having occurred on 1-7-25. Resident #130 stated he bought Resident #131 cigarettes and Resident #131 refused to pay him for them. He stated he had indeed used drugs but not in the facility, only outside. This statement was found to be false as staff stated they had removed drugs and drug paraphernalia from his room, and documented that at 4:00 AM on 12-20-24 the Resident was found in the dining room after using drugs in the facility, and was also using in the facility on 9-19-24, and 1-3-25.
On 1-9-25 at 3:30 pm, Resident #131 in person, and his spouse by phone were interviewed. They both stated that Resident #130 had made advances toward Resident #131, however, Resident #131 stated he made it Clear that I am straight, married, and got no interest in no [NAME]. Resident #131 stated he would ask me to dress in front of him to see my chest, and I didn't care about that, because he said he would get me some cigarettes, but when he cornered me in the room and wouldn't let me leave the room and grabbed my D k and said I'm gonna F k you in the A , that was it! I screamed for help and pushed him through the door and the nurses almost got knocked down coming in, they heard it all just ask them. Resident #131 stated the temp agency nurse (name) and the other nurse who works here all the time (name) came. Resident #131 stated He (#130 name) and (Resident #106 name) smoke stuff in the room and have overdosed sometimes. I just want out of here. Resident #131 was asked if he had reported the sexual abuse, and he stated I told the nurses, they saw it happen! I told the Administrator who said I would be arrested for pushing him if I called the police, and I've told everybody, but they just moved me to another room.
On 1-9-25 A copy of all Facility Reported Incidents (FRI's) for the prior 6 months were requested. 9 were provided by the Administrator, and all 9 followed the standardized format and documentation included notification of the state agency the Virginia Department of Health Office of Licensure and Certification (VDH/OLC), the state Long Term Care Ombudsman, and Adult Protective Services (APS). The 9 completed FRI's were all prior to 9-20-24.
On 1-9-25 at 4:00 pm the facility Administrator was asked for any investigation from 1-7-25 involving Residents #130, and #131.
On 1-10-25 at 5:00 pm Resident #130 was interviewed by surveyors and stated I feel as though I'm being targeted by a staff member. The Director of Nursing (DON) she don't like me and wants me out of here. She believes anything anyone tells her. He continued to say, Yes I smoke weed but not on the property and I use heroin sometimes, not a lot. The surveyor asked how do you use it, and he replied, I smoke it. The surveyor asked if he received it from someone in the facility. He replied, No I get it outside. He was asked where do you use it? His response was I use it at the bus stop, I go out almost every day. He was asked if he was caught by staff in the facility with drugs or alcohol, and he replied, No they said I was smoking weed in my room, but I won't. He was questioned about the accusations from his roommate, and he stated, I bought him cigarettes, I didn't touch that [NAME] I didn't ask him for no sex. He didn't give me money for the cigarettes he is a liar. They gave me a notice to leave but I got nowhere to go.
On 1-10-25 The Administrator delivered a 2-page document dated 1-10-25 entitled Facility Reported Incident (FRI), Date reported 1-10-25, and was signed by the current Administrator. The synopsis was a simple typed document on a clean white unlined sheet of copy paper, and did not state that it was an initial FRI, nor a 5 day follow up. The document described a portion of the incident of 1-7-25, and the fact that Resident #131 alleged that his roommate (Resident #130) had made sexual advances to him and had attempted to block the doorway to keep him (Resident #131) from leaving the room. This was the third time that the allegation of abuse was made to someone in the facility, and to others. The first being the day of the occurrence to staff witnesses, the second to APS who reported it to the facility, to police, and the state agency, and the third on this day 1-10-25.
The document reported that Resident #131 had moved Resident #130 out of the way and exited the room. The document included that Resident #131 stated again he was tired of his roommate (Resident #130) making sexual advances at him and he wanted to be out of that room. Resident #131 also stated he wanted to be discharged .
The Administrator documented on 1-10-25 that Resident #130 denied the allegation of sexual abuse, and that the facility had concluded that the allegation was unsubstantiated, and was first reported to them on this day. These assertions are incorrect as staff were aware and present on 1-7-25 when the abuse was alleged to have occurred and was first documented. Further the Resident stated to the Administrator (as written in the above portion of the Administrators document) that he was blocked from leaving by his roommate, he was tired of his roommate (Resident #130) making sexual advances at him and he wanted to be out of that room. Sexual abuse and sexual harassment are both crimes. By the facility staff's documentation, and own admission this was reported repeatedly to them, observed by floor baseline staff when it occurred, reported to APS by a complainant, and they continued to report it as unsubstantiated.
The facility Resident Protections from abuse policy failures included all of the following 4 areas;
1. The facility was expected to complete background checks on all employees to protect the Resident population from abuse, also training was to be conducted annually for staff. (Training)
2. The Abuse policy document also stated that Residents would be protected if an allegation of abuse was made, and the police involved if that allegation alleged that a crime had happened. (Protection)
3. The Abuse policy document also stated that a comprehensive investigation would be conducted. (Investigation)
4. The document further stated that the state agency and other stake holders would be notified within 24 hours of an allegation of abuse, and that the report would occur within 2 hours if injury occurred. Then the initial report would be followed by a five day follow up report which would be sent to the state agency after the facility investigated to reveal their findings. (Reporting)
The facility staff failed to conduct required education for staff, failed to complete background checks in compliance with regulations. The facility staff failed to report the allegation of abuse to the state agency until the state agency reported it to them again 3 days after the allegation was made to, and witnessed by, staff. Police were not called after an allegation that a crime had occurred which was requested by the Resident and his spouse, and a comprehensive investigation was not conducted until the state agency asked for one 3 days after the allegation of abuse was known by staff
The facility Abuse policies were not implemented specifically involving and including the following evidence;
TRAINING failure: Protections from Abuse and other annual training records in the facility were reviewed and revealed that Certified Nursing Assistants (CNA's) 12 hours of required annual training was not completed for 4 of the 6 employees reviewed, and background checks for staff were also found to be deficient.
PROTECTION failure: Resident #131 was not afforded police intervention, he was protected by a room move, however, there were no other Resident interviews to ascertain if any other Residents in the building had ever experienced this abuse, and if from this abuser.
INVESTIGATION failure: None of the staff witnesses of the 1-7-25 incident were interviewed, nor were statements received, and Resident #4's previous and current roommates were not interviewed. The spouse of Resident #131 was not interviewed, and other Residents on the unit were not interviewed.
The FRI document stated that on 1-10-25 the first notification by the Resident was obtained. This was incorrect, as staff witnessed the incident partially, if not fully, and documented it. A witness to the incident called APS on 1-7-25.
The Resident was blockaded from leaving his room which was witnessed by staff, as he was told police would arrest him for pushing his aggressor, proving involuntary seclusion/kidnapping, and he screamed for help which resulted in staff intervention.
Further the Resident wanted a room change because of the allegation which was made by Resident #131 to staff.
The allegation of abuse was alleged by a witness to APS, alleged by the Resident's spouse, alleged by the Resident, and by Administration in their synopsis/FRI (facility reported incident) to the state agency on 1-10-25.
The 1-10-25 initial facility document does not include many of the avenues that were available to the facility for a complete investigation, and thus they were unable to reach a more comprehensive conclusion of events.
Initial REPORTING failure: The 1-10-25 FRI document was the first report by the facility after the allegation of a sexual abuse that facility staff were made aware of on 1-7-25. This document was derived on 1-10-25 only after surveyors requested documentation of it, and 3 days after the abuse occurred.
Any allegation of abuse is mandated to be reported within 24 hours if no serious injury occurred to the state agency (VDH/OLC) Virginia Department of Health/Office of Licensure and Certification. The Department of Social Services office of Adult protective Services (APS) were not notified by the facility, and the police were not called by the facility as was requested by Resident #131 and his spouse on the day of the occurrence.
INVESTIGATION follow up RESULTS failure: The 5-day mandated follow up reporting after a full investigation; The Administrator's synopsis on 1-10-25 alleges that the abuse was unsubstantiated. A review of all the above evidence by the state agency reveals it to be substantiated, in part, or in all. A police investigation would have been appropriate in this case, as both Residents were alert, and oriented to person, place, time, and situation, however, this was not afforded to Resident #131.
On 1-10-25 Two nursing staff members spoke to surveyors on agreement of anonymity as they feared retaliation if it were known that they had spoken to surveyors. The two Nursing staff members worked on the units where Residents #131, and #130 were housed and both agreed that Resident #130 bought cigarettes for Resident #131, however, they stated that they had never known of a problem with that as no one complained about it, and they agreed that Resident #131 always went outside to smoke and had not created an issue. One was an agency nurse who worked in the facility, and one was a facility employee. Both stated they were aware of the incident involving Residents #130, and #131, and stated they wondered when the situation would blow up because Resident #130 was obviously grooming and pursuing Resident #131 (name), with the cigarettes, and Resident #131 (name) was married. The nurses were asked if the Administration was aware and they both stated yeah they knew, we all knew.
During interview on 1-29-25 and review of the clinical record, it was found that the Social Worker had only been there a short time, however, was aware of the incident with Resident's #131, and #130. She stated that Resident #131 (name) had been discharged on 1-23-25 to a group home in (name) closer to family a near by county. She also stated that Resident #130 would be discharging on 1-29-25 to a different group home closer to the facility.
At that time the Administrator was informed that the investigation was incomplete, and no FRI was ever received at the state agency VDH/OLC for the first allegation of abuse. She was further notified they had not implemented their policies on abuse.
The allegations were never reported to the state agency until the day after surveyors asked for an investigation. Residents were not protected from a known abuser. Abuse was not investigated fully, and the facility policy was not implemented for the protections of Residents from abuse. Further, there was never any added staff supervision for Resident #130 to prevent the abuse from continuing with another Resident.
No staff ever reported the suspicion of a crime, and no police report was ever filed. The first alleged report by the Administrator was incomplete and had errors in information giving the appearance of a verbal altercation and that the victim was not touched. APS, was not notified of the alleged abuse by facility Administration, and was instead notified by a complainant resulting in an investigation being opened by the state agency.
On 1-30-25 at approximately 4:00 p.m., the facility Administrator, Corporate Registered Nurse, and DON were notified of the findings. They stated they had no further information or documentation to offer.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the resident record review, staff interviews and a review of facility documents, the facility staff failed to notify th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the resident record review, staff interviews and a review of facility documents, the facility staff failed to notify the Office of the State Long-Term Care Ombudsman in writing of a hospital discharge for 1 of 63 residents (Resident #50), in the survey sample.
The findings included:
Resident #50 was originally admitted to the facility 10/27/2016 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included a stroke with right hemiparesis and expressive aphasia.
The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/22/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 10 out of a possible 15. This indicated Resident #50's cognitive abilities for daily decision making were moderately impaired.
A nurses' note dated 11/10/24 at 3:36 AM stated the resident was observed with a large amount of dark bloody liquid coming from his rectum and the resident complained of lower abdominal pain that radiated to the groin area. The note further stated the on-call Practitioner was notified and an order was received to transfer the resident to the emergency room by ambulance. Another nurse's note dated 11/10/24 at 12:07 PM stated the resident was admitted to the local hospital with a diagnosis of a GI Bleed.
An interview was conducted with the Social Services Director (SSD) on 2/5/25 at approximately 3:30 PM. The SSD stated there was no documentation that the Office of the State Long-Term Care Ombudsman was notified of Resident #50's 11/10/24 discharge to the hospital. The SSD stated she had faxed the information after ours interview and conformation would be provided as soon as it was available.
On 2/5/25 at approximately 4:20 PM, a final interview was conducted with the Administrator, Director of Nursing and four Corporate Consultants. The administrative team was informed of the above information. No additional information was provided and no concerns were voiced.
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
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 and clinical record review, the facility staff failed to ensure an accurate minimum data set (MDS) asse...
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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 an accurate minimum data set (MDS) assessment for 1 of 63 residents in the survey sample (Resident # 139), a closed record resident.
The findings include:
Resident #139 was originally admitted to the facility 11/27/24 after an acute care hospital stay. The resident had an unplanned discharged from the facility on 12/01/24. The current diagnoses included; Chronic Pain Syndrome and Unspecified Fracture of the Lower end of Left Radius, Subsequent Encounter for Closed Fracture with Routine Healing. The 5-day, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/01/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #139 cognitive abilities for daily decision making were intact.
Resident # 139's MDS dated [DATE] coded the resident as being admitted to the hospital instead of coding that resident was discharged to the community.
The current diagnoses included; Chronic Pain Syndrome and Unspecified Fracture of the Lower end of Left Radius, Subsequent Encounter for Closed Fracture with Routine Healing.
A review of nursing notes on 12/1/2024 9:09 PM., read: Resident left AMA.
A review of the clinical record documented a MDS dated [DATE]. Coded section A2105 as short-term going to the hospital.
On 2/05/25 at approximately 11:25 AM., an interview was conducted with the MDS Coordinator (MDS) N, concerning The Centers for Medicare & Medicaid Services. (CMS) generated Hospital discharge. The MDS N said that the resident's 12/01/24 discharge says she was discharged to a hospital, but according to the medical records the resident left Against Medical Advice (AMA). The MDS N, also said that according to the progress notes, it looks like an inaccurate assessment.
On 2/05/25 at approximately 12:20 PM., The MDS, N returned saying that according to the medical records, the resident was coded in error that Resident #139 went to the hospital.
(1)Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.18.11, Centers for Medicare & Medicaid Services, Revised October 2023.
On 2/05/25 at approximately 7:00 PM., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review and staff interview, the facility staff failed to ensure a Pre-admission Screening ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review and staff interview, the facility staff failed to ensure a Pre-admission Screening and Resident Review (PASARR) was completed prior to admission for 4 Residents (Residents #3, #32, #59, and #132) in a sample of 63 residents.
The Findings included:
1. Resident #3 was admitted on [DATE] with diagnoses including: Bipolar Disorder, Anxiety, and Dementia.
Physicians orders for medications were reviewed and revealed psychotropic medications actively being administered for those diagnoses.
On 1-30-25, an observation was conducted of Resident #3. The Resident was sitting in her room in a wheel chair and talked with the surveyor who had entered the room and addressed her in a greeting, while attempting conversation and interview. The Resident was also talking to herself with questions and answers to an apparent inner monolog with herself.
On 1-30-25 a review of Resident #3's clinical record was conducted. No previous to Long Term Care Skilled Nursing (after acute hospitalization) admission PASARR (preadmission screening & resident review) had been completed. The PASARR assesses for mental illness or intellectual disability needs prior to admission, and none were found in the Electronic Health Record (EHR). Facility staff were asked to locate any previous PASARR documents, and they stated none had been completed for this admission.
On 1-31-25 the new social worker delivered a medicaid Assisted Living Annual Reassessment document dated 8-28-19, and stated this is all we have. Imbedded in the document was a DMAS-96 (Department of Medical Assistant Services) completed PASARR II document for the Resident, however there were errors and the document was incomplete. No previous or current PASARR I was found.
It is notable to mention that the employee records review revealed no social worker in the building for months, and on 2 different occasions in the past year. The new Social worker (#3 in the past year) had just recently begun and was interviewed on 1-30-25 and 1-31-25. She revealed that the former Social worker resigned and had been there only a short while, and that the social worker before that had only been in the position for a short while. This indicates a lack of oversight in meeting the needs of Residents to include preadmission screenings.
On 1-31-25 the Social worker's license and curriculum vitae were requested for verification and vetting as part of the employee records review for competency of staff. It was noted that the required course work and degree required by state and federal regulation for this employee was sufficient for the role.
The Administrator and Director of Nursing were informed of the findings at the end of day meeting on 1-31-25. The Administrator stated, we will correct this immediately and indicated they would be auditing residents' PASARR's. No further documents were provided.
2. For Resident # 32, facility staff failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed prior to admission.
Resident # 32 was admitted on [DATE] with diagnoses including but not limited to: Bipolar Disorder, Diabetes, Amputation of Right lower leg, End Stage Renal Disease, Dialysis, and Atrial Fibrillation.
Resident #32's most recent MDS (Minimum Data Set) was a Quarterly Assessment with an ARD (Assessment Reference Date) of 1/10/2025 coded the Resident as having a BIMS (Brief Interview of Mental Status) score of 15 out of 15 indicating no cognitive impairment.
Review of the clinical record revealed that Resident #32 did not have a PASARR level 1 completed prior to admission to the facility from the acute care hospital.
Physicians orders for medications were reviewed and revealed the following psychotropic medications actively being administered and ongoing behavior monitoring:
Duloxetine HCL (Hydrochloride) Capsule Delayed Release Particles 20 milligrams Give 1 capsule by mouth
Further review of Resident # 32's clinical record was conducted on 1/30/2025. No previous to admission PASARR (preadmission screening & resident review) for mental illness or intellectual disability was found in the Electronic Health Record. Facility staff were asked to locate any previous PASARR documents, and they stated none had been completed prior to that date. A copy of the facility's policy was requested and received.
The PASARR Policy stated the following on Pg. 2 Paragraph 4:
Relationship Between LTSS and PASARR
1)
Prior to an individual's admission, the Social Worker, Admissions Coordinator, or designee will review the completed screening forms via e-PAS and obtain a copy for placement in the electronic medical record.
i)
Nursing Facilities shall not accept paper screening forms as proof that admission criteria have been met and documented.
2)
Because the PASRR screening is coupled with the LTSS Screening for Medicaid program, the screening team responsible for conducting the PASRR screening prior to admission is determined by who is required to complete the LTSS Screening
a)
Prior to admission (hospital- inpatient, community-residing in community/Assisted Living)
i)
Already Medicaid members
ii)
Financially eligible by way of application as verified by the ePAS system
b)
Nursing Facility
i)
Medicare
ii)
Private Pay
On 2/3/2025 at approximately 1:00 p.m., an interview was conducted with the Social Worker who stated that she was a new employee who was hired on 1/6/2025. She stated was aware that PASARRs should be done prior to admission and that it should have been done prior to the resident's admission. The Social Worker stated she would check the clinical record of Resident # 32 for any documentation of a PASARR being done prior to admission.
On 2/4/2025 at approximately 2:15 p.m., an interview was conducted with the Director of Nursing (DON) who stated that PASARRs should be completed prior to admission to the facility.
On 2/4/2025 at 3:30 p.m., the Social Worker reported that she found no documentation that a PASARR was done on Resident # 32 prior to admission.
On 2/4/2025 during the end of day meeting, the Administrator, Corporate Nurse Consultants and Director of Nursing were made aware of the findings.
No further information was provided.
2. For Resident #59 the facility staff failed to ensure that a PASARR (Pre-admission Screening and Resident Review) was conducted prior to admission to the facility, and none has been done since his admission on [DATE].
Resident #59 was admitted to the facility on [DATE] with diagnoses that included but were not limited to diabetes, PTSD (Post Traumatic Stress Disorder), benign prostatic hyperplasia, major depressive disorder, hemiplegia following a cerebral infarction, mood disorder due to known physiological condition, hearing loss and blindness in one eye.
Resident #59's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/27/24 coded Resident #59 as having a BIMS (Brief Interview of Mental Status Score) of 10 / 15, indicating severe cognitive impairment.
Resident #59's clinical record revealed that he had orders for medications that included:
Paxil 20 mg every day [an anti-depressant]
Divalproex Sodium 125 mg every 12 hours related to mood disorder
On 2/5/25 at approximately 1:00 p.m., an interview was conducted with the Director of Social Services [Employee D] who stated that she was aware that PASARRs should be done prior to admission. She stated that if the PASARR was not done prior to admission, she would complete them once the residents were admitted to the facility. She stated that she had only been at the facility for 1 month now and was not aware that this Resident did not have a completed PASARR.
On 2/5/25 at approximately 2:15 p.m., an interview was conducted with the Director of Nursing (DON) and the Administrator who stated that PASARRs should be completed prior to admission to the facility.
A review of the PASARR Policy revealed the following excerpt:
PASARR Policy
Pg. 2 Paragraph 4
Relationship Between LTSS and PASARR
1)
Prior to an individual's admission the Social Worker , Admissions Coordinator, or designee will review the completed screening forms via e-PAS and obtain a copy for placement in the electronic medical record.
i)
Nursing Facilities shall not accept paper screening forms as proof that admission criteria have been met and documented.
2)
Because the PASRR screening is coupled with the LTSS Screening for Medicaid program, the screening team responsible for conducting the PASRR screening prior to admission is de-determined by who is required to complete the LTSS Screening
a)
Prior to admission (hospital- inpatient, community residing in community / Assisted Living)
i)
Already Medicaid members
ii)
Financially eligible by way of application as verified by the ePAS system
b)
Nursing Facility
i)
Medicare
ii)
Private Pay
On 12/18/2024 during the end of day meeting, the Administrator and Director of Nursing were made aware of the issues and no further information was provided.
4. The facility staff failed to obtain or complete a Preadmission Screening and Resident Review (PASRR) Level I for Resident #132.
Resident #132 was originally admitted to the facility 9/23/24. The resident's diagnoses included acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, schizoaffective disorder, and essential hypertension.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/30/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 10 out of a possible 15. This indicated Resident #132's cognitive abilities for daily decision making were moderately impaired.
An interview was conducted on 2/4/25 at 3:08 PM with the Director of Social Services. The Director of Social Services stated that the facility does not have a PASRR level I for Resident #132. The Director of Social Services also stated that this should have been received by the facility at the time the resident was admitted to the facility, or the facility should have completed a PASRR level I for Resident #132 after the resident was admitted .
A review of Resident #132's medical records revealed that a Preadmission Screening and Resident Review (PASRR) Level I was not completed for Resident #132.
On 2/5/25 at 6:55 PM a final interview was conducted with the Administrator, Director of Nursing, Regional MDS, Regional Nursing Consultant, Regional Maintenance Director, [NAME] President of Clinical Services, Regional Risk Management, and Regional Director 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
(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 observation, resident interview, staff interview, clinical record review and facility documentation review, the facilit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to follow the professional standards of quality regarding treatments for one (1) resident (Resident # 24) in survey sample of 63 residents.
The findings included:
The facility staff failed to implement medication policy to ensure that Resident #24 had all of his medications on hand as ordered by the physician, and further failed to administer the medications and treatments as ordered by the physician.
Resident #24 was admitted to the facility on [DATE] with diagnoses that include but are not limited to paranoid schizophrenia, diabetes, chronic kidney disease, mild intellectual disabilities, hypertension, hypothyroidism, bipolar disorder, major depressive disorder, severe with psychotic features, and anxiety.
A review of the clinical record revealed that Resident #24 had orders that included:
[NAME] Moisture Barrier Cream (Skin Protectants, Misc.) Apply to Sacrum, buttocks topically every day and evening shift for protection/prevention -Start Date- 09/29/2020 0700 -Hold Date from 01/27/2025 to 01/30/2025
Cerave Lotion with Petroleum Jelly Apply to face & bilateral legs topically two times a day for scabs/ dry skin
-Start Date-03/07/2024 1700 -Hold Date from 01/27/2025 to 01/30/2025
Eucerin Advanced Repair External Cream (Emollient) Apply to bilateral heels topically every day and evening shift for dry Heels -Start Date- 08/02/2023 0700 -Hold Date from 01/27/2025 to 01/30/2025
A review of the clinical record revealed that the above ordered creams were documented in the progress notes as unavailable or awaiting from pharmacy on the following dates:
[NAME] Moisture Barrier Cream [twice daily] - 1/4, 1/10, 1/22 - 1/31 and 2/1 - 2/5/2025
Cerave Lotion with Petroleum Jelly [twice daily] - 1/10, 1/22 - 1/31 and 2/1 - 2/5/2025
Eucerin Advanced Repair External Cream [twice daily] - 1/4, 1/10, 1/22 - 1/31 and 2/1 - 2/5/2025
On 2/5/25 at approximately 3:00 p.m., an interview was conducted with LPN C who was asked the procedure if a medication is unavailable, she stated that they are to the physician to see if they would like to substitute it with a different med that is available, notify the family or the Resident and then change the order, and document the changes.
On the afternoon of 2/5/25 the DON was asked what the expectation is for nurses when medications are unavailable and she stated, The nurse should call first check the stat box, then call the pharmacy to find out what is available, and when the medication can be obtained, then call the physician and make them aware of the issue, and see if they would like to change the order, or place it on hold until the medication arrives. Then they need to put in any new orders and discontinue any old ones if they were changed, phone the pharmacy and make them aware. Notify the Resident and or Responsible Party.
A review of the Policy # 6.10 entitled Unavailable Medications effective date 09/2018 revised on 8/2020, read:
The nursing staff shall: 1. Notify the attending physician (or on-call physician when applicable) of the situation and explain the circumstances, expected availability, and the alternative therapies available. If the facility nurse is unable to obtain a response from the attending physician or on-call physician, the nurse should notify the nursing supervisor and contact the facility Medical Director for orders and or direction.
2. Obtain a new order rand cancel / discontinue the order for the non-available medications.
3. Notify the pharmacy of the replacement order.
On 2/5/25 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, facility documentation review and clinical record review, the facilit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, facility documentation review and clinical record review, the facility staff failed to ensure proper Activities of Daily Living services were provided for three (3) residents (Residents #123, #83 and #24) in a survey sample of 63 residents.
The findings included:
1. For Resident # 123, the facility staff failed to provide lotion after bathing.
Resident #123 was admitted to the facility on [DATE] with the diagnoses of, but not limited to: Dementia with Agitation, Diabetes, Hypertension, and Legal blindness.
The most recent Minimum Data Set (MDS) was an admission Assessment with an Assessment Reference Date (ARD) of 9/10/2024. Resident # 123's BIMS (Brief Interview for Mental Status) Score was a 14 out of 15, indicating no cognitive impairment.
Review of the clinical record was conducted on 1/28/2025 to 1/31/2025 and 2/3/2025 to 2/5/2025.
Resident #123 complained about not getting lotion on her body. She stated some facility staff members told her it was written on her chart that she could not have lotion. She stated they never use lotion on me.
The surveyor entered the room on 2/3/2025 while the Certified Nursing Assistant was providing care to the residents in the room. Resident #123 was loudly telling the Certified Nursing Assistant that she wanted lotion. It was observed that no lotion was applied to Resident # 123's skin. The Certified Nursing Assistant stated she provided ADL care but did not see any lotion for the resident.
Resident #123 asked the surveyor why she could not have lotion on her skin. She stated she had used lotion since she was [AGE] years old and wanted to continue using it. There was no lotion noted on the nightstand where other personal items were located.
Review of the Physicians Orders revealed no documentation of orders being written regarding no use of lotion on the skin.
Review of the care plan revealed no documentation of lotion not being used on the skin.
On 2/4/2025 at approximately 2:00 p.m., an interview was conducted with Licensed Practical Nurse-E who stated residents should have lotion applied to the skin after bathing or per their request. Licensed Practical Nurse-E stated lotion was available for the residents to use.
During the end of day debriefing, the facility Administrator, Director of Nursing and Corporate Consultants were informed of the findings. No further information was provided.
2. For Resident # 83, the facility staff failed to provide care to the feet.
During the initial tour of the facility on 1/28/2025 at 1:30 p.m., Resident # 83 was observed lying in bed. The left foot was uncovered. Observation of the toenails on the left foot revealed the toenails were long, and dark in color. The left great toenail was approximately a half inch to 3/4 of an inch long, dark purple in color with jagged edges. The nail on the second toe was approximately a half inch long, discolored and pointed in shape. The skin on the feet looked very dry.
On 1/28/2025 at approximately 2:30 p.m., an interview was conducted with Resident # 83 who stated she was embarrassed about her feet. She stated her toenails needed to be cut. Resident # 83 stated she did not want anybody to see her feet. She stated it had been a long time since she had foot care.
Review of the clinical record was conducted 1/28/2025 -1/31/2025 and 2/3/2025- 2/5/2025.
Review of the Podiatry records revealed that Resident # 83 was listed as one of the Residents to be seen in October 2024 and August 2024. Review of the clinical record revealed no documentation that the resident was treated by the Podiatrist during those months.
On 1/29/2025 at 11:50 a.m., an interview was conducted with Registered Nurse-B who stated proper nail care should be provided to residents. She stated the nursing staff would do routine skin care. Registered Nurse-B stated Resident # 83 should be seen by the Podiatrist for nail care. She stated Resident # 83 was a Diabetic and needed proper nail care to prevent complications. She stated she was unsure of the last time Resident # 83 was seen by the Podiatrist. Resident # 83 stated the Podiatrist usually came to the facility monthly on Saturdays and saw residents according to those placed on a list. Registered Nurse-B stated the facility staff should provide skin care to the feet routinely.
On 2/4/2025 at 3:05 p.m., an interview was conducted with the Unit Secretary who stated she was the one who scheduled appointments for residents with the Podiatrist. She stated the Podiatrist came every two months on a Saturday. She stated the facility had a new Podiatrist who started approximately 5 months ago. Review of the clinical record revealed only one Podiatrist note that was written in June of 2023.
Further review revealed no other documentation of foot care being provided.
On 2/4/2025 during the end of day meeting, the Administrator, Corporate Nurse Consultants and Director of Nursing were made aware of the findings. No further information was provided.
3. For Resident # 24, the facility staff failed to provide ADL care.
Resident #24 was observed on several days with greasy hair, long fingernails with visible debris under the nails, had an odor of urine and body odor and was in the bed dressed in a hospital gown all day.
Resident #24 was admitted to the facility on [DATE] with diagnoses that include but are not limited to paranoid schizophrenia, diabetes, chronic kidney disease, intellectual disabilities, hypertension, hypothyroidism, bipolar disorder, major depressive disorder, severe with psychotic features, and anxiety. Resident #24's most recent BIMS (Brief Interview of Mental Status) score dated 12/23/24 coded Resident #24 as having a BIMS score of 13/15 indicating intact cognitive skills for daily decision making.
The following observations were made of Resident #24:
01/30/25 11:50 AM- Nails long brown substance under nails, in need of shower/bath, hair appears greasy Resident has body odor and smells of urine. In bed only in hospital gown and brief.
01/31/25 11:38 AM- Resident # 24 in bed dressed in hospital gown nails still appear dirty and hair greasy. Continues to have body odor.
Interview with Resident #24: When asked does the staff usually get you up and get you dressed, he responded, No not usually, I can't walk. When asked does the staff get you up and put you in the wheelchair he responded, No not unless I have to go somewhere. When asked does the staff get you up and put you in the shower, he stated that they usuallygave him bed baths. When asked when the last time is his hair was washed, he stated that he did not know.
A review of the Point of Care documentation (CNA documentation of ADL care) revealed that during the period of time from 12/16/24 -12/31/24 Resident #24 had no documented showers. During the period of time from 1/1/25 through 2/1/25, Resident #24 had two (2) showers documented.
On 2/3/25 at approximately 11:00 a.m., an interview was conducted with CNA B who stated that Resident #24 was care planned for refusing a shower. When asked does if that means he does not get one CNA B stated that they usually just wash him up in the bed. When asked how many times a week does a Resident get a shower and CNA B stated that usually Residents are scheduled for 2 showers a week.
A review of the Resident's care plan revealed the following :
FOCUS: [Resident #24 name redacted] has an ADL self-care performance deficit r/t Confusion, Dementia,
Impaired balance, Limited Mobility, Intellectual disability, functional quadriplegia. He req. assist from staff with bed mobility, transfers, dressing, toileting, personal hygiene,and bathing.
GOAL:[Resident name redacted] Mr. [NAME] will receive appropriate staff support with adl care daily through next review. Date Initiated: 12/12/2018 Revision on: 01/29/2025 Target Date: 03/25/2025
INTERVENTIONS: Check nail length and trim and clean on bath day and as necessary. Report any
changes to the nurse. Date Initiated: 12/12/2018 Revision on: 12/12/2018
[Resident name redacted] is able to: feed self after set up assist from staff. Date Initiated: 12/12/2018
[Resident name redacted] requires assistance by staff to dress. Date Initiated: 12/12/2018 Revision on: 09/29/2020
[Resident name redacted] requires assistance by staff to turn and reposition in bed. Date Initiated: 12/12/2018 Revision on: 07/24/2019
[Resident name redacted] requires assistance from staff to provide bath/shower. Date Initiated: 12/12/2018
Revision on: 09/29/2020
[Resident name redacted] requires assistance by staff for transfers. Date Initiated: 12/12/2018 Revision on: 09/29/2020
[Resident name redacted] receives assistance by staff for incontinence care. Date Initiated: 12/12/2018
Revision on: 09/29/2020.
02/03/25 01:04 PM Resident # 24 positioned too low in bed to sit up and eat properly, Resident had lima beans and gravy on his blanket which was under his chin, fruit cup was not opened and Resident was struggling to open it attempted with spoon to poke hole in it then attempted with fork still unable to open it, drink was unopened in cup, and Resident ate rice with his fingers. attempted with fork but kept falling off and he ended up picking up by hand.
A review of Resident #24's MDS with an ARD (Assessment Reference Date) of 12/23/24 question GG0130A3 states that the Resident requires Set Up / Clean Up Assistance,
On 2/3/25 at 1:10 p.m. an interview was conducted with LPN D (Unit Manager) who stated that the danger of Resident #24 being so low in the bed is that he could aspirate or choke on his food. When asked is this the expectation of how a Resident should be set up for meals and she stated that the expectation for CNA's to set up Resident's tray are all food and drink containers should be opened he should have his bed upright as close to a 90-degree angle as is comfortable and he should be sitting upright in the bed.
On 2/5/25 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
Deficiency F0685
(Tag F0685)
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 Residents ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview clinical record review and facility documentation the facility staff failed to ensure Residents receive treatment and assistive devices to maintain vision for 1 Resident in a survey sample of 38 Residents.
The findings included:
For Resident #125 the facility staff failed to ensure the Resident received vision services for a resident with a diagnosis of glaucoma.
Resident #125 was admitted to the facility on [DATE] with diagnoses that included but we're not limited to UTI, kidney stones, protein calorie malnutrition, asthma, epilepsy, repeated falls, COPD, chronic renal failure, colostomy, major depressive disorder, DVT, muscle weakness, traumatic brain injury, acute angle - closure, glaucoma, dysphasia, and hypertension. Resident #125 is wheelchair, bound and requires assistance with all aspects of care except for eating. His most recent BIMS (Brief Interview of Mental Status) scored the resident at 15 out of 15 indicating no cognitive impairment.
On 5/21/25 at 11:00 a.m. Resident #125 was interviewed and he stated that he could not see well. He indicated that he had been diagnosed with glaucoma before he was admitted to the facility and that he needed glasses because it was now getting hard to see his phone.
On 5/21/25 an interview was conducted with the Social Worker who stated that Resident #125 was scheduled for the optometrist on 5/1/25, however he refused. When asked if the appointment was rescheduled, she indicated that it had not been.
A review of the clinical record revealed that the Resident was not on any prescribed eye drops to control the intraocular pressure and had no follow up exams with the ophthalmologist since admission.
On 5/22/25 during the end of day meeting the Administrator was made aware of the concern and no further information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility documentation review and clinical record review, the facility failed to prevent,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility documentation review and clinical record review, the facility failed to prevent, assess, identify and treat an avoidable pressure ulcer for one Resident (Resident #63) in a survey sample of 63 Residents.
The findings included:
Resident #63 was originally admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses of, but not limited to Alzheimer's, muscle weakness, difficulty walking, vitamin deficiency, cognitive communication deficit, chronic kidney disease, anxiety, and repeated falls.
Resident #63's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 12/7/2024 was a quarterly assessment. The MDS coded Resident #63 with a BIMS (Brief Interview for Mental Status) score of 00 out of 15 possible points, indicating severe cognitive impairment. The MDS coded Resident #63 as dependent with Activities of Daily Living (ADL's), dependent or 2 persons assist for all function abilities and frequently incontinent for bowel and bladder.
On 1/28/2025 at approximately 12:55 p.m., during initial tour of the facility, Resident #63 was observed sitting in a wheelchair in day room of the Memory Care unit. Gauze dressing observed to the right lower extremity. Resident #63 was alert but not oriented.
On 02/05/2024, at 2:00p.m. an interview was conducted with wound care nurse. When asked if she could confirm the date Resident #63 pressure ulcers to the left and right lower extremities were observed and documented. The wound care nurse states that she was new to the facility, but she was able for find notes that in the residents record the resident did admit with a pressure ulcer on 02/13/2024. She could not find any documentation in the wound care book or the residents record regarding pressure ulcers to the right and left lower extremities prior to 06/05/2024. When asked when skin evaluations are conducted. She stated by nursing weekly, daily with Activities of Daily Living (ADL) Care, physician assessments, and whenever an issue is reported.
Facility policies and procedures were reviewed. The policy titled Skin assessments stated that skin assessments would be conducted by nursing weekly and daily with ADL care.
A review of Resident #63 clinical record was conducted 01/28/2025-01/31/2025 and 02/03/2025-02/05/2025 and revealed:
The 12/21/2023, Care plan revealed no documentation Focus: Resident has potential for impairment for skin integrity. Goal: Resident will have no impaired skin integrity through next review.
The 02/24/2024, Care plan revealed Focus: Resident is at nutrition risk r/t obesity alzheimers, prediabetes, depression, suicidal ideations, HTN, HLD, vitamin deficiency. Goal: Resident will maintain adequate nutrition status without s/sx of malnutrition with no further weight gain through next review date. Intervention: Diet as ordered and per resident's preferences. Monitor/record/report to MD PRN s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. RD to monitor and f/u per protocol. Weigh per facility protocol.
A review of the care plans revealed no documentation of focus, goal or intervention related to pressure ulcers 02/13/2024-06/05/2024.
The 08/17/2023, Nutritional At-Risk Assessment revealed: Height: 59.0 inches. Weight: 155 pounds. Related diagnosis: Alzheimer's with early onset, history of falling, aphasia, prediabetes, major depressive disorder, essential hypertension, hyperlipidemia, and vitamin deficiency. -Diet: Regular, Fluid consistency: thin. Weight: stable; Nutritional Needs: Calorie Needs: 1410-1762, explanation of Calculations 20-25k cals/kg.
Protein needs: 56-85, Explanations of calculation 0.8-1.2 PRO/kg; Fluid needs: 1410-1762.
-Plan of Care: Problem statement: Annual assessment for 70yo COVID-19+ LTC female w/hx of pre-DM, HTN, HLD, vit deficiency, alzheimer's disease, depression. Ht 59, wt 155#, BMI 31.3. No significant weight change x 30, 60, 90, 180 days. Diet is CCD w/regular textures. PO 76-100% overall per PCC.
Goal: No chewing/swallowing problems reported. Skin wnl. Pertinent meds: donepezil, atorvastatin, B complex vit, losartan, hydrochlorothiazide, vit D, memantine, bowel regimen, antidepressant. Labs 6/1 na 140, k 4.2, cl 103, bun 19.5, creat 0.52, ca 8.5, hgb 10.9 L, hct 34.2 L.
Intervention: No nutrition-related recommendation at this time, continue to monitor PO and weight change status.
The 02/13/2024, discharge summary from CJW Medical Center hospital, revealed Discharge diagnosis: encephalopathy secondary to urinary tract infection Hospital course: This is a [AGE] year-old female with PMH HTN, advanced dementia, Depression and DLD presents to hospital from nursing home by EMS with altered mental status. History is very difficult to obtain and very scant since patient is only alert oriented times 0. Patient presented septic with leukocytosis 18K, and etiology Urinary Tract Infection. [NAME] Cx grew gram positive and gram negative.
Objective Head/Eyes: atraumatic, EOMI, PERRLA Neck: no JVD Cardiovascular: regular rate rhythm, no murmur Respiratory: aerating well, clear to auscultation, no distress Abdomen: non-tender, normal bowel sounds, soft, no distention Extremities: no edema Musculoskeletal: normal inspection Neuro/CNS: CNII-XII intact, verbal, not oriented to person, place or time - baseline Skin: dry, intact, no rash Psychiatry: unable to evaluate Free Text Obj Notes Free Text Obj
Notes: GENERAL: not alert oriented to place/time/self, able to follow simple commands SKIN: No rashes HEENT: No jaundice. No oral thrush or ulcerations. No sinus tenderness NECK: No JVD, supple; no palpable lymphadenopathy LUNGS: Clear to auscultation. No wheezes or crackles HEART: S1, S2; regular rate and rhythm. No murmurs ABDOMEN: Bowel sounds positive. Soft, no tenderness, no palpable organomegaly EXTREMITIES: Negative for edema, positive pulses NEURO: Awake, alert and oriented to place, person and time. No focal deficits MS: No joint swelling or muscle tenderness.
Discharge Instructions: PCP follow-up: PCP: NO PRIMARY OR FAMILY PHYSICIAN Discharge to: Nursing Home (ICF,ECF) Additional Discharge Routines: Add. instructions Diet: Soft bite sized diet Additional instructions: follow up blood pressure at facility no longer to take blood pressure medications complete antibiotic Quality: Discharge Advanced Care Plan 65 or Older Discussed with: patient, nurse Current Medications Current medication review: I attest that the foregoing medication list in the medical record is true, accurate, and complete to the best of my knowledge.
The 02/13/2024, Weekly Wound Evaluation Assessment revealed that Resident #63 had one pressure ulcer to the Coccyx. Type: vascular length 3, width 3, and depth 1. Comments: Has area to L inner buttock, noted with bruising all extremities.
Resident #63's Weekly Wound Evaluation Assessments were reviewed for dates 02/13/2024 through 06/05/2024. There was no documentation of a wound or pressure ulcer to the left or right lower extremity.
The 06/05/2024, Vohora initial wound evaluation summary, revealed Patient presents with wounds on her right knee; left anterior medial foot; left medial heel. At the request of the referring provider, a thorough wound care assessment and evaluation was performed today. She has condition(s) as listed above. Details about current wound(s) and any skin conditions are outlined below. There is no indication of pain associated with this condition.
SKIN Head/Face Normal Left lower extremity Wound present. See Focused Wound Exam below, right lower extremity Wound present. See Focused Wound Exam below
SITE 1: SURGICAL EXCISIONAL DEBRIDEMENT PROCEDURE INDICATION FOR PROCEDURE Remove Necrotic Tissue and Establish the Margins of Viable Tissue consent for procedure Treatment options-risks-benefits and the possible need for subsequent additional procedures on this wound were explained on 06/05/2024 to the health care surrogate; Max Fresquez; who indicated agreement to proceed with the procedure(s) procedure note The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade was used to surgically excise devitalized tissue and necrotic subcutaneous level tissues were removed at a depth of 0.2 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 10 percent to 0 percent. Hemostasis was achieved and a clean dressing was applied. Post-operative recommendations and updates to the plan of care are documented in the Assessment and Plan section below.
Focused Wound Exam (Site 2) UNSTAGEABLE DTI OF THE LEFT, ANTERIOR, MEDIAL FOOT UNDETERMINED THICKNESS Etiology (quality) Pressure MDS 3.0 Stage Unstageable DTI with intact skin Duration > 1 days Objective Healing/Maintain Healing Wound Size (L x W x D): 3.1 x 2.1 x Not Measurable cm Surface Area: 6.51 cm² Exudate: None Skin: Intact with purple/maroon discoloration Blister: Blood Filled DRESSING TREATMENT PLAN Primary Dressing(s) Skin prep apply Q-shift (3xday) for 30 days PLAN OF CARE REVIEWED AND ADDRESSED Recommendations Off-Load Wound ; Reposition per facility protocol ; Float Heels in Bed
Focused Wound Exam (Site 3) UNSTAGEABLE DTI OF THE LEFT, MEDIAL HEEL UNDETERMINED THICKNESS Etiology (quality) Pressure MDS 3.0 Stage Unstageable DTI with intact skin Duration > 1 days Objective Healing/Maintain Healing Wound Size (L x W x D): 1.2 x 1.5 x Not Measurable cm Surface Area: 1.80 cm² Exudate: None Skin: Intact with purple/maroon discoloration Blister: Blood Filled DRESSING TREATMENT PLAN Primary Dressing(s) Skin prep apply Q-shift (3xday) for 30 days PLAN OF CARE REVIEWED AND ADDRESSED Recommendations Off-Load Wound ; Reposition per facility protocol ; Float Heels in Bed
A review of the Physician's orders, 02/13/2024-06/05/2024.No orders were found for wound care to Resident #63, left or right lower extremities.
A review of the progress notes only included documentation regarding pressure ulcer to the right buttock.
Resident #63 experienced an avoidable pressure ulcer injury which was not identified until a, VOHRA, initial wound evaluation was conducted on 06/05/2024. The Resident was at risk for skin breakdown. No orders or plan of care was implemented to protect the extremities from wounds.
On 2/04/2025 at 3:00pm, the Administrator, Director of Nursing, and Corporate Nurse were notified that the survey team was considering a harm level deficiency. The facility staff was given the opportunity to provide any further information or explanation.
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 observation, resident interview, staff interview and clinical record review and facility documentation review, the faci...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview and clinical record review and facility documentation review, the facility staff failed to ensure proper foot care was provided to one (1) resident (Resident # 83) in a survey sample of 63 residents.
For Resident # 83, the facility staff failed to ensure proper nail care was provided.
Resident # 83 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included but were not limited to: Chronic Obstructive Pulmonary Disease, Hypertension, Chronic Kidney Disease, Diabetes, Acute Respiratory Failure and Congestive Heart Failure.
The most recent Minimum Data Set (MDS) was an Annual Assessment with an Assessment Reference Date (ARD) of 11/3/2024. Resident # 83's BIMS (Brief Interview for Mental Status) Score was a 15 out of 15, indicating no cognitive impairment. Resident # 83 required assistance with Activities of Daily Living.
During the initial tour of the facility on 1/28/2025 at 1:30 p.m., Resident # 83 was observed lying in bed. The left foot was uncovered. Observation of the toenails on the left foot revealed the toenails were long, and dark in color. The left great toenail was approximately a half inch to 3/4 of an inch long, dark purple in color with jagged edges. The nail on the second toe was approximately a half inch long, discolored and pointed in shape. The skin on the feet looked very dry.
On 1/28/2025 at approximately 2:30 p.m., an interview was conducted with Resident # 83 who stated she was embarrassed about her feet. She stated her toenails needed to be cut. Resident # 83 stated she did not want anybody to see her feet. She stated it had been a long time since she had foot care.
Review of the clinical record was conducted 1/28/2025 -1/31/2025 and 2/3/2025- 2/5/2025.
Review of the Podiatry records revealed that Resident # 83 was listed as one of the Residents to be seen in October 2024 and August 2024. Review of the clinical record revealed no documentation that the resident was treated by the Podiatrist during those months.
On 1/29/2025 at 11:50 a.m., an interview was conducted with Registered Nurse-B who stated proper nail care should be provided to residents. Registered Nurse-B stated Resident # 83 should be seen by the Podiatrist for nail care. She stated Resident # 83 was a Diabetic and needed proper nail care to prevent complications. She stated she was unsure of the last time Resident # 83 was seen by the Podiatrist. Resident # 83 stated the Podiatrist usually came to the facility monthly on Saturdays and saw residents according to those placed on a list.
On 2/4/2025 at 3:05 p.m., an interview was conducted with the Unit Secretary who stated she was the one who scheduled appointments for residents with the Podiatrist. She stated the Podiatrist came every two months on a Saturday. She stated the facility had a new Podiatrist who started approximately 5 months ago. The Unit Secretary stated she had documentation of the list of residents who had been scheduled to see the Podiatrist. Copies of all residents seen by the Podiatrist were requested. The Unit Secretary stated that sometimes the residents on the list were not seen if they refused or if they weren't available when the Podiatrist visited their room. Review of the clinical record revealed only one Podiatrist note that was written in June of 2023.
Further review revealed no other documentation of foot care being provided by the Podiatrist.
On 2/4/2025 during the end of day meeting, the Administrator, Corporate Nurse Consultants and Director of Nursing were made aware of the findings. No further information was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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, resident interview, staff interview, and resident record review, the facility staff failed to provide inco...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and resident record review, the facility staff failed to provide incontinence care for one (1) of 63 residents (Resident #21), in the survey sample.
The findings included:
Resident #21 was originally admitted to the facility 05/27/2022 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included high blood pressure and bilateral lower extremity swelling.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/31/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #21's cognitive abilities for daily decision making were intact. In section H0300 the resident was coded as occasionally incontinent of urine.
On 1/28/25 at approximately 4:07 PM, Resident #21 was observed in his room with a puddle of urine beneath his wheel chair and his pants were saturated. The resident propelled the wheel chair out in the corridor leaving a trail of urine on the floor. An interview was conducted with the resident. Resident #21 stated he washes himself up and changes his incontinence briefs as needed. The staff did not come to the resident's assistance to provide incontinence care.
Resident #21 was observed again on 1/30/25 at approximately 1:45 PM in the Dayroom on Unit Four. The resident was again with urine saturated pants. The resident stated his bladder was weak and he could no longer hold his urine. He went into the linen closet and obtain washcloths and towels. No staff came to the resident's aid to provide incontinence care.
The resident's person centered care plan dated 06/06/2022 had a problem which stated (name of the resident) has bladder incontinence related to new admission and Arthritis. The goals stated the resident will remain free from skin breakdown due to incontinence and brief use through the review date, 3/30/25 and the resident's risk for septicemia will be minimized through the review date, 3/30/25. The interventions included the resident uses disposable briefs. Change as needed and check as required for incontinence. Wash, rinse and dry perineum. Change clothing as needed after incontinence episodes, urinal at bedside when in bed.
On 2/5/25 at approximately 4:20 PM, a final interview was conducted with the Administrator, Director of Nursing and four Corporate Consultants. The administrative team was informed of the the above information. No additional information was provided and no concerns were voiced.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facili...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure residents did not sustain significant unplanned weight loss for one (1) Resident (# 109) in a survey sample of 63 residents.
The findings included:
For Resident #109 the facility staff failed to ensure the Resident's food preferences were addressed and failed to act on a significant unplanned weight loss of 13.25% in 6 mos.
On 1/28/25 at approximately 12:45 p.m., an interview was conducted with Resident #109 who stated the food was not good at the facility. When asked to elaborate the Resident complained that a lot of times the food was burnt or overcooked. The Resident stated that they did not have any seasoning in the food and it was bland. He stated that he has lost weight since being at the facility and it was not intential weight loss. When asked if he had seen the Registered Dietician, he stated that he had not. When asked if anyone had contacted him and asked him about food preferences, he stated that the nurse did when he was admitted and she asked about allergies and food he couldn't eat. When asked if anyone from the dietary department had spoken with him to get a list of his likes and dislikes, he stated that they had not. When asked how much weight he had lost he stated that he had lost at least 20 lbs.
Resident #109 was admitted to the facility on [DATE] with diagnoses that included but were not limited to weakness unsteadiness on feet, difficulty in walking, abnormalities of gait and mobility, occlusion or stenosis of right middle cerebral artery, muscle spasms, chronic pain, insomnia, and attention deficit hyperactivity disorder. Resident #109's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/13/24 coded Resident #61 as having a BIMS (Brief Interview of Mental Status) score of 15/15 indicating no cognitive impairment. A review of the clinical record revealed that Resident #61 was weighed on 7/15/24 and he weighed in at 234 lbs. On 1/27/25 Resident #61 weighed in at 203 lbs. thus, indicating a 31 lb. (or 13.25%) weight loss in 6 months.
A review of the clinical record revealed the following entries for Resident's weight:
7/30/24 - 231.2 Lbs.
9/9/24 - 227.2 Lbs.
10/10/24 - 224.8 Lbs.
11/2/24 - 224.5 Lbs.
11/4/24 - 221 Lbs.
12/10/24 - 216.0 Lbs.
1/7/25 - 204.4 Lbs.
1/27/25 -203 Lbs.
A review of the clinical record revealed that Resident #109 had a Nutritional at Risk Assessment completed and signed by the Registered Dietician on 12/19/24 excerpts are as follows:
Diet and consistency: Regular Diet Regular Texture
Fluid consistency: Thin
Supplements / Snacks: HS snack / Large Portions
Page 4
9. Weight History - Stable
Page 7
9B. Weight loss over last 3 months? 3. No Weight Loss
9C. Mobility - able to get out of bed / chair but does not go out.
9E. Neuropsychological problem - Severe dementia or depression [Please note Resident has no dx of dementia and BIMS of 15]
Page 8
10 - 1. Do you have preferred beverages for breakfast? [left unanswered]
2. Do you have preferred beverages for lunch? [left unanswered]
3. Do you have preferred beverages for dinner? [ left unanswered]
4. Are your preferred mealtimes outside of the facility times? [ left unanswered]
5. If yes specify . [left unanswered]
6. Food likes - obtained and noted by DM (Dietary Manager)
7. Food dislikes [left unanswered]
Page 9
Comments [left unanswered]
Plan of care - No nutrition problem
Page 10
Goals [left unanswered]
3. Interventions / approaches - Will continue POC & follow up as indicated
A review of the care plan for Resident #109 revealed the following:
FOCUS: NUTRITIONAL STATUS: The resident is at risk for weight loss, malnutrition or poor hydration status related to cognitive impairment Date Initiated: 11/11/2024
GOALS: the resident will have optimal nutrition and hydration status thru review period Date Initiated: 11/11/2024 Target Date: 12/11/2024
INTERVENTIONS: Review dietary preferences with the resident as needed
Date Initiated: 11/11/2024
On 2/4/25 at 12:50 PM., a telephone interview was conducted with the dietician she was asked how often she sees Residents and she stated that she only works remotely as she lives in Ohio. When asked how she gets her information she stated that she gets her information from the electronic health record. When asked how she would get the food preference data from Residents, she stated I wouldn't be doing food preferences because that's what the dietary manager should be doing. The dietician said that orders are given to the Director of Nursing (DON).
On 2/5/25 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.
,
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident # 2, the facility staff failed to ensure several medications were available for administration as ordered by the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident # 2, the facility staff failed to ensure several medications were available for administration as ordered by the physician.
Resident #2 was admitted on [DATE] with diagnoses including but not limited to: Epilepsy, Seizures, Confirmed Physical Abuse, Confirmed Psychological Abuse, Major Depressive Disorder, Anxiety Disorder, and Neoplasm of the Brain.
Resident #2's most recent MDS (Minimum Data Set) was a Quarterly Assessment with an ARD (Assessment Reference Date) of 12/27/2024 coded the Resident as having a BIMS (Brief Interview of Mental Status) score of 13 out of 15 indicating no cognitive impairment.
Review of the clinical record was conducted on 1/28/2025 to 1/31/2025 and 2/3/2025 to 2/5/2025.
Review of the Progress Notes and January 2025 Medication Administration Record (MAR) revealed documentation of medications being unavailable for administration including but not limited to:
Effective Date: 01/22/2025 00:22 Type: Orders - Administration Note
Note Text : Oxycodone Hydrochloride Tablet 5 milligrams
Give 1 tablet by mouth every 6 hours for pain
Not available. On order. Awaiting from pharmacy.
Effective Date: 01/22/2025 05:08 Type: Orders - Administration Note
Note Text : Oxycodone Hydrochloride Tablet 5 milligrams
Give 1 tablet by mouth every 6 hours for pain
Not available. On order. Awaiting from pharmacy.
Effective Date: 01/28/2025 00:13 Type: Orders - Administration Note
Note Text : Lorazepam Tablet 1 MG
Give 1 tablet by mouth every 8 hours for anxiety for 14 Days
awaiting arrival
Effective Date: 01/27/2025 14:07 Type: Orders - Administration Note
Note Text : Lorazepam Tablet 1 MG
Give 1 tablet by mouth every 8 hours for anxiety for 14 Days
awaiting pharmacy, script was faxed and np (Nurse Practitioner) notified and aware
Effective Date: 01/27/2025 07:39 Type: Orders - Administration Note
Note Text : Lorazepam Tablet 1 MG
Give 1 tablet by mouth every 8 hours for anxiety for 14 Days
Medication on order from pharmacy per previous nurse
Effective Date: 01/26/2025 14:30 Type: Orders - Administration Note
Note Text : Lorazepam Tablet 1 MG
Give 1 tablet by mouth every 8 hours for anxiety for 14 Days
awaiting pharmacy
Effective Date: 01/26/2025 05:48 Type: Orders - Administration Note
Note Text : Lorazepam Tablet 1 MG
Give 1 tablet by mouth every 8 hours for anxiety for 14 Days
Not available. To soon to order.
On 1/29/2025 at 3:05 p.m., an interview was conducted with LPN (Licensed Practical Nurse)-E who stated the medications from the Pharmacy for each resident. The blister pack should have the medications for each scheduled dose. LPN-E stated if the medication was not available, the nurse was expected to check the Omni Cell (in house Stat box) for an available supply of the medication and to notify the Pharmacy that the medication was not available. The nurse would order the medication from the Pharmacy so it would be available for the next scheduled dose. The nurse should notify the physician that the medication was not available for administration as ordered.
On 2/4/2025 at 12:50 p.m., an interview was conducted with the Director of Nursing who stated medications should be available for administration as ordered by the physician. She stated the nurses should call the Pharmacy to inform them that the medication was not available in the medication cart, order the medication, check the Omnicell and notify the physician if the medication was not available to be administered. She stated the Pharmacy delivers twice a day at the facility. She also stated the expectation was for the Pharmacy to send medications on the next delivery after notification that a medication was not available as ordered. A copy of the Omnicell contents was requested and received on 2/5/2025.
Review of the Omnicell contents revealed the medication, Oxycodone 5 milligrams, was available in the inventory. There were 10 tablets usually kept in the inventory. There was no documentation that the Omnicell was checked and the supply was not available.
Five doses of Lorazepam 1 milligram were not available according to the documentation in the Progress notes. Review of the Omnicell contents revealed Lorazepam 0.5 milligrams tablets were available in the Omnicell.
There was documentation that one dose of the Lorazepam was given from the Omnicell on 1/15/2025 as written:
Effective Date: 01/25/2025 07:18 Type: Orders - Administration Note
Note Text : Lorazepam Tablet 1 MG
Give 1 tablet by mouth every 8 hours for anxiety for 14 Days.
Late entry- Patient received one time order from omnicell for medication until pharmacy deliver medication.
During the end of day debriefing on 12/18/2024, the Facility Administrator, Regional Nurse Consultant and and Director of Nursing were informed of the findings. They stated medications should be available for administration.
No further information was provided.
Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide routine medications to two (2) Residents (Residents #24, and #2) in a survey sample of 63 Residents.
The findings included:
1. For Resident #24 the facility staff failed to ensure that the resident received the medications and treatments as ordered by the physician.
Resident #24 was admitted to the facility on [DATE] with diagnoses that include but are not limited to paranoid schizophrenia, diabetes, chronic kidney disease, mild intellectual disabilities, hypertension, hypothyroidism, bipolar disorder, major depressive disorder, severe with psychotic features, and anxiety.
A review of the clinical record revealed that Resident #24 had orders that included:
[NAME] Moisture Barrier Cream (Skin Protectants, Misc.) Apply to Sacrum, buttocks topically every day and evening shift for protection/prevention -Start Date- 09/29/2020 0700 -Hold Date from 01/27/2025 to 01/30/2025
Cerave Lotion with Petroleum Jelly Apply to face & bilateral legs topically two times a day for scabs/ dry skin
-Start Date-03/07/2024 1700 -Hold Date from 01/27/2025 to 01/30/2025
Eucerin Advanced Repair External Cream (Emollient) Apply to bilateral heels topically every day and evening shift for dry Heels -Start Date- 08/02/2023 0700 -Hold Date from 01/27/2025 to 01/30/2025
A review of the clinical record revealed that the above ordered creams were documented in the progress notes as unavailable or awaiting from pharmacy on the following dates:
[NAME] Moisture Barrier Cream [twice daily] - 1/4, 1/10, 1/22 - 1/31 and 2/1 - 2/5/2025
Cerave Lotion with Petroleum Jelly [twice daily] - 1/10, 1/22 - 1/31 and 2/1 - 2/5/2025
Eucerin Advanced Repair External Cream [twice daily] - 1/4, 1/10, 1/22 - 1/31 and 2/1 - 2/5/2025
On 2/5/25 at approximately 3 p.m. an interview was conducted with LPN C who was asked the procedure if a medication is unavailable, she stated that they are to the physician to see if they would like to substitute it with a different med that is available, notify the family or the Resident and then change the order and document the changes.
On the afternoon of 2/5/25 the DON was asked what the expectation is for nurses when medications are unavailable and she stated, The nurse should call first check the stat box, then call the pharmacy to find out what is available, and when the medication can be obtained, then call the physician and make them aware of the issue, and see if they would like to change the order, or place it on hold until the medication arrives. Then they need to put in any new orders and discontinue any old ones if they were changed, phone the pharmacy and make them aware and notify the Resident and or Responsible Party.
A review of the Policy # 6.10 entitled Unavailable Medications effective date 09/2018 revised on 8/2020, read:
The nursing staff shall: 1. Notify the attending physician (or on-call physician when applicable) of the situation and explain the circumstances, expected availability, and the alternative therapies available. If the facility nurse is unable to obtain a response from the attending physician or on-call physician, the nurse should notify the nursing supervisor and contact the facility Medical Director for orders and or direction.
2. Obtain a new order rand cancel / discontinue the order for the non-available medications.
3. Notify the pharmacy of the replacement order.
On 2/5/25 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
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to e...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure Residents were free from significant medication errors for two (2) Residents (Residents #24, and #139) in a survey sample of 63 Residents.
The findings included:
1. For Resident #24 the facility staff failed to ensure that the Resident received the medications and treatments as ordered by the physician.
Resident #24 was admitted to the facility on [DATE] with diagnoses that include but are not limited to paranoid schizophrenia, diabetes, chronic kidney disease, mild intellectual disabilities, hypertension, hypothyroidism, bipolar disorder, major depressive disorder, severe with psychotic features, and anxiety.
A review of the clinical record revealed that Resident #24 had orders that included:
Lisinopril Oral Tablet 20 MG - Give 1 tablet by mouth at bedtime related to essential (primary) hypertension -Start Date- 12/30/2024
Levothyroxine 25 mcg give 1 tablet by mouth in the morning for hypothyroidism -Start Date- 08/14/2023
Lorazepam 0.5 mg tablet give 1/2 tablet by mouth two times a day related to anxiety disorder -Start Date-12/20/20
On 2/5/25 a review of the progress notes revealed that Lisinopril 20 mg was documented as unavailable for Resident #24 on 12/17/24, 12/25/24, and 12/26/24, Levothyroxine 25 mcg. was documented at unavailable 1/15/25-1/17/25, and the Lorazepam was documented as unavailable from 1/3/25-1/5/25.
A review of the MAR (Medication Administration Record) for Resident #24 revealed the following blood pressures:
12/17/24 - 128/69
12/18/24 - 136/86
12/25/24 - 158/91
12/26/24 - 160/80
On 2/5/25 at approximately 3 p.m., an interview was conducted with LPN C who was asked the procedure if a medication is unavailable, she stated that they are to be reported to the physician to see if they would like to substitute it with a different med that is available, notify the family or the resident and then change the order if necessary and document the changes.
On the afternoon of 2/5/25, the Director of Nursing (DON) was asked what the expectation was for nurses when medications are unavailable and she stated, The nurse should call first check the stat box, then call the pharmacy to find out what is available, and when the medication can be obtained, then call the physician and make them aware of the issue, and see if they would like to change the order, or place it on hold until the medication arrives. Then they need to put in any new orders and discontinue any old ones if they were changed, phone the pharmacy and make them aware. The Resident and or Responsible Party should be notified of any changes.
On 2/4/25 a review of the stat box contents revealed that the following medications were available for administration to Resident #24:
Lisinopril 10 mg tabs
Levothyroxine 25 mcg tabs
Lorazepam 0.5 mg tabs
A review of the Policy # 6.10 entitled Unavailable Medications effective date 09/2018 revised on 8/2020, read:
The nursing staff shall: 1. Notify the attending physician (or on-call physician when applicable) of the situation and explain the circumstances, expected availability, and the alternative therapies available. If the facility nurse is unable to obtain a response from the attending physician or on-call physician, the nurse should notify the nursing supervisor and contact the facility Medical Director for orders and or direction.
2. Obtain a new order rand cancel / discontinue the order for the non-available medications.
3. Notify the pharmacy of the replacement order.
On 2/5/25 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
2. The facility staff failed to administer Resident #139, a significant medication, Methadone for 4 days, 11/28/24, 11/29/24, 11/30/24 and 12/01/24.
Resident #139 was originally admitted to the facility 11/27/24 after an acute care hospital stay. The resident had an unplanned discharged from the facility on 12/01/24. The current diagnoses included; Chronic Pain Syndrome and Unspecified Fracture of the Lower end of Left Radius, Subsequent Encounter for Closed Fracture with Routine Healing.
The 5-day, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/01/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #139 cognitive abilities for daily decision making were intact.
The Care Plan dated on 11/27/24 read that Resident #139 is at risk for complications related to the use of opioid secondary. The Goal for Resident #139 was the resident will be free from complications related to opioid use thru review period. An intervention for Resident #139 was to administer medications as needed.
The November 2024 Medication Administration Record (MAR) read:
Methadone HCl Oral Solution, Give 80 mg by mouth one time a day for pain.
Start Date 11/28/2024 9:00 AM., Coded as 9 meaning= no explanation given in the medical record.
The Pain rating/level on 11/28/24 was documented a 2 out of 10.
The November MAR read: Pain evaluation every day shift every day shift for Monitoring of patient's pain level-Start Date 11/28/2024 7:00 AM- discharge date [DATE] 10:03 PM. 11/28/24 pain level =4, 11/29/24 pain level = 0, 11/30/24 pain level =0
Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 2 tablet by mouth every 6 hours as needed for mild pain for 10 Days (11/27/2024).
The Pain Level on the following dates were : 11/27=5, 11/28=4, 11/29=4, 11/30=8.
The December 24 MAR read: Methadone HCl Oral Solution 10 MG/5ML Give 80 mg by mouth one time a day for pain 11/28/24 9:00 AM. Pain=NA, Coded #5=Spoke to pharmacy regarding script.
A review of an admission note dated on 11/27/2024 at 3:10 PM., read: Resident arrived via EMT for admission from local hospital. Cast to left forearm due to fracture. Both heels bruised. No IV lines noted. Medications entered into system. VS taken and entered. Resident asking about her Methadone. Prescription faxed to pharmacy. Paperwork placed in Nurse Practitioner (NP) communication book.
The Physician Progress note dated 11/30/24 at 8:09 AM., read She is seen today lying in bed. She reports feeling ill due to not having had her methadone today. She reports having been on methadone for 15 years after being addicted to Oxycodone following a car accident. She is followed by a treatment center.
A review of nursing note dated 12/1/2024 at 2:51 PM., read: Spoke with pharmacy regarding script for methadone, pharmacy states they are unable to fill dosage that has been put on script of 1200 ml due to resident has to have methadone clinic send medication for dosing, they are only able to do three 1 x doses until they are unable to send medication again. methadone clinic called and office is closed. resident is aware. Called third eye who says they are unable to call in script and methadone clinic needs to be contacted. called Nurse Practitioner (NP), NP faxed a 1 x script over to pharmacy. Resident notified and stated she would like to leave Against Medical Advice (AMA) when her roommate comes. Spoke with resident regarding AMA and informed her of the unsafe discharge. NP/MD made aware of resident wanting to leave AMA. Resident states she will decide when her roommate comes. Script faxed over for residents' methadone.
A review of nursing notes on 12/1/2024 9:59 PM., read: Writer was in and spoke with resident at approximately 3:30 PM., to address any issues. Resident adamite on leaving and returning to the community. Responsible Party (RP) and NP aware of discharge.
A review of nursing notes on 12/1/2024 9:09 PM., read: Resident left AMA. NP aware. Resident advised of dangers/risks to health. AMA formed and signed by resident. Took all belongings with her. Resident is own RP.
A review of the Delivery Manifest showed that the Methadone was delivered to the facility on [DATE] at 12:24 AM. The Methadone was delivered one (1) day after the resident had already left the facility Against Medical Advice (AMA).
On 2/05/25 at approximately 10:30 AM., a phone call was made to speak to Resident #139. The Resident's daughter/Family Member (FM) #1, said that her mother was not staying with her but gave a phone number to reach the resident after 12:00 PM., today. FM #1 said that her mother wasn't getting her Methadone. The staff informed her that her medication shipment wasn't in yet due to the holiday.
On 2/05/25 at approximately 3:15 PM., a phone call was made to Resident #139. A voice message was left.
On 02/05/25 at approximately 3:05 PM., an interview was conducted with the Director of Nursing (DON) concerning Resident #139. The DON said that the resident left Against Medical Advice (AMA) was advised of the safety risk on leaving AMA. The DON also said that the residents' Methadone prescription was faxed to the pharmacy, but they (facility) were waiting on pharmacy to send it. The DON also mentioned that It's never acceptable because the resident was being treated for chronic pain. The DON said that she would check to see if pharmacy received the prescription from the facility.
Methadone is used to treat moderate to severe pain when around-the-clock pain relief is needed for a long period of time. This medicine should not be used to treat pain that you only have once in a while or as needed. Methadone is also used together with medical supervision and counseling to treat opioid use disorder (eg, heroin or other morphine-like drugs). Methadone belongs to the group of medicines called opioid analgesics (pain medicines). It acts on the central nervous system (CNS) to relieve pain. The use of methadone to treat opioid use disorder in the US is only available through opioid treatment programs (methadone clinics). This medicine is available only with your doctor's prescription. https://www.mayoclinic.org/drugs-supplements/methadone-oral-route/description/drg-20075806.
Missed methadone doses: If one of two doses are missed the patient can be maintained on the same methadone dose. If three doses are missed the next methadone dose should be reduced by 25% to adjust for the possible reduction in tolerance. If it is well tolerated, doses can return to previous dose levels. If four doses are missed the next dose should be reduced by 50% to adjust for the potential reduction in tolerance. If the dose is well tolerated doses can be increased over several days to previous levels. If more than four doses are missed, patients should resume induction from baseline. ttps://www.ncbi.nlm.nih.gov/books/NBK143167/
On 2/05/25 at approximately 7:00 PM., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.
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
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facilit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to reflect resident's cultural and ethnic needs of the resident by not providing meal preferences for one (1) of 63 residents (Resident #36), in the survey sample.
The findings included:
Resident #36 was originally admitted to the facility on [DATE]. The resident has never been discharged from the facility. The current diagnoses included; Magnesium and Vitamin D Deficiency.
The Annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/21/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 8 out of a possible 15. This indicated Resident #36 cognitive abilities for daily decision making were moderately impaired.
On 1/30/25 at approximately 12:00 PM., an interview was conducted with Resident #36. Resident #36 was asked if she had concerns with the food. The resident mentioned that she was from Ghana and would like to eat red beans and rice but it is never served to her.
On 2/03/25 at approximately 3:25 PM., an interview was conducted with the dietary manager concerning Resident #36. The dietary manager said that she will try to accommodate the residents by providing food preferences but Resident #36 never said anything about the food that she was eating.
The Physician's Order Summary (POS) dated 4/05/21 read: Regular diet, Regular texture, Regular/Thin consistency.
Dietary profile was not completed on 4/7/2021. The Nutritional Evaluation Initial and Annual RD only, was Completed on 4/07/21. Diet History and Food Preference document was left blank.
On 2/04/25 at the dietary manager approached the surveyor and resident in the dining room. The dietary manager showed the surveyor pictures of the resident eating Red Beans and [NAME] and chicken on 2/2/25. The resident said that it tasted okay, but it was the first time she received a preferenced meal since her admission.
02/05/25 10:25 AM Received dietary timeline from the Regional Nurse Consultant. The list of remote dieticians was reviewed, no gap services was noted.
The care plan dated 10/23/24 for Resident #36 read that resident is at risk for alteration in nutritional status. The Goal is for the resident to maintain stable weight. The interventions for Resident #36 are to weigh the resident per protocol and to identify and honor preferences.
On 2/04/25 at approximately 12:50 PM., a telephone interview was conducted with the dietician concerning Resident #36 cultural food preferences. The dietician said that she worked remotely as she lives in Ohio. The dietician also said that she does not review food preferences because it was the role of the dietary manager. The dietician also mentioned that she can make recommendations, but the dietary manager needed to ensure food preferences are updated. The dietician said that orders are given to the Director of Nursing (DON).
The Policy Read: A Dietician is a qualified, competent, and skilled Dietician will help oversee the food and nutrition services in the facility. Specific Procedures: Developing and implementing person centered education programs involving food and nutrition services for all facility staff.
On 2/05/25 at approximately 7:00 PM., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.
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 F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to ensure that a resident's lunch was palatable and att...
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Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to ensure that a resident's lunch was palatable and attractive for one (1) of 63 residents (Resident #129), in the survey sample.
The findings included:
Resident #129 was originally admitted to the facility 8/20/24. The resident has never been discharged from the facility. The current diagnoses included; Unspecified Protein Calorie Malnutrition.
The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/23/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #129 cognitive abilities for daily decision making were intact.
The care plan dated on 1/16/25 read that Resident #129 was at risk for weight loss, malnutrition or poor hydration status related to chronic disease. The goal for Resident #129 was for the resident to have optimal nutrition and hydration status. The intervention for Resident #129 was to record the meal percentage intake.
The Physicians Order Summary (POS) for February 2025 read: Regular diet, Regular texture, Regular/Thin consistency for double portions as of 8/20/24.
On 1/30/25 at approximately 1:15 PM., Surveyor G, entered Unit 4 with the dietary manager to sample a test tray due to facility staff saying food is cold and unpalatable. Resident #129 was heard complaining about his lunch while sitting in the dining room. This surveyor (G), assured resident that she will speak to him in shortly as she was getting ready to sample her test tray with the dietary manager present. The lunch Test Tray Meal consisted of Salsbury Steak (145 F), Mashed Pot & Gravy (150 F)., Peas (136.4 F), roll (dark brown on top, appears burnt) and a brownie. The meal presentation was good except the dark brown roll, the taste was ok.
On 1/30/25 at approximately, 1:20 PM., an observation was made to Resident #129's tray. Two brown beef patties appeared dark brown around the edges, the roll was dark brown on the top, with an appearance of being burnt, peas and mashed potatoes appeared to be ok. Resident #129 asked surveyor G, You from the government? This is what they feed me; would you serve this to anybody? You got the nerve to serve this to me (looking at the dietary manager), this bread (Roll) is black, burned and I am a baker. The patties are burnt, and overly cooked. Look at this, the food is criminal here. The dietary manager offered several times to bring the resident another plate food or to fix something else, but the resident declined and said she was just upset. The resident then asked the dietary manager if she was ashamed, The food is like this all of the time.
On 2/03/25 an interview was conducted with the dietary manager at approximately 3:27 PM., concerning Resident #129. The dietary manager said that the resident's food tray is checked everyday by her and or the staff to ensure the meal is okay.
On 2/05/25 at approximately 7:00 PM., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.
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
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, Resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure the facility maintained a safe, sanitary, and comfo...
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Based on observation, Resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure the facility maintained a safe, sanitary, and comfortable environment to prevent the transmission of communicable diseases and infections for the facility in general, and for two (2) residents (Residents #3, and #130) in a survey sample of 63 residents
The findings included:
1. On 1-28-25 during resident room observations, the room of Resident #3 was noted to have a sticky, tape style insect trap, hanging from the ceiling in the bathroom. The 2 inch wide by 24 inch long tape was so covered in insects that it had the appearance of fur covering it. A nurse was coming down the hall at that time and was asked to view the area. When asked if he thought it was safe and sanitary for the Resident, he stated no. Resident #3 stated yes, they have pest control bug people come and spray, however, she stated they only spray the halls, not the rooms, because they don't want to move things around in the room.
During the entire survey there were fruit flies as well as large flies, and cock roaches noted on all 4 living units, and in the common areas as well. A review of the pest control logs revealed that the facility is having pest control services come to the building monthly, however, the pests continue to be in the facility.
On 2-5-25 at the time of survey exit the facility Administrator, and Director of Nursing stated that pest control services had been in and treated rooms on unit #2, and that they had nothing further to provide.
2. On 1-28-25 during resident room observations, the room of Resident #130 was noted to have small red bugs on the floor under the bed of the Resident's room mate. The room mate was wearing stained dirty clothing with wet spots noted in his lap while he sat in a wheel chair. A nurse was coming down the hall at that time and was asked to view the area. When asked if he thought it was safe and sanitary for the Resident, he stated no. He further stated he would get the Maintenance Director to have pest control come and treat the room. Resident #130 also stated yes, they have pest control bug people come and spray, however, they only spray the halls, not the rooms, because they don't want to move things around in the room.
During the entire survey there were fruit flies as well as large flies, and cock roaches noted on all 4 living units, and in the common areas as well. A review of the pest control logs revealed that the facility is having pest control services come to the building monthly, however, the pests continue to be in the facility.
On 2-5-25 at the time of survey exit the facility Administrator, and Director of Nursing stated that pest control services had been in and treated rooms on Unit #2, and had eradicated the bed bugs in Resident #130's room, and that they had nothing further to provide.
3. The facility staff failed to prevent contamination of the clean linens in the closet on Unit Four.
On 1/30/25 at approximately 1:45 PM in the Dayroom on Unit Four Resident #21 was observed wearing urine saturated pants. The resident stated his bladder was weak and he could no longer hold his urine. He was observed opening the linen closet and obtain washcloths and towels.
Also on 1/30/25 at approximately 1:55 PM in the Dayroom on Unit Four Resident #33 was observed removing linen from the linen closet. The resident stated most of the time she comes to the linen closet to obtain her needed linens. She further stated if staff is on their break when she enters the Dayroom they would obtain the linens for her.
An interview was conducted with the Environmental Services Director (EVSD) on 1/31/25 at approximately 11:00 AM. The EVSD stated she was aware that some residents on Unit Four was helping themselves to the linen, but it was not preferable due to any cross contamination going in and out of the cart. He stated the linen has been assessable to the residents because the staff had misplaced the lock to the linen closet again. She stated the lock had been missing for approximately one month. The EVSD also stated the missing lock had been reported to the Maintenance Director but it had not been acted upon yet.
An interview was conducted with the Maintenance Director on 2/5/25 at 12:56 PM. The Maintenance Director stated keeping a lock on the linen closet is an ongoing concern and he has purchased numerous locks and applied them but the key or the lock is soon misplaced, never to be found again. The Maintenance Director stated provided an invoice for a new lock and stated it was added to the Unit Four linen closet on 1/31/25.
On 2/5/25 at approximately 4:20 PM, a final interview was conducted with the Administrator, Director of Nursing and four Corporate Consultants. The administrative team was informed of the the above information. No additional information was provided and no concerns were voiced.
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 F0914
(Tag F0914)
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, the facility staff failed to ensure rooms had visual privacy for five...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, the facility staff failed to ensure rooms had visual privacy for five (5) Residents (Residents # 123, # 2, # 128, # 132 and #46 ) in a survey sample of 63 residents.
Findings included:
1. For Resident # 123, the facility staff failed to ensure the room was equipped with curtains that would extend around the bed.
Resident # 123 was admitted to the facility on [DATE] with the diagnoses of, but not limited to: Dementia with Agitation, Diabetes, Hypertension, and Legal blindness.
The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 1/7/2025. Resident # 123's BIMS (Brief Interview for Mental Status) Score was a 13 out of 15, indicating no cognitive impairment.
Review of the clinical record was conducted on 1/28/2025 to 1/31/2025 and 2/3/2025 to 2/5/2025.
On 1/29/2025 at 10:20 a.m., the surveyor observed a Certified Nursing Assistant providing ADL (Activities of Daily Living) care to Resident # 123. There was no privacy curtain around the bed.
Interviews were conducted with the Director of Housekeeping who stated she had been trying to obtain replacement curtains and curtain hooks for several rooms. The Director of Housekeeping stated due to the fact that there were not enough curtains, the housekeeping staff would remove the curtains when soiled, wash them and re-hang them when taken out of the laundry. The Director of Housekeeping stated she realized the importance of the residents having privacy.
On 2/4/2025 during the end of day meeting, the Administrator, Corporate Nurse Consultants and Director of Nursing were made aware of the findings. No further information was provided.
2. For Resident # 2, the facility staff failed to ensure the room was equipped with curtains that would extend around the bed.
Resident # 2 was admitted on [DATE] with diagnoses including but not limited to: Epilepsy, Seizures, Confirmed Physical Abuse, Confirmed Psychological Abuse, Major Depressive Disorder, Anxiety Disorder, and Neoplasm of the Brain.
Resident #2's most recent MDS (Minimum Data Set) was a Quarterly Assessment with an ARD (Assessment Reference Date) of 12/27/2024 coded the Resident as having a BIMS (Brief Interview of Mental Status) score of 13 out of 15 indicating no cognitive impairment.
Review of the clinical record was conducted on 1/28/2025 to 1/31/2025 and 2/3/2025 to 2/5/2025.
Observations were made of there being one quarter panel curtain suspended above Resident # 2's bed. The curtain did not extend around the bed to completely provide visual privacy while ADL care was being provided.
Resident # 2 had a roommate in the room. The roommate (Resident # 123) was in the room while ADL care was being provided for Resident # 2.
The Certified Nursing Assistant stated she was an agency employee. The Certified Nursing Assistant stated she pulled the curtain as far as she could and tried to shield the resident while providing care.
There was no privacy curtain pulled around Resident # 2's bed. The privacy curtain was a quarter panel, covering only a portion of the resident and the bed. The panel was not wide enough to cover the entire bed but only approximately one fourth of the area around the bed.o
Interviews were conducted with the Director of Housekeeping who stated she had been trying to obtain replacement curtains and curtain hooks for several rooms. The Director of Housekeeping stated due to the fact that there were not enough curtains, the housekeeping staff would remove the curtains when soiled, wash them and re-hang them when taken out of the laundry. The Director of Housekeeping stated she realized the importance of the residents having privacy.
On 2/4/2025 at approximately 3:24 p.m., the Housekeeping Director was observed in the hallway near Resident # 2's room. The Housekeeping Director went into the room with the surveyor. She was interviewed and stated she knew the curtain was not large enough to completely cover the bed. The Housekeeping Director stated she was trying to get more curtains for all of the rooms.
On 2/4/2025 during the end of day meeting, the Administrator, Corporate Nurse Consultants and Director of Nursing were made aware of the findings. No further information was provided.
3. For Resident # 128 , the facility staff failed to ensure the room was equipped with curtains that would extend around the bed.
During rounds on 2/4/2025, the surveyor observed Resident # 128 was lying in bed. Resident # 128 quickly pulled the covers up when the surveyor entered the room. Resident # 128 stated the curtains could not completely protect him when he was trying to use the urinal. He stated the curtains did not fit completely. When you pull one side, the other is exposed. Resident # 128 asked the surveyor to try to pull the curtain so he could use the urinal privately. The curtain did not fit around the bed. Resident # 128 stated he always had to make sure the door to the room was closed so he could quickly try to void before someone came into the room.
Interviews were conducted with the Director of Housekeeping who stated she had been trying to obtain replacement curtains and curtain hooks for several rooms. The Director of Housekeeping stated due to the fact that there were not enough curtains, the housekeeping staff would remove the curtains when soiled, wash them and re-hang them when taken out of the laundry. The Director of Housekeeping stated she realized the importance of the residents having privacy.
On 2/4/2025 during the end of day meeting, the Administrator, Corporate Nurse Consultants and Director of Nursing were made aware of the findings. No further information was provided.5. The facility staff failed to ensure that Resident # 46 had a privacy curtain large enough to maintain privacy while the resident was receiving incontinence and Activity of Daily Living (ADL) care.
Resident #46 was originally admitted to the facility 1/04/22 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Chronic Kidney Disease.
The annual, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/28/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #46 cognitive abilities for daily decision making were intact.
In sectionGG(Functional Abilities Goals) the resident was coded as requiring supervision with eating, upper body dressing, requires substantial/maximal assistance with toileting hygiene, showers/bathing, lower body dressing and personal hygiene.
The care plan dated 7/11/23 read that resident has an ADL self-care performance deficit r/t Weakness, Acute Kidney Failure, history of Falling, Epilepsy and Bipolar Disorder, history of falls. The Goal is the resident will improve current level of function in through the review date (11/21/23). The intervention: Monitor/document/report as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function.
On 01/29/25 at approximately 11:30 AM., while rounding in the hallway on unit 4, Resident #46 was heard yelling for his Certified Nurse's Assistant (CNA) B, by her first name several times.
On 01/29/25 at approximately 11:39 AM., CNA B entered Resident #46 room (403B unit 4). The resident had informed her that he had a Bowel Movement (BM). After receiving permission from Resident #46 to observe his care, CNA B began incontinent and ADL care on the resident. There was a partial privacy curtain preventing the resident across from him to seeing the ADL care, the door to room [ROOM NUMBER] B was closed. Visibly from the door the resident could be seen receiving care. A timeline of events: 11:51 AM., there was a knock at the door, two staff quickly entered the room while the resident was exposed, receiving Activities of Daily Living (ADL), incontinent care. 11:54 AM., there was a knock at the door, then quickly, the door opened, entered one staff, resident still exposed, while receiving ADL care. 11:56 AM., there was a knock at the door, the Assistant Director of Nursing (ADON) quickly entered the room and said I'm just rounding. CNA B, said I'm ok.
On 02/05/25 at approximately 1:56 PM., an interview was conducted with CNA F concerning the above incident. CNA F said that She shouldn't have walked into the residents' room while he was receiving care. CNA F also said that months ago that she informed a nurse that some of the rooms didn't have privacy curtains. CNA F also said that if the rooms don't have privacy curtains, she will just make sure the door is closed.
On 2/03/25 at approximately 4:21 PM., an interview was conducted with the Director of Nursing (DON) concerning the privacy curtains. The DON said after knocking on a resident's closed-door staff should wait to hear what the CNA is saying first before entering.
On 02/03/25 at approximately 3:19 PM., an interview was conducted with CNA B concerning Resident #46. CNA B said that no one should walk in the room while care is being provided. CNA B also said that the resident only had a portion of a privacy curtain when care was being rendered.
On 2/05/25 at approximately 7:00 PM., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information, but no additional information was provided.
4. The facility failed to provide a window blind to provide full visual privacy for Resident #132 in a resident room (room [ROOM NUMBER]-Unit two (2).
Resident #132 was originally admitted to the facility 9/23/24. The resident's diagnoses included acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, schizoaffective disorder, and essential hypertension.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/30/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 10 out of a possible 15. This indicated Resident #132's cognitive abilities for daily decision making were moderately impaired.
During an observation on 12/29/25 at 11:30 AM the window blind in the window of room [ROOM NUMBER] was severely damage, allowing individuals to look into the window from the outside.
On 12/29/25 at 11:40 AM an interview was conducted with Licensed Practical Nurse (LPN) (E). LPN (E) stated that the window blind in room [ROOM NUMBER] should have been fixed and this is a privacy issue due to individuals being able to see in the window from the outside.
During an observation on 2/3/25 at 2:15 PM the window blind in room [ROOM NUMBER] was still not repaired or replaced, continuing to allow individuals to look into the window from the outside.
On 2/3/25 at 2:25 PM an interview was conducted with the Regional Director of Maintenance. The Regional Director of Maintenance stated that due to the window blind in room [ROOM NUMBER] missing slates and individuals being able to look in the room from the outside, this is a privacy issue.
On 2/5/25 at 6:55 PM a final interview was conducted with the Administrator, Director of Nursing, Regional MDS, Regional Nursing Consultant, Regional Maintenance Director, [NAME] President of Clinical Services, Regional Risk Management, and Regional Director 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
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, Resident interview, staff interview and clinical record review, the facility staff failed to provide servi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, Resident interview, staff interview and clinical record review, the facility staff failed to provide services in the facility with reasonable accommodation of resident needs and preferences, for 4 Residents (# 123, #2, # 76 and # 113) in a survey sample of 63 Residents.
The findings included:
1. For Resident # 123, the facility staff failed to ensure the clock on the bedroom wall had the proper time.
Resident # 123 was admitted to the facility on [DATE] with the diagnoses of, but not limited to: Dementia with Agitation, Diabetes, Hypertension, and Legal blindness.
The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 1/8/2025. Resident # 123's BIMS (Brief Interview for Mental Status) Score was a 13 out of 15, indicating no cognitive impairment.
Review of the clinical record was conducted on 1/28/2025 to 1/31/2025 and 2/3/2025 to 2/5/2025.
During rounds on 1/28/2025 at 1:15 p.m., Resident # 123 was observed lying in the bed. Resident # 123 was alert, oriented and able to converse with the surveyor. Resident # 123 stated the facility staff acted like she didn't know what she was talking about and stated that clock is wrong. The time on the clock in Resident # 123's room closest to her bed was observed to have the time of 2:15. The second hand was working. Resident # 123 stated she technically was blind but could see some things. She pointed to a watch on her right arm and stated it was hard to see the time on it. She stated the watch was very special to her.
The room was a quad room designed and equipped to house four residents. However, there were only 2 residents residing in the room. One resident ( Resident # 2) was in the bed on the far left corner with the bed in a vertical position and Resident # 123 was in the far right corner with the bed in a horizontal position.
There was another clock approximately 6 feet away from Resident # 123's bed that was positioned over a space where another resident must have resided formerly. There was nobody residing in that space during the time of the survey. The time on that clock had the time of 6:42 over the area with an empty bed space. It was observed that the second hand was not working.
On 1/29/2025 at 11:02 a.m., the clock had the time of 12:02. The time on that clock over the empty space adjacent to Resident # 123's bed had the time of 6:42.
On 1/30/2025 at 9:40 a.m., the clock had the time of 10:40. The time on that clock over the empty space adjacent to Resident # 123's bed had the time of 6:42.
On 1/31/2025 at 2:03 p.m., the clock had the time of 3:03. The time on that clock over the empty space adjacent to Resident # 123's bed had the time of 6:42.
On 2/3/2025 at 3:15 p.m., an interview was conducted with Registered Nurse-B who stated it was important for the time on the clocks to be correct. She stated the correct time helped the residents with orientation of time.
Staff persons were observed in the room picking up food trays, and delivering ice and water. No staff person addressed the issue of the clock having the wrong time.
The Director of Nursing stated the clock in the rooms should have had the correct time because it was important for the orientation of the residents. She stated staff members should have observed the clock was wrong and should have corrected the issue.
During the end of day debriefing on 1/31/2025, the Facility Administrator, two Regional Nurse Consultants and Director of Nursing were informed of the findings that the clock closest to Resident # 123's bed was working properly but was always one hour ahead of time and the clock over the empty space was not working and had the time of 6:42. They all stated the clocks in residents' rooms should be accurate. No further information was provided.
2. For Resident # 2, the facility staff failed to ensure the clock on the bedroom wall had the correct time.
Resident # 2 was admitted on [DATE] with diagnoses including but not limited to: Epilepsy, Seizures, Confirmed Physical Abuse, Confirmed Psychological Abuse, Major Depressive Disorder, Anxiety Disorder, and Neoplasm of the Brain.
Resident #2's most recent MDS (Minimum Data Set) was a Quarterly Assessment with an ARD (Assessment Reference Date) of 12/27/2024 coded the Resident as having a BIMS (Brief Interview of Mental Status) score of 13 out of 15 indicating no cognitive impairment.
Review of the clinical record was conducted on 1/28/2025 to 1/31/2025 and 2/3/2025 to 2/5/2025.
During rounds on 1/28/2025 at 1:15 p.m., Resident # 2 was observed lying in the bed watching TV. Resident # 2 was alert, oriented and able to converse with the surveyor.
On 1/29/2025 at 11:02 a.m. during rounds, Resident # 2 was heard yelling loudly in the room. When the surveyor entered the room and asked what was wrong, Resident # 2 stated that she wanted to know why the staff had not brought her lunch. Resident # 2 seemed upset and agitated. The surveyor stated it was only 11:02 and asked what time lunch normally was served. Resident # 2 yelled that they always bring her food late. She looked diagonally across the room to the clock over her roommate's bed and stated it's after 12 and no lunch yet. The time on the clock over the roommate's bed ( Resident # 123) was observed to have the time of 12:02. The second hand was working properly. Resident # 2 stated she did not have a clock near her bed so she always looked at the clock over her roommate's bed. When the surveyor told her the time was after 11, Resident # 2 stated the time on the clock said 12 so that's what time she thought it was.
The room was a quad room designed and equipped to house four residents. However, there were only 2 residents residing in the room. Resident # 2 was in the bed on the far left corner with the bed in a vertical position and the roommate (Resident # 123) was in the far right corner with the bed in a horizontal position.
There was another clock approximately 6 feet away from Resident # 123's bed that was positioned over a space where another resident must have resided formerly. There was nobody residing in that space during the time of the survey. The time on that clock had the time of 6:42 over the area with an empty bed space. It was observed that the second hand was not working.
Resident # 2 could look to her left and see the clock over her roommate's bed and the the clock over the empty space beside the roommate.
On 1/29/2025 at 11:02 a.m., the clock had the time of 12:02. The time on that clock over the empty space adjacent to Resident # 123's bed had the time of 6:42.
On 1/30/2025 at 9:40 a.m., the clock had the time of 10:40. The time on that clock over the empty space adjacent to Resident # 123's bed had the time of 6:42.
On 1/31/2025 at 2:03 p.m., the clock had the time of 3:03. The time on that clock over the empty space adjacent to Resident # 123's bed had the time of 6:42.
Staff members were observed providing care, delivering and picking up trays during the survey. No staff member addressed the time on the clock. The time on the clock over the roommate's bed was always one hour ahead and the time on the clock over the empty space was 6:42.
On 2/3/2025 at 3:15 p.m., an interview was conducted with Registered Nurse-B who stated it was important for the time on the clocks to be correct. She stated the correct time helped the residents with orientation of time.
The Director of Nursing stated the clock in the rooms should have had the correct time because it was important for the orientation of the residents. She stated staff members should have observed the clock was wrong and should have corrected the issue.
During the end of day debriefing on 1/31/2025, the Facility Administrator, two Regional Nurse Consultants and Director of Nursing were informed of the findings that both clocks in the room had the wrong time. One clock closest to the roommate's bed ( Resident # 123) bed was working properly but was always one hour ahead of time and the clock over the empty space was not working and had the time of 6:42. They all stated the clocks in residents' rooms should be accurate. No further information was provided.
3. For Resident # 76, the facility staff failed to ensure the clock on the bedroom wall had the proper time.
Resident # 76 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, Hemiplegia and Hemiparesis following Cerebral Infarction, Bipolar Disorder, Osteoarthritis, Type 2 Diabetes, Contracture of Left hand, and Blindness in right eye.
The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 12/7/2024. Resident # 76's BIMS (Brief Interview for Mental Status) Score was a 13 out of 15, indicating no cognitive impairment.
Review of the clinical record was conducted on 1/28/2025 to 1/31/2025 and 2/3/2025 to 2/5/2025.
During rounds on 1/28/2025 at 1:15 p.m., Resident # 76 was observed lying in the bed. Resident # 76 was alert, oriented and able to converse with the surveyor. The time on the clock in Resident # 76's room was above the bed of the roommate (Resident # 113.) The time on the clock was 12:15. The second hand was working properly.
On 1/29/2025 at 12:04 p.m., the clock had the time of 11:04.
On 1/30/2025 at 10:45 a.m., the clock had the time of 9:45.
On 1/31/2025 at 2:10 p.m., the clock had the time of 1:10.
Staff persons were observed in the room picking up food trays, and delivering ice and water during the survey. No staff person addressed the issue of the clock having the wrong time.
On 2/03/2025 at 01:28 p.m.- Observed the time on the clock was wrong during 5 days of survey- Interview conducted with Resident # 76 who stated he uses his phone but sometimes he can't find the phone. Stated he likes to look at the clock.
On 2/3/2025 at 3:15 p.m., an interview was conducted with Registered Nurse-B who stated it was important for the time on the clocks to be correct. She stated the correct time helped the residents with orientation of time.
The Director of Nursing stated the clock in the rooms should have had the correct time because it was important for the orientation of the residents. She stated staff members should have observed the clock was wrong and should have corrected the issue.
During the end of day debriefing on 2/5/2025, the Facility Administrator, two Regional Nurse Consultants and Director of Nursing were informed of the findings that the clock closest to Resident # 113's bed was working properly but was always one hour behind time. They all stated the clocks in residents' rooms should be accurate.
No further information was provided.
4. For Resident #113, the facility staff failed to ensure the clock on the bedroom wall had the proper time.
Resident # 113 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, Diabetes, Chronic Kidney Disease, Acute and Chronic Respiratory Failure, Hypertension, Non-[NAME] Lymphoma, Congestive Heart Failure, Major Depressive Disorder, Venous Thrombosis and Embolism and Ischemic Heart Disease.
The most recent Minimum Data Set (MDS) was a Quarterly Assessment with an Assessment Reference Date (ARD) of 1/1/2025. Resident # 123's BIMS (Brief Interview for Mental Status) Score was a 14 out of 15, indicating no cognitive impairment.
Review of the clinical record was conducted on 1/28/2025 to 1/31/2025 and 2/3/2025 to 2/5/2025.
During rounds on 1/28/2025 at 3:15 p.m., Resident # 113 was observed sitting on the side of the bed and watching television. Resident # 113 was alert, oriented and able to converse with the surveyor. The time on the clock at the head of the bed stated 2:15.
On 1/29/2025 at 12:04 p.m., the clock had the time of 11:04.
On 1/30/2025 at 10:45 a.m., the clock had the time of 9:45.
On 1/31/2025 at 2:10 p.m., the clock had the time of 1:10.
On 2/03/2025 at 01:28 p.m.- Observed the time on the clock was wrong during 5 days of survey. An interview was conducted with Resident # 113. When asked about any concerns, Resident # 113 stated he had was wondering why the staff never fixed the time on the clock. He stated they don't even look at the clock. Resident # 113 pointed to a clock on the wall and laughed. The time on the clock in Resident # 113's room was observed to have the time of 12:15. Resident # 113 stated they leave it alone so that they only have to change it once a year. It's only wrong when the time changes. He stated he was going to check to see how long they were going to let it be wrong. He stated he used his phone but sometimes the phone could be off.
On 2/3/2025 at 3:15 p.m., an interview was conducted with Registered Nurse-B who stated it was important for the time on the clocks to be correct. She stated the correct time helped the residents with orientation of time.
The Director of Nursing stated the clock in the rooms should have had the correct time because it was important for the orientation of the residents. She stated staff members should have observed the clock was wrong and should have corrected the issue.
During the end of day debriefing on 1/31/2025, the Facility Administrator, two Regional Nurse Consultants and Director of Nursing were informed of the findings that the clock closest to Resident # 123's bed was working properly but was always one hour behind time. They all stated the clocks in residents' rooms should be accurate.
No further information was provided.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility failed to ensure residents on three of three living units were free from misappropriation of resident property, to include specifics for one Resident #441 in a sample of 63 residents.
The findings included;
On three of three units the facility staff failed to prevent misappropriation of resident property.
1. On 1/31/2025 at 1:10 p.m., an interview was conducted with the Social Services Assistant who stated the facility staff conducted clothing drives for residents. He stated that whenever clothing was located in the Laundry department that did not have labels with names of residents identified, those items were placed in an area for residents to search through at a later time.
The Social Services Assistant stated family members were not asked to search through the unlabeled clothing when there were complaints about missing clothing.
On 1/31/2025 at 2:20 p.m., an interview was conducted with the Housekeeping Director who stated all clothing without labels that came to the laundry would be placed in a designated area. The Housekeeping Director stated that sometimes the laundry staff would find personal items rolled in the soiled linens. There was no way to determine who the personal items belonged to if there were no names on the items. The unlabelled items could come from any of the three units. The Housekeeping Director stated residents and families could search in the Designated area if accompanied by a facility staff member.
On 2/4/2025 at 1:10 p.m., an interview was conducted with the Director of Social Services and the Social Services Assistant who both stated they did not have any information about unlabeled clothing. Both were new in their positions at the facility. They stated the facility should try to ensure resident's belongings get returned to them. They stated families and residents were encouraged to put their names in their clothing so they could be identified.
Review of the Grievances Log revealed documentation of complaints from residents and families about missing clothing.
One surveyor reported that a family member of one of the Residents complained of seeing another resident wearing his jacket. The family member told that surveyor that he knew for a fact that the jacket did not belong to the resident who was seen wearing it.
During the end of day debriefing on 2/4/2025, the facility Administrator, Director of Nursing and Corporate Consultants were informed of the findings that the facility did not ensure there was no misappropriation of resident property. They stated the facility should ensure residents' have their personal belongings returned to them.
No further information was provided.
2. The facility failed to prevent misappropriation of Residents #441's property.
Resident #441 was admitted to the facility on [DATE], with the diagnoses of, but not limited to, sequalae cerebral infarct, diabetes mellitus, major depressive disorder, and dysphagia. The resident was discharged to another facility on 07/02/2024 and did not return.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 06/19/2024 coded Resident #441 with a Brief Interview for Mental Status (BIMS) with a score of 14 out of a possible score of 15 demonstrating minimal cognitive impairment.
On 01/28/2025, during the initial tour of facility, residents were observed in wheelchairs in the first-floor activity room going to the smoking area attached to the activity room, dressed in jackets and coats. The activity director stated that some of the residents obtained coats, jackets and clothing items from the clothing drive on 01/24/2025.
On 01/31/2025, at 11:15 a.m., an interview was conducted with Facility Housekeeping manager and the Regional Housekeeping manager who stated that the clothing issue has improved since they purchased a new label maker. They also educated the unit managers to re-educate staff and families that all clothing items should be labeled. The Housekeeping Manager states that they had a clothing drive coordinated with Social Services and the Activity Director. Residents were allowed to look through unidentified and unclaimed clothing items (lost and found) that remained in the laundry department along with donated clothing. The residents could pick items that they wanted. The clothing items were then labeled with the resident's name and the resident was allowed to keep the items.
On 01/31/2025, a review of the facility grievance logs revealed, although there were no grievances related to Resident #441 missing clothing or a jacket, there were multiple grievances regarding other residents in the facility missing clothing and personal property.
On 01/31/2025, and interview was conducted with the Director of Nursing (DON). She was asked if she was aware that there were multiple reports residents missing clothing. The DON stated that she is new to the facility, but that she was informed that resident clothing was going to laundry unidentified therefor not being returned to the residents. She went on to say that they a new label maker and iron and have re-educated the staff on units regarding the importance of having all resident clothing items labeled.
A closed record review was conducted during 3 days of the survey 01/28/2025-02/03/2025 revealed that there was no documentation that it was reported that resident #441 was missing clothing or personal items.
On 2/03/2025 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review and facility documentation review the facility staff failed to review and revise the ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review and facility documentation review the facility staff failed to review and revise the care plans for 5 Residents (#42, 106, 124, 130, and #132) in a survey sample of 63 Residents.
The findings included:
For Resident #42 the facility staff failed to review and revise the care plan after non-compliance with alcohol and substance abuse incidents.
Resident #42 was admitted to the facility on [DATE] with diagnoses that included but were not limited to COPD (Chronic Obstructive Pulmonary Disease), bipolar disorder, sleep apnea, hypertension, fusion of cervical spine, heart failure, major depressive disorder, history of venous thrombosis, (blood clot), anxiety disorder and viral hepatitis C.
A review of the clinical record revealed the following incidents involving Resident #42:
7/15/24, 9/9/24 and 10/3/24 Resident #1 was caught smoking in the facility.
10/11/24 - Cheeking PRN Narcotic Pain Meds (storing meds in cheek to avoid swallowing, this is done to hoard medication for later consumption)
10/22/24 - Sent to ER for intoxication
12/27/24 - Sent to ER for AMS (Altered Mental Status) ER notes document Resident #1 admitted to use of heroin.
12/30/24 - MD notes refer to Resident #1 being on LOA (Leave of Absence) and being sent to the ER while on LOA for overdose of heroin.
A review of the clinical record revealed the following care plan entry with regard to substance use:
FOCUS: BEHAVIORS- the resident has admitted behaviors of drug and alcohol abuse when leaving the facility. Date Initiated: 01/03/2025.
GOAL: [left blank; no data entered]
INTERVENTION: Notify MD as indicated Date Initiated: 01/03/2025
Referral to inpatient drug abuse recovery center. Date Initiated: 01/03/2025 Revision on: 01/03/2025
FOCUS: Potential for safety hazard, injury r/t smoking. Date Initiated: 06/13/2024
GOAL - [Resident #1 name redacted] will not smoke without supervision through the review date.
Date Initiated: 06/13/2024 Revision on: 06/13/2024
Notify charge nurse immediately if it is suspected that [NAME] has violated facility smoking policy.
Date Initiated: 06/13/2024
Observe oral hygiene. Date Initiated: 06/13/2024
Smoking allowed only in designated smoking areas. Smoking only allowed by long term residents that have been grandfathered in by policy. Date Initiated: 06/13/2024
While smoking, will have direct supervision by staff or family member. Date Initiated: 06/13/2024.
2. For Resident #106 the facility staff failed to review and revise the care plan after non-compliance with alcohol and substance abuse incidents and non-compliance with weapons in the facility.
Resident #106 was admitted to the facility on [DATE] with diagnoses that included but were not limited to history of multiple medical problems including gunshot wound to the head with stroke secondary to injury, hemiplegia, moderate recurrent major depression disorder, seizure disorder, late effect of traumatic brain injury, insomnia, and muscle spasms.
A review of the clinical record revealed the following incidents involving Resident #106:
8/21/24 - Resident #106 admitted to taking money from roommate to buy alcohol and methamphetamine
9/9/24 - Resident #106 was found knife / boxcutter.
9/16/24 - Alcohol found on Resident #106 who was showing signs of AMS (Altered Mental Status) and was sent to ED found to be positive for alcohol, marijuana and cocaine use.
12/16/24 - Resident #106 found with AMS and admitted to staff obtaining Suboxone and beer and using them both in facility.
12/23/24 - Resident #106 was sent to the ER for AMS returned without paperwork from ER
12/31/24 - Resident #106 was found in the facility with alcohol
1/4/25 - Resident #106 was found making weapons in his room with lighter and fork (removed all but 1 of the tines on 2 forks found burning them with a lighter)
A review of the care plan revealed the following with regard to smoking, and substance abuse. The care plan did not address the weapon making in the facility.
FOCUS: Potential for safety hazard, injury r/t smoking. Date Initiated: 05/23/2024
GOAL: Will not cause injury to self or others, or damage to property r/t smoking. Date Initiated: 05/23/2024 Revision on: 05/30/2024
INTERVENTION: Keep all smoking materials at nurses station. Smoking materials to be returned to nurse's station after smoke break. Date Initiated: 05/23/2024
While smoking, will have direct supervision by staff or family member. Date Initiated: 05/23/2024.
FOCUS: BEHAVIORS: the resident has drug and alcohol behaviors when leaving the facility and has been caught with alcohol while in the facility Date Initiated: 01/03/2025
GOAL -The resident's behaviors will cause them less distress thru the review period Date Initiated: 01/16/2025
he resident's behaviors will not cause them or other resident's distress thru the review period Date Initiated: 01/16/2025
INTERVENTIONS: 1:1 activities as needed Date Initiated: 01/16/2025
Explain all procedures to the resident before starting and allow the resident time to adjust to changes Date Initiated: 01/20/2025
Physician review of medications as needed Date Initiated: 01/16/2025
referred to inpatient recovery for drug and alcohol abuse. Date Initiated: 01/03/2025 Revision on: 01/03/2025
3. For Resident #124 the facility staff failed to review and revise the care plan after non-compliance with alcohol and substance use.
Resident #124 was admitted to the facility on [DATE] with diagnoses acute osteomyelitis, type diabetes, chronic viral hepatitis, hypertension, complications of skin graft, major depressive disorder, chronic kidney disease, and diabetic foot ulcer.
A review of the clinical record revealed the following incidents involving Resident #124:
12/12/24 - Resident #124 found with chest pain and shortness of breath after going LOA 7-11 am
admitted to snorting and unknown substance that he believes it was laced with fentanyl. NP asked resident to do a drugs test. Resident refused to go to ER and Refused drug testing.
12/13/24 - Sent to the ER - Resident #124 found sweating profusely and stated, I feel like I'm withdrawing from something, admitted to snorting something starting 3 days ago and not knowing what it was, also stated I snorted a little something this morning.
1/4/25 - Sent to the ER for withdrawals.
A review of the care plan revealed the following with regard to smoking, and substance abuse.
Focus - HX OF DRUG USE: The resident is at risk for complications due to a history of illicit drugs use Date Initiated: 12/16/2024 Revision on: 12/16/2024
GOAL: The resident will not have any adverse reactions related to alcoholism thru review period Date Initiated: 12/16/2024 Target Date: 03/16/2025
INTERVENTION: Observe resident for any signs and symptoms of intoxication or withdrawal from drugs such as tremors, nausea/vomiting(severe), sweating and notify MD as indicated Date Initiated: 12/16/2024
Administer medication as ordered Date Initiated: 12/16/2024
vitals as needed Date Initiated: 12/16/2024.
4. For Resident #130 the facility staff failed to review and revise the care plan after non-compliance with alcohol and substance use.
Resident #130 was admitted to the facility on [DATE] with diagnoses included but were not limited to sepsis due to methicillin susceptible staph, major depressive disorder, anxiety disorder, acquired hypertension, acute kidney failure, type 2 diabetes, nicotine dependence, protein calorie malnutrition, and history of infectious parasitic disease.
A review of the clinical record revealed the following incidents involving Resident #130:
9/9/24 - Resident #130 was caught smoking marijuana in room refused to give it to staff.
12/20/24 - Resident #130 was found by staff at 4:00 a.m. in dining room with AMS (Altered Mental Status), very lethargic sitting in wheelchair stated, I'm high as a bitch. Refused to go to the ER
1/3/25 - Staff reported strong odor of marijuana in Resident #130's room.
A review of the clinical record revealed the following care plan entry with regard to the use of illicit drugs and or alcohol:
FOCUS: BEHAVIORS: the resident has behaviors of (SPECIFY) Resident has behavior in using drugs and alcohol while on premise. Drugs have been confiscated from resident's room. Date Initiated: 11/06/2024 Revision on: 01/03/2025
GOAL: the resident's behaviors will cause them less distress thru the review period Date Initiated: 11/06/2024 Target Date: 01/06/2025
INTERVENTIONS: Approach with a calm quiet voice, divert attention, and remove from the situation
and take to an alternative location as needed Date Initiated: 11/06/2024
Assure the resident they are safe and being cared for if they become distressed Date Initiated: 11/06/2024
Explain all procedures to the resident before starting and allow the resident time to adjust to changes Date Initiated: 11/06/2024
Monitor behavior episodes and attempt to determine the underlying cause. Consider location, time of day, persons involved and situations. Date Initiated: 11/06/2024
Notify MD as indicated Date Initiated: 11/06/2024
Physician review of medications as needed Date Initiated: 11/06/2024
A review of the facility policy entitled Care Planning Comprehensive Person-Centered, revealed the following excerpts:
15. Behavior intervention plan (BIP) may be developed when a resident exhibit behaviors that may place the resident, other resident or staff at risk or impedes on their rights.
a.
The BIP will be developed in collaboration with the resident, interdisciplinary team and mental health professionals as appropriate.
b.
The BIP will be incorporated into the resident's comprehensive care plan
i.
The BIP will be reviewed and updated as needed to address changes in the resident's behaviors.
c.
The BIP will clearly identify the behaviors being addressed, interventions/approaches to reduce behaviors and expected outcomes. The BIP will also include consequences and actions that may be taken should the resident not comply with the agreed expectations.
i.
The plan will honor the residents rights and dignity.
16. The care planning / interdisciplinary Team is responsible for the review and updating of care plans
a. When requested by the resident / resident representative
b. When there has been a significant change in the resident's condition.
c. When the desired outcome is not met.
d. When goals needs and preferences change
e. At least quarterly and after each OBRA MDS assessment.
On the morning of 1/12/25 an interview was conducted with the DON who was asked about care plans of Resident #'s 42, 106, 124 and 130 with regard to drug and alcohol use. When asked if the care plans had adequately addressed supervision of Residents after it was discovered they were using illicit drugs and / or alcohol, she stated that they had not. When asked what they could have implemented she stated that they could have implemented 1:1 supervision, and nursing assessments after LOA (Leave of Absence) from the building.
On 1/12/25 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.
5. Resident #132. The facility staff failed to revise the care plan timely in the area of receiving 1:1 staff supervision (Resident #132).
Resident #132 was originally admitted to the facility 9/23/24. The resident's diagnoses included acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, schizoaffective disorder, and essential hypertension.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/30/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 10 out of a possible 15. This indicated Resident #132's cognitive abilities for daily decision making were moderately impaired.
Observations were made of Resident #132 on 1/29/25 at 11:30 AM having 1:1 staff supervision.
A review of the Care Plan interventions on 1/29/25 at 11:50 AM did not reveal Resident #132 having 1:1 staff supervision.
An interview was conducted on 1/29/25 at 2:25 PM with the MDS (Minimum Data Set) Coordinator. The MDS Coordinator stated that Resident #132 has been receiving 1:1 staff supervision since 1/1/25. The MDS Coordinator also stated that the care plan was not updated in a timely manner. The MDS Coordinator further stated that she updated the care plan today however the care plan should have been updated at an earlier date due to Resident #132 being on 1:1 staff supervision for a few weeks now.
On 2/5/25 at 6:55 PM a final interview was conducted with the Administrator, Director of Nursing, Regional MDS, Regional Nursing Consultant, Regional Maintenance Director, [NAME] President of Clinical Services, Regional Risk Management, and Regional Director 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)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, resident record review, and a review of facility documents, the facility staff failed t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, resident record review, and a review of facility documents, the facility staff failed to apply a Occupational Therapy (OT) recommended splitting/orthotic device for one (1) of 63 residents (Resident #50), in the survey sample.
The findings included:
Resident #50 was originally admitted to the facility 10/27/2016 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included a stroke with right hemiparesis and expressive aphasia.
The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/22/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 10 out of a possible 15. This indicated Resident #50's cognitive abilities for daily decision making were moderately impaired.
Resident #50's Physician's Order Summary included an order dated 12/31/24 to start 1/1/25 for the following: Apply resting hand splint to Right Upper Arm (RUE) for up to four (4) hours as tolerated- daily with skin checks and hand hygiene per shift for contracture management every day shift.
Resident #50 received OT services from 11/18/24 through 12/26/24. The discharge plan dated 12/31/24 stated OT recommended that Resident #50 wear an orthotic to his right upper extremity for 2-4 hours per day as tolerated for contracture management. Observations were made of Resident #50 daily from 1/31/25 through 2/5/25, but a right upper extremity was not witnessed. The resident was noted to have the right arm bent upwards at all time.
An interview was conducted with the OT on 2/5/25 at approximately 3:37 PM. The OT stated the right upper extremity splinting/orthotic was to be applied by staff and worn daily during the day shift up to 4 hours as tolerated, beginning 1/1/25. No documentation of application or tolerance was identified in the resident's record.
On 2/5/25 at approximately 4:20 PM, a final interview was conducted with the Administrator, Director of Nursing and four Corporate Consultants. The administrative team was informed of the above. No additional information was provided and no concerns were voiced.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, resident record review, the facility staff failed to obtain dental se...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, resident record review, the facility staff failed to obtain dental services for two (2) of 63 residents (Resident #27 and 96), in the survey sample.
The findings included:
1. Resident #27 was originally admitted to the facility 01/30/2015 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included COPD and a major depressive disorder.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/2/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #27's cognitive abilities for daily decision making were intact.
On 1/28/25 at approximately 3:25 PM an interview was conducted with Resident #27. Resident #27 stated his primary concern was obtaining dentures. He further stated he had made his dental concerns known to staff but no one had followed-up with him. A review of the resident's record revealed he had seen the dentist and completed a dental assessment on 11/22/24. The recommendation was for upper full denture for mastication, and to resubmit for approval of the upper full denture.
An interview was conducted with Social Services members on 2/4/25 at 1:53 PM, neither was aware that the resident's desired dental services or the information in the previous dental assessment. On 2/5/25 at approximately 12:40 PM the Social Services Director stated the dentist would be returning to the facility in March 2025 and the resident would be seen.
The resident's person centered care plan had a problem dated 3/3/23 which stated (name of resident) will have consults as ordered, Dental, audiology, podiatry, optometry/ophthalmologist, psychiatry/psychology, wound, and dietary. The goal stated Resident will have consults maintained and followed as ordered through the review date, 5/3/25. The intervention stated follow consults as ordered.
On 2/5/25 at approximately 4:20 PM, a final interview was conducted with the Administrator, Director of Nursing and four Corporate Consultants. The administrative team was informed of the the above information. No additional information was provided and no concerns were voiced.
2. Resident #96 was originally admitted to the facility 07/21/2023 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included traumatic subdural hemorrhage and high blood pressure.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/6/2024 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #96's cognitive abilities for daily decision making were intact.
On 1/28/25 at approximately 2:50 PM an interview was conducted with Resident #96. Resident #96 stated he had dental concerns and is very self-conscious of his dental status. No documentation regarding the resident's oral status was documented in the resident's record.
The person centered care plan had a problem dated 08/09/2023 which stated the resident had oral/dental health problems related to poor oral hygiene. The goal stated The resident will comply with mouth care at least daily through review date, 2/20/25. The interventions included monitor/document/report as needed any signs/symptoms of of oral/dental problems needing attention: pain (gums, toothache, palate), abscess, debris in mouth, lips cracked or bleeding,
teeth missing, loose, broken, eroded, decayed, tongue (black, coated, inflamed,
white, smooth), ulcers in mouth, or lesions.
An interview was conducted with Social Services members on 2/4/25 at 1:53 PM, neither was aware that the resident's desired dental services. On 2/5/25 at approximately 12:40 PM the Social Services Director stated the dentist would be returning to the facility in March 2025 and the resident was scheduled to be evaluated.
On 2/5/25 at approximately 4:20 PM, a final interview was conducted with the Administrator, Director of Nursing and four Corporate Consultants. The administrative team was informed of the the above information. No additional information was provided and no concerns were voiced.
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 F0947
(Tag F0947)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, the facility failed to ensure the required in-service training for nurses' aides be sufficient and no less than 12 hours per year for 4 of 6 Certified Nursi...
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Based on record review and staff interview, the facility failed to ensure the required in-service training for nurses' aides be sufficient and no less than 12 hours per year for 4 of 6 Certified Nursing Assistant's (CNA's) reviewed during the survey.
The findings included:
An interview was conducted on 2/5/25 at 11:35 AM with the Human Resources Manager. The Human Resources Manager stated that the required 12 hours of nurses' aide training was not completed for CNA(C), CNA(D), and CNA(E). The Human Resources Manager also stated that the facility has not had a full-time Human Resources Manager, and she works at various facilities and has been filling in at the position until the facility hires a new Human Resources Manager.
A review of the facility's records revealed that CNA(C), CNA(D), and CNA(E) did not complete the required 12 hours per year of in-service training for nurses' aides.
On 2/5/25 at 6:55 PM a final interview was conducted with the Administrator, Director of Nursing, Regional MDS, Regional Nursing Consultant, Regional Maintenance Director, [NAME] President of Clinical Services, Regional Risk Management, and Regional Director 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
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Unit two:
For Resident #3, the facility staff failed to maintain a clean, comfortable, homelike living environment.
On 1-28-2...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Unit two:
For Resident #3, the facility staff failed to maintain a clean, comfortable, homelike living environment.
On 1-28-25 during resident room observations, the room of Resident #3 was noted to have a sticky, tape style insect trap, hanging from the ceiling in the bathroom. The 2 inch wide by 24 inch long tape was so covered in insects that it had the appearance of fur covering it. A nurse was coming down the hall at that time and was asked to view the area. When asked if he thought it was safe and sanitary for the Resident, he stated no. Resident #3 stated yes, they have pest control bug people come and spray, however, she stated they only spray the halls, not the rooms, because they don't want to move things around in the room.
Pest Control Review:
During the entire survey there were fruit flies as well as large flies, and cock roaches noted on all three living units, and in the common areas as well. A review of the pest control logs revealed that the facility is having pest control services come to the building monthly, however, the pests continue to be in the facility.
The Resident's room was shared with a second Resident. The room tour included but was not limited to the following being observed;
broken vinyl window blinds, a urine soaked bathroom with a bedpan full of urine stained panties on the floor, a pervasive smell of urine and feces in the room and on the entire unit.
The floor of the room was sticky and made a sucking sound as one walked across it, and the base board was peeling and drooping over in places. The floor was crusted with crumbs, brown debris, and black particles. The walls were scraped and stained, and covered in crayon coloring book pages completed by the Resident, which encircled the walls of the entire room and were also on the room door
The bed divider curtain had brown stains and smeared tan substances on it. The Residents both had a 16 ounce Styrofoam cup with a plastic lid and straw in it for water which were stained.
The Maintenance Director was a member of the corporate staff and not regular staff in the facility. The facility Maintenance director had resigned leaving the position open for a substantial period of time, and the Corporate Maintenance Director was on site during survey training the new Maintenance Director who had just started while survey was being conducted.
On 1-29-25 during a meeting with the Administrator, Director of Nursing, and Corporate clinical support consultant, the facility staff were made aware of the above concerns and that unit #2 was not safe, clean and comfortable, and homelike.
On 2-5-25 at the time of survey exit the facility Administrator, and Director of Nursing stated that pest control services had been in and treated rooms on unit #2, and that they had nothing further to provide.
4. Unit Two:
For Resident #130, the facility staff failed to maintain a clean, comfortable, homelike living environment. On 1-28-25 during resident room observations, the room of Resident #130 was noted to have small red bugs on the floor under the bed of the Resident's room mate. The room mate was wearing stained dirty clothing with wet spots noted in his lap while he sat in a wheel chair. A nurse was coming down the hall at that time and was asked to view the area. When asked if he thought it was safe and sanitary for the Resident, he stated no. He further stated he would get the Maintenance Director to have pest control come and treat the room. Resident #130 also stated yes, they have pest control bug people come and spray, however, they only spray the halls, not the rooms, because they don't want to move things around in the room.
Pest Control Review;
During the entire survey there were fruit flies as well as large flies, and cock roaches noted on all 3 living units, and in the common areas as well. A review of the pest control logs revealed that the facility is having pest control services come to the building monthly, however, the pests continue to be in the facility.
The Resident's room tour included but was not limited to the following being observed;
broken vinyl window blinds, a urine soaked bathroom a pervasive smell of urine and feces in the room and on the entire unit. The overbed tables, and bedside tables were littered with crumbs, smears, dried food particles, used paper napkins and waste from food containers, and were unclean.
The floor of the room was sticky and made a sucking sound as one walked across it, and the base board was peeling and drooping over in places. The floor was crusted with crumbs, brown debris, and black particles. The walls were scraped and stained, and had holes in various areas.
The bed divider curtain had brown stains and smeared tan substances on it. The Residents both had a 16 ounce Styrofoam cup with a plastic lid and straw in it for water which were stained.
The Maintenance Director was a member of the corporate staff and not regular staff in the facility. The facility Maintenance director had resigned leaving the position open for a substantial period of time, and the Corporate Maintenance Director was on site during survey training the new Maintenance Director who had just started while survey was being conducted.
On 1-29-25 during a meeting with the Administrator, Director of Nursing, and Corporate clinical support consultant, the facility staff were made aware of the above concerns and that Unit #2 was not safe, clean and comfortable, and homelike.
On 2-5-25 at the time of survey exit the facility Administrator, and Director of Nursing stated that pest control services had been in and treated rooms on unit #2, and had eradicated the bed bugs in Resident #130's room, and that they had nothing further to provide.
Based on observations, resident interviews, staff interviews, facility document reviews, and review of the facility's policy, the facility staff failed to provide a sanitary, comfortable, and homelike environment on three of three units (Unit 2, 3 and 4 only operational units, Unit 1 under renovation) and in the main entryway, which resulted in Substandard Quality of Care.
The findings included:
1. Unit Four:
Upon entering the facility on 1/31/25 at approximately 11:30 AM, water was observed leaking overhead between the two entryway doors. A large amount of water continued to pool in the entryway making the area unsanitary as people walked and pulled bags through the water into the facility. Each day through 2/5/25 the overhead of the entryway dripped water and it accumulated into puddles which was brought into the facility.
At approximately 12:55 PM, after exiting the elevator on the second floor to reach Unit Four, a pervasive stench engulfed the area outside the elevator. Upon reaching the corridor of Unit Four the stench grew in intensity and the search for causative factors revealed, Resident #26 was observed in a wheelchair, urine saturated, wandering the corridor and in and out of other resident rooms. No staff were observed to intervene.
At approximately 1:13 PM, a 3/4 full urinal of dark yellow urine was observed hanging on the side of a trash can in room [ROOM NUMBER]. Piles of clothing were observed on the floor between the TV stands, on the TV stand, and in the corner bedside the wardrobe. The wardrobe's right door was falling off.
Resident #27 was observed sitting in a wheel chair in room [ROOM NUMBER], he had a disheveled appearance. The resident's skin was extremely dry and scaly, there was an unpleasant body odor and the resident's clothing was remarkably soiled.
a. Resident #27 was originally admitted to the facility 01/30/2015 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included COPD and a major depressive disorder. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/2/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #27's cognitive abilities for daily decision making were intact.
An interview was conducted with Resident #27 at approximately 1:15 PM. He stated he wanted to keep the long beard but, he very much desired a haircut and maybe a hot bath. Resident #27 was overheard asking a Certified Nursing Assistant (CNA) in the corridor for a haircut and the staff member stated she did not have her clipper with her therefore she could not cut his hair that day.
b. During observation rounds on 1/28/25 at 2:15 PM it was observed in room [ROOM NUMBER] that the light fixture above the sink was missing a light fixture cover, and the inside of the sink was very stained with a yellow discoloration. Also, the wall under and around the sink was very dirty with black marks, damage to the wall, and the floor was very dirty around the perimeter of the room where the floor meets the baseboard.
On 2/2/25 approximately 3:09 PM addtional observations were made in room [ROOM NUMBER]. Beside Resident #81's bed, was a large amount of clothing were on the floor and the four bed room had much debris on the floor, a left over breakfast tray on a table and unpleasant odors.
Resident #81 was originally admitted to the facility 12/9/2024 after an acute care hospital stay. He had never been discharged from the facility. The current diagnoses included a right buttock wound secondary to a peri-rectal abscess, fecal diversion surgery status post colostomy to prevent reinfecting the wound and heart attack.
The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/16/2024 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #81's cognitive abilities for daily decision making were intact.
An interview was conducted with Resident #81. The resident stated he was not going to pick the clothing up because roaches were beneath the clothing and they would stay there if he did not disturb them. Two small roaches were observed crawling along the floor beside the clothing. The privacy curtain between Resident #81's bed and the bed beside his, had a large amount of a dark brown substance on it and the curtain was missing many top hooks which allowed draping at the top.
c. During general observations, in room [ROOM NUMBER] the privacy curtain also required hooks for proper hanging and was it appeared soiled. There was debris on the floor and pieces of paper. In room [ROOM NUMBER] the faucet at the sink allowed the water to drip rapidly.
d. Resident #21 returned to room [ROOM NUMBER] at approximately 4:10 PM, his pants were extremely saturated with urine. The urine made a puddle on the floor beneath the resident's chair, next to his bed and when the resident rolled into the hallway, trails of urine was observed up and down the corridor.
Resident #21 was originally admitted to the facility 05/27/2022 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included high blood pressure and bilateral lower extremity swelling.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/31/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #21's cognitive abilities for daily decision making were intact.
An interview was conducted with Resident #21, he stated he was not the cause of the odors in room [ROOM NUMBER], it was his roommate who does not bathe. Resident #21 stated he does not like living with the bad odors.
On 2/1/25 at approximately 10:00 AM upon exiting the elevator on the Unit Four the same pervasive stench engulfed the area outside the elevator. Upon entering the corridor to Unit Four the intense stench remained. Environmental Services staff were observed mopping floors but as you progressed to the higher room numbers the pervasive stench continued to permeate the unit.
On 2/4/25 at 4:20 PM an interview was conducted with the Administrator, Director of Nursing and four Corporate staff members. They all acknowledged the pervasive odors as you exit the elevator on the second floor. The Administrator stated they conducted Angel rounds every morning Monday through Friday and if concerns are identified the appropriate department is notified and follow up on the concern is revisited prior to the end of the day.
5. Unit Two:
For Resident # 128, the facility staff failed to ensure the walls near the bed were painted.
Resident # 128 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, Diabetes, Amputation of Left Leg-Above the Knee, Osteomyelitis of Vertebra, Sacral and Sacrococcygeal region, and Benign Prostatic Hyperplasia of lower urinary tract.
The most recent Minimum Data Set (MDS) was an admission Assessment with an Assessment Reference Date (ARD) of 9/10/2024. Resident # 128's BIMS (Brief Interview for Mental Status) Score was a 14 out of 15, indicating no cognitive impairment.
Review of the clinical record was conducted on 1/28/2025 to 1/31/2025 and 2/3/2025 to 2/5/2025.
During rounds on 1/28/2025 at 1:15 p.m., Resident # 128 was observed lying in the bed. Resident # 128 stated the rooms look pretty bad. He stated the walls were left with white patches when the walls were repaired. Resident # 128 stated he did not like the way the room looked with all of the white patches where the walls were repaired. Resident # 128.
On 2/3/2025 at 3:15 p.m., an interview was conducted with Registered Nurse-B who stated it was important for the residents' rooms to be comfortable and homelike. She stated the rooms did not look homelike.
During the end of day debriefing on 2/3/2025, the Facility Administrator, two Regional Nurse Consultants and Director of Nursing were informed of the findings.
No further information was provided.
6. Unit two:
For Resident #113, the facility staff failed to ensure a clean, comfortable homelike environment due to the unpainted walls and the presence of roaches.
During rounds on 1/28/2025 at 3:15 p.m., Resident # 113 was observed sitting on the side of the bed and watching television. The walls on the side of the bed were noted to have large white colored areas that looked like holes had been patched. Resident # 113 stated the room looked like that for a while. When asked if there were any other problems, he stated there were a lot of roaches were in the facility.
On 2/03/2025 at 01:28 p.m.- An interview was conducted with Resident # 113 who stated there were lots of areas on the walls that were repaired. He stated the walls had not been painted and they looked bad. He stated roaches were in the residents' rooms and in the hallways. He also stated he had seen roaches in the facility several times.
On 2/3/2025 at 3:15 p.m., an interview was conducted with Registered Nurse-B who stated it was important for the residents' rooms to be comfortable and homelike. She stated the rooms did not look homelike.
During the end of day debriefing on 2/3/2025, the Facility Administrator, two Regional Nurse Consultants and Director of Nursing were informed of the findings.
No further information was provided.
7. Unit two:
For Resident # 2, the facility staff failed to ensure a clean, comfortable homelike environment.
Resident # 2 was admitted on [DATE] with diagnoses including but not limited to: Epilepsy, Seizures, Confirmed Physical Abuse, Confirmed Psychological Abuse, Major Depressive Disorder, Anxiety Disorder, and Neoplasm of the Brain.
Resident #2's most recent MDS (Minimum Data Set) was a Quarterly Assessment with an ARD (Assessment Reference Date) of 12/27/2024 coded the Resident as having a BIMS (Brief Interview of Mental Status) score of 13 out of 15 indicating no cognitive impairment.
Review of the clinical record was conducted on 1/28/2025 to 1/31/2025 and 2/3/2025 to 2/5/2025.
Resident # 2 complained that the room looked terrible. She stated she had recently moved to that room and there was stuff everywhere.
Clutter was observed in the empty areas where residents formerly resided. The room was equipped for four residents but only two resided there during the survey.
On 2/3/2025 at 3:15 p.m., an interview was conducted with Registered Nurse-B who stated it was important for the residents' rooms to be comfortable and homelike. She stated the rooms did not look homelike.
During the end of day debriefing on 2/3/2025, the Facility Administrator, two Regional Nurse Consultants and Director of Nursing were informed of the findings.
No further information was provided.
8. Unit Three:
On 1/15/25 approximately 1:45 p.m. getting off of the elevator on the Unit three a strong odor of urine and body odor was detected. The shower room on the 300's hall had 2 dirty towels on the floor a washcloth hanging over the arm of the shower chair. The walls were patched up where holes had been repaired but never painted over, the shower chairs were soiled with brown substance, and there was a soiled brief in the corner near the trash can. The shower curtains do not completely cover the shower stalls, and they are stained with brownish yellow substance.
On 1/16/25 at approximately 10:30 a.m., getting off of the Unit three elevator once again there was a strong odor of urine and body odor, while interviewing Resident #24 noted his blanket had what appeared to be food stains and the sheet had black marks on it.
Throughout the rest of the survey all subsequent trips to the second-floor surveyors encountered this same odor of urine and body odor on the second floor.
Throughout the 300's hall floors were noted to be dirty in the hallway and in Resident rooms. Strong stale cigarette smell in the dining room on the first floor as residents smoke in the patio area outside of the dining room door.
On 2/3/25 at 11:00 an interview was conducted with Employee H & Employee J from the housekeeping dept. Employee H was asked how often floors are washed she stated they are washed daily. Employee J was asked about the shower curtains, and she stated that the shower curtains were on back order since December. She stated that they have to wash and re-hang whatever is here now until a new shipment comes in. When asked about the odor on the second floor she stated that there are Residents who refuse to bathe and that it is a nursing issue not a housekeeping issue.
On 2/5/25 during the end of day meeting the Administrator was made aware of the issues and no further information was provided.
Unit Four:
2. On 1/28/25 at approximately 1:45 PM., immediately after stepping off the elevator on Unit 4 were strong urine odors which lasted throughout the survey.
A brief tour was conducted on unit four (400 Unit) of various rooms.
On 1/29/25 at approximately 12:26 PM., room [ROOM NUMBER]B had a partial privacy curtain, not fully providing the resident privacy from all 3 beds present in his room.
On 1/29/25 at approximately 3:45 PM., a brief tour of shower room was conducted. Upon entering the shower room, rusty pipes were observed near the sink and wall area. The walls had several areas of peeling paint, a Hoyer lift was stored in a shower stall. There were missing privacy curtains from 2 shower stalls, towels and hospital gowns were observed on the floor. A roach was observed crawling on the floor.
On 01/30/25 at approximately 10:45 AM., an interview was conducted with Resident #33 concerning the shower room. Resident #33 said I want to use the shower down stairs because the shower on this floor has rusty pipes.
On 02/05/25 at approximately 1:56 PM., an interview was conducted with CNA F. CNA F said that months ago she had informed a nurse that some of the rooms didn't have privacy curtains. CNA F also said that if the rooms don't have privacy curtains, she will just make sure the door is closed.
A tour was conducted in room [ROOM NUMBER] on 1/28/25 3:48 PM., piles of clothing were observed in several corners of the room, as well as large open trash bags with clothing exposed on the floor. The Resident located in C bed (room [ROOM NUMBER] C) said that she's afraid roaches may be in the clothing and could crawl into her area.
On 2/03/25 at approximately 4:41 PM., an interview was conducted with the Director of Nursing (DON), concerning the 400 hall (located on Unit 4) shower room. The DON said maintenance is going to see what can be down about the rust. The DON also said that Resident #33 can use the other shower room on the 300 hall.
On 02/03/25 at approximately 2:57 PM., the shower room on the 400 hall was toured with Certified Nurses Aide (CNA) H. CNA H said that only 1 resident at a time can enter the shower room due to having one privacy curtain.
10. Unit Three (memory care, locked unit):
On 01/28/2025, during the initial tour of facility, all units were toured. The halls had a strong smell of urine upon exiting the elevator on the second floor. Residents were observed in wheelchairs, and some ambulating, in the halls. The Memory care unit had a nurse assigned to the door as the door lock was broken. The Blinds, in rooms [ROOM NUMBER], of the Memory Care Unit, all had damage, broken slats, and openings on the sides preventing privacy.
On 02/03/2025, at approximately 2:00 p.m., an interview was conducted with the Regional Maintenance Director. When asked if he was aware that there are multiple rooms on the memory unit with broken and ill-fitting blinds? He stated that he is aware that there are a number or window blinds and privacy curtains that need to be replaced. He went to say, He just hired a maintenance director for the building and that he is training him. He also stated that the blinds and curtain hooks have been ordered but are on back order.
On 02/04/2025, at approximately 1:30 p.m., the above findings were shared with the Administrator and Regional Administrator. Regional Administrator states that on 01/01/2025, she re-educated the staff regarding Angel Rounds and introduced a new form to be used during morning rounds. The Rounds include a wall-to-wall tour with documentation and follow up regarding anything that is out of order in the common areas, on the units and in the residents' rooms. An opportunity was offered to the facility's staff to present additional information. A copy of the Angel Round Forms was provided by the Regional Administrator. The forms documents some of the broken items seen on observation and that some of the items needed to repair or replace the item had been requested through Tells, the service request system, but there was no documentation of the broken blinds in the rooms listed.
On 2/04/2025 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.
9. Conference room:
During observation rounds on 1/28/25 at 3:00 PM and on 2/5/25 at 2:10 PM it was observed in the Conference Room that (2) two light fixtures had a large number of dead pests in the light fixtures covers.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
Based on observation, resident interview, staff interview, and facility documentation review, the facility staff failed to maintain an effective pest control program in the rooms of Resident # 3 and #...
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Based on observation, resident interview, staff interview, and facility documentation review, the facility staff failed to maintain an effective pest control program in the rooms of Resident # 3 and #130 and throughout the entire facility.
The findings include:
1. On 1-28-25 during resident room observations, the room of Resident #3 was noted to have a sticky, tape style insect trap, hanging from the ceiling in the bathroom. The 2 inch wide by 24 inch long tape was so covered in insects that it had the appearance of fur covering it. A nurse was coming down the hall at that time and was asked to view the area. When asked if he thought it was safe and sanitary for the Resident, he stated no. Resident #3 stated yes, they have pest control bug people come and spray, however, she stated they only spray the halls, not the rooms, because they don't want to move things around in the room.
During the entire survey there were fruit flies as well as large flies, and cock roaches noted on all 4 living units, and in the common areas as well. A review of the pest control logs revealed that the facility is having pest control services come to the building monthly, however, the pests continue to be in the facility.
On 2-5-25 at the time of survey exit the facility Administrator, and Director of Nursing stated that pest control services had been in and treated rooms on unit #2, and that they had nothing further to provide.
2. On 1-28-25 during resident room observations, the room of Resident #130 was noted to have small red bugs on the floor under the bed of the Resident's room mate. The room mate was wearing stained dirty clothing with wet spots noted in his lap while he sat in a wheel chair. A nurse was coming down the hall at that time and was asked to view the area. When asked if he thought it was safe and sanitary for the Resident, he stated no. He further stated he would get the Maintenance Director to have pest control come and treat the room. Resident #130 also stated yes, they have pest control bug people come and spray, however, they only spray the halls, not the rooms, because they don't want to move things around in the room.
During the entire survey there were fruit flies as well as large flies, and cock roaches noted on all 4 living units, and in the common areas as well. A review of the pest control logs revealed that the facility is having pest control services come to the building monthly, however, the pests continue to be in the facility.
On 2-5-25 at the time of survey exit the facility Administrator, and Director of Nursing stated that pest control services had been in and treated rooms on Unit #2, and had eradicated the bed bugs in Resident #130's room, and that they had nothing further to provide.
3. Throughout the facility during the course of the survey, there was evidence of live pests including cock roaches and bed bugs.
During the initial tour of the facility on 1/28/2025 at 1:30 p.m., the surveyor was touring the rooms of residents on Unit 2. As the surveyor walked in the hallway in front of the nurses station, one Certified Nursing Assistant-G stopped the surveyor and said Excuse me, there is a bug on your back. He knocked the bug off of the surveyor's back and killed it once it fell on the floor. The bug was medium brown in color (cock roach) and approximately an inch long. The surveyor thanked the Certified Nursing Assistant for observing and removing the bug. The surveyor asked if that was a frequent problem in the facility. Certified Nursing Assistant-G stated, yes.
There were residents standing in the hallway and in the doorways of their rooms. One Resident, who was standing in the doorway of the room that the surveyor was about to enter, laughed and stated there were lots of bugs in the facility. The Resident stated, bugs are everywhere.
During the Resident Council meeting conducted on 1/29/2025, residents complained about roaches in the facility.
There were more than four staff members at the nurses station and in the hallway. When the surveyor asked if they saw bugs in the facility, the staff members stated there were bugs seen in the facility.
Throughout the days of survey, flying and crawling bugs were observed in several areas of the facility including residents' rooms, in hallways, in shower rooms, on the elevator and in the stairwell.
The Maintenance Director stated (the following day after the observation of the bed bugs) that We had the pest control company come in and erradicate the bed bugs.
During the end of day debriefings on 2/3/2025 and 2/4/2025, the Administrator, Director of Nursing and Corporate Consultants were informed of the findings. No further information was provided.
Mar 2024
16 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0559
(Tag F0559)
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 failed to ensure the Resident's right to righ...
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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 failed to ensure the Resident's right to right to choose a roommate when practicable, and the right to receive written notice, including the reason for the change, before the resident's room or roommate is changed, for 1 Residents (# 5) in a survey sample of 16 Residents.
The findings included:
1. For Resident #5 the facility staff failed to notify the Resident prior to changing rooms.
On 3/27/24 a review of the clinical record revealed that Resident #5 was admitted into room [ROOM NUMBER] and subsequently moved to room [ROOM NUMBER] however no documentation was found to support Resident or RP notification of room change.
On 3/28/24 at approximately 9:00 AM an interview was conducted with the Social Worker who was asked about the process for changing a Resident's room. The Social Worker explained that if a Resident requested a room change or get a different room mate the Social Worker would intervene to ensure that there are no negative interactions between Residents. She stated that if it is a Personality conflict that cannot be mediated or resolved the facility will make attempts to change rooms or find a roommate that will be more compatible. When asked what is done if it is a facility initiated room change? She stated if a facility initiates a room change they must first contact the Resident and or Representative and discuss the reasons for the room change and they must agree on the change. When asked would there ever be a case when a room was just changed with no notification, she stated that there would not. The Social worker was then asked to provide documentation of the conversations with the Resident and Resident Representative of the room change for Resident #5 when moving from room [ROOM NUMBER] to room [ROOM NUMBER].
On 3/28/24 at 10:45 the Social Worker returned to the surveyor and stated, Unfortunately in Resident #5's case I cannot find evidence that policy was followed, there are no notes in the chart about contacting family or the Resident about the room change.
On 3/28/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0563
(Tag F0563)
Could have caused harm · This affected 1 resident
Based on staff interview and facility documentation review, the facility staff failed to allow visitation for one resident (Resident # 1) in survey sample of 16 residents.
Findings included:
For Resid...
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Based on staff interview and facility documentation review, the facility staff failed to allow visitation for one resident (Resident # 1) in survey sample of 16 residents.
Findings included:
For Resident # 1, the facility staff failed to allow visitation during a COVID outbreak in August 2023.
Resident # 1 was admitted to the facility on with diagnoses that included but were not limited to: Chronic Embolism and Thrombosis of the left femoral vein, , Acute Kidney Failure, Pressure Ulcer, Nontraumatic hematoma of soft tissue, Acute Embolism and Thrombosis of deep veins of lower extremity,Bipolar Disorder, History of falling, Acute Posthemorrhagic Anemia,Schizoaffective Disorder, Contracture of Muscle, Unspecified site.
The most recent MDS (minimum data set) assessment was a Quarterly assessment with an ARD (Assessment Review Date) of 7/1/2023. The MDS coded Resident # 1 with a BIMS (Brief Interview for Mental Status) score of 4 (of a possible 15 points) which indicated severe cognitive impairment. Resident # 1 required assistance with ADLs (activities of daily living.)
During the initial tour of the facility on 3/26/2024, there were signs located in the front lobby which included information about COVID infections, infection control practices and the optional use of masks.
On 3/27/2024 at 10:00 a.m., an interview was conducted with the receptionist who stated visitors should be allowed to visit residents even during a COVID outbreak. The receptionist stated there was a period of time when the previous administration stopped allowing visitation.
On 3/27/2024 at 10:27 a.m., an interview was conducted with the Administrator and Director of Nursing. They stated they had not been involved with the incidents involving Resident # 1. Both stated they had only been employed in their positions for four weeks at the time of the survey. The Administrator and Director of Nursing stated residents had the right to have visitation.
The Director of Nursing stated the staff who were involved in the incident were no longer employed at the facility. A copy of the communication sent to families regarding no visitation allowed during a COVID outbreak was requested.
On 3/27/2024 during the end of day debriefing, the facility Administrator and Director of Nursing were interviewed. Both stated residents had the right to have visitors even during a COVID outbreak. Both stated visitors were allowed to visit residents.
On 3/28/2024, the facility documentation of the communication sent to families was received.
Review of documentation of the voice communication sent to families on 8/11/2023 revealed the following information:
INITIATED AT: 2023-08-11 13:56:11
SENT VIA: voice
SENT TO: +1 ____(Telephone number redacted) RESIDENT EXTERNAL ID: _____(redacted) RESIDENT LOCAL ID: _____(redacted)
SUBJECT: Positive or Suspected Case of COVID-19
MESSAGE CONTENT: We want to provide you with an update from __(name of facility redacted) Center regarding COVID-19. As of August 11, 2023- 18 residents or staff have confirmed COVID-19. When a resident tests positive, we notify residents and their representative(s) of their condition and implement protocols for their care and treatment. We also follow guidance from the Centers for Disease Control and Prevention (CDC) and the Center for Medicare and Medicaid Services (CMS), including return to work guidance, for staff who test positive. We know you are concerned about your loved one, but it is crucial that we restrict visitation to reduce the spread of this virus to others. We will contact you directly if your loved one is suspected or diagnosed with COVID-19. Please call us at ______ (telephone number redacted) or email us at ______(email address redacted). Sincerely, ____RN Director of Nursing (name of former Director of Nursing redacted).
Review of the Communicable Disease Outbreak -Visitation Practices, original date 2/1/22, Revision 10/24/22 revealed the following information:
Policy: The facility is committed to having systems and processes in place for visitation during a communicable disease outbreak. Visitation will be accomplished using the core principles of infection prevention and the current guidelines from CMS, CDC and state and local health departments.
The policy stated the following excerpts:
Indoor Visitation Guidelines
1) Facilities must always allow indoor visitations for all residents as permitted under the regulations
a)Although there is no limit on the number of visitors that a resident can have at one time, visits should be conducted in a manner that adheres to the safe infection control practices and common courtesy to others.
The policy also stated:
Visitation during an Outbreak Investigation,
1) While an outbreak investigation is occurring, facilities may limit visitor movement in the facility.
4) a) Visits will occur in the resident room.
b) The resident will wear a well-fitting mask if required with isolation precautions
c) Visitors will be educated on the potential risks of visiting and precautions required for visiting the resident
Additionally, the policy stated:
2) Visitation is allowed during an outbreak investigation.
a) Visits will occur in the resident room.
b) The resident will wear a well-fitting mask if required with isolation precautions
c) Visitors will be educated on the potential risks of visiting
d) Visitors will be encouraged to wear a face covering or masks during visit, regardless of vaccination status
e) Visitors should physically distance themselves from other residents and staff, when possible, during outbreak investigation
During the end of day debriefing on 3/28/2024, the Administrator, Director of Nursing and two Corporate Nurse Consultants (Employee-M and Employee-N) were informed of the findings. They stated residents should be allowed to have visitation when they choose and the facility should not refuse to allow visitation even during an outbreak.
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 F0573
(Tag F0573)
Could have caused harm · This affected 1 resident
Based on interview, clinical record review and facility documentation the facility staff failed to allow the Resident Representative access to the clinical record in a timely manner for two Residents ...
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Based on interview, clinical record review and facility documentation the facility staff failed to allow the Resident Representative access to the clinical record in a timely manner for two Residents ( Resident #7 & #1) in a survey sample of 16 Residents.
The findings included:
1. For Resident #7 the facility staff failed to provide Medical Records to the POA (Power of Attorney) in a timely manner.
On 3/28/24 at approximately 2PM an interview was conducted with the Administrator who was asked about Resident #7's family requesting medical records. She indicated she would look into the matter and get back with the survey team.
On 3/28/24 at approximately 5 PM the Administrator admitted there was a delay in getting the medical records to the Resident #7's family. The Administrator stated that the person requesting the records (Resident #7's mother) was not the power of attorney. The Administrator stated that the girlfriend / significant other was the power of attorney on record. When surveyor mentioned the name of the Resident's power of attorney the Administrator stated, That is not who what have listed as the POA. The clinical record had the POA (mothers correct name) but in the relationship box it said girlfriend / or significant other.
The following excerpt if from the hospital discharge summary given to the facility on admission:
12/5/23 -Mother has copies of POA and advanced directives that have been placed in patient chart.
The following excerpt is from the Physician Progress notes written by the Medical Director:
12/13/23 - He is a poor historian and according to nursing staff his mother is his power of attorney. All of his medications and extensive medical records have been reviewed.
A review of the facility policy entitled Release of Medical Records was conducted on 3/28/24 and excerpts are below:
Page 1 Paragraph 7.
Upon receipt of a request for closed medical record copies, the facility should notify the requesting party, in writing, of the cost for obtaining records, that the facility shall have 30 days to process their request and that payment for record processing is required. Copies should not be released prior to the receipt of payment for copying charges and validation that the person making the request has legal authority to request the records.
On 3/28/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.2. For Resident # 1, the facility staff failed to provide access to the medical records upon discharge AMA (against medical advice.)
Resident # 1 was admitted to the facility on with diagnoses that included but were not limited to: Chronic Embolism and Thrombosis of the left femoral vein, , Acute Kidney Failure, Pressure Ulcer, Nontraumatic hematoma of soft tissue, Acute Embolism and Thrombosis of deep veins of lower extremity,Bipolar Disorder, History of falling, Acute Posthemorrhagic Anemia,Schizoaffective Disorder, Contracture of Muscle, Unspecified site.
The most recent MDS (minimum data set) assessment was a Quarterly assessment with an ARD (Assessment Review Date) of 7/1/2023. The MDS coded Resident # 1 with a BIMS (Brief Interview for Mental Status) score of 4 (of a possible 15 points) which indicated severe cognitive impairment. Resident # 1 required assistance with ADLs (activities of daily living.)
Review of the clinical record was conducted 3/26/2024-3/28/2024.
Review of the clinical record revealed documentation that the facility's staff refused to provide any documentation of the medical record to the resident and/ family.
The Progress Notes stated: 9/8/2023 at 8:50 p.m.:
Residents R/P (Responsible Party) ________ Name redacted (niece) came to the facility to discharge her and take her home, against medical advice, GNP (nurse practitioner) was notified and made aware of her wanting to be discharge, ____ (name redacted) was informed of GNP (nurse practitioner) not approving this resident to be discharged at this time, and that she would not be able to receive any discharge instructions from this facility r/t (related to) the residents continuing care at home, residents niece refused to sign the AMA (against medical advice) form, this nurse and the house supervisor signed the form to acknowledge the conversation, regarding the risks, All residents personnel (sic) belongings where gathered and packed by staff and sent with her, resident was escorted via wheelchair to the front entrance and transported by the nieces, personnel (sic) vehicle.
Another note stated:
Effective Date: 09/08/2023 14:11 Type: *Communication with Family/NOK (next of kin) /POA (power of attorney)
Note Text : Writer spoke with ________(Responsible Party's name redacted) who stated, They want me to pay $2000, no she will be coming with me, and Anthem don't want to pay for it.' Writer explained the risks of leaving AMA (Against Medical Advice) to ____(Responsible Party's name redacted), but she continued to demand discharge paperwork and meds (medications) for resident. Policy and procedures of leaving AMA were also explained unsuccessfully. ____(Responsible Party's name redacted) refused to sign AMA form and stated, 'I'll be back to get her in a while'. DON (Director of Nursing) and GNP (Nurse Practitioner) notified.
Further review revealed no documentation of a copy of the medical record being provided to the resident and/or family.
On 3/27/2024 at 10:27 a.m., an interview was conducted with the Administrator and Director of Nursing. They stated they had not been involved with the incident involving the discharge of Resident # 1. Both stated they had only been employed in their positions for four weeks at the time of the survey. The Administrator stated she had been informed about the incident when she was hired in February 2024. The Director of Nursing stated she had been employed as a Registered Nurse at the facility at the time of the incident but had no knowledge of the specifics of what happened.
The Administrator stated the facility's policy regarding AMA (Against Medical Advice) discharges was that residents were expected to be given assistance including discharge instructions, copies of the medications and referrals to physicians for follow up. She also stated the facility would notify Adult Protective Services to inform them of the AMA discharge. The Administrator stated she did not have any additional information other that which was documented in the clinical record.
The Director of Nursing stated the staff who were involved in the incident were no longer employed at the facility. The previous Director of Nursing, the Licensed Practical Nurse assigned to work with Resident # 1 on the day of discharge and the Nursing Supervisor were no longer employed at the facility. A list of the current employees was requested. A list of New Hires and Terminations for the previous 6 months was requested.
Review of the Current Employees list revealed documentation that none of the staff members involved in the incident were still employed at the time of the survey. However, the Nurse Practitioner was still a provider at the facility. The Administrator and Director of Nursing were informed that the survey team wanted to interview the Nurse Practitioner. The Nurse Practitioner did not contact the survey team prior to the end of the survey.
The Medical Director met with the survey team on 3/28/2024 at approximately 2:45 p.m. The Medical Director stated he was informed about the incident involving the AMA discharge of Resident # 1. He stated the nursing staff should have provided the face sheet and discharge information to Resident # 1 and/or family at the time of the discharge. The Medical Director stated the staff should have given all of the medications for Resident #1 that were already at the facility to the family. The Medical Director stated the medications on the medication cart were already paid for by the Resident and could not be utilized by anyone else. He stated that would have been helpful to the Resident and family. The Medical Director stated it was not acceptable for the the facility's staff to refuse to provide assistance, education, discharge instructions and follow up appointments to residents who leave Against Medical Advice. The Medical Director stated the Nurse Practitioner was in a situation where the nursing staff informed her of the incident after everything had happened. The Medical Director stated Residents should be given copies of their medical records when requested.
On 3/28/2024 at 12:27 p.m., a voicemail message was left for the insurance company supervisor (Other B). A telephone interview was conducted with Other B who stated she remembered that there was difficulty receiving the medical records for Resident # 1. Other B stated the family apparently had been complaining of being unhappy for a while. Other B stated she did not know if that information had been communicated due to changes in staffing time and had expressed the desire to leave the facility. Other B stated the facility staff would not give the medical records, list of medications and instructions.
During the end of day debriefings on 3/27/2024 and 3/28/2024, the facility's Administrator, Director of Nursing and two Corporate Nurse Consultants (Employee-M and Employee N) were informed of the findings. Documentation in the clinical record confirmed that the facility staff failed to give copies of the resident's medical records .
No further information was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation, interview, clinical record review and facility documentation, the facility staff failed to ensure the Residents right to a safe clean comfortable and homelike environment for res...
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Based on observation, interview, clinical record review and facility documentation, the facility staff failed to ensure the Residents right to a safe clean comfortable and homelike environment for residents on three of four units inhabited by facility residents.
The findings included:
1. For Resident # 6 the facility staff has failed to maintain the Resident room in a clean and sanitary manner.
Observations:
On 3/26/24 during the initial tour of the building offensive odors were noticed on Unit 1 patient care area as well as in the hallways. The Resident rooms were cluttered and unkempt, there were visible stains on the tile floor in Resident rooms and common areas as well. Several rooms had fruit flies in them, Residents had open food and snacks at their bedside.
On 3/27/24 at approximately 2PM observations were made of Resident #6's room and the room was cluttered there were visible stains on the floor there was debris (dust and dirt) in the corners of the room, there were fruit flies noted on the privacy curtain. The room smelled of urine.
On 3/27/24 at approximately 11:45 AM an interview was conducted with Resident #6 who stated that the room is not as clean as she would like, I guess they do the best they can. When asked if there were roaches or other pests in the room, she stated that she had not seen anything but a few spiders she also stated, that she wished they would sweep the floors more often. Resident #6 stated that the housekeeping dept has gotten a little better since That lady complained. When asked who that lady was referring to she stated, I cannot pronounce it but it's like someone to speak for us. When asked if she was referring to the Ombudsman, she stated that she was.
A review of the facility documentation revealed a grievance form dated 2/6/24 from the local Ombudsman. Stating The room was very disorganized and dirty. There was trash all over the floor by the Resident's bed and the floor seemed like it had not been mopped in weeks.
On 3/28/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.
3. For residents residing on three out of four units inhabited by residents, the facility staff failed to provide a clean, comfortable, home-like environment.
During initial tour of the facility on 3/26/2024, there were offensive odors of urine noted on Unit 2 located on the first floor. There were rooms noted with blinds in disrepair on Unit 2. One room had warped blinds along with missing sections of blinds. There were several rooms with blinds in disrepair on the second floor on Units 3 and Unit 4. Some blinds were broken, some were warped and others were missing entire sections.
Surveyor C wrote the following observations:
On 3-26-24 at approximately 11:45 a.m., an initial tour of the second floor of the facility was conducted. The main hallway was congested with linen carts, wheel chairs, and other equipment carts loaded with various supplies. Residents in wheelchairs were trying to traverse the obstacles and having difficulty moving from room to room and to the elevator while bumping into each other, requiring staff assistance to disentangle their chairs. There was a pervasive odor of urine. Resident rooms were noted to be cluttered with boxes, bags, resident clothing, trash, food, and personal items strewn around each room in a scattered manner, The resident's beds were in disarray with linens partially on the floor and partially on some beds with other beds stripped having no linen.
Surveyor D documented the following observations:
On initial observation of the facility on 03/26/2024, there were strong odors of urine noted on resident units 2, 3 and 4. The were residents sitting and attempting to navigate the halls sometimes running in to each other.
On day 2 (03/27/2024) during an afternoon observation, there were rooms noted with blinds in disrepair on Unit 2. There were strong smells of both urine and feces in the resident side of the first floor and the second floor units 3 and 4. Resident rooms were observed to be cluttered, soiled corners and broken blinds. Some rooms had warped blinds along with missing sections of blinds.
On 3/27/2024 at 3:45 p.m., an interview was conducted with the Regional Housekeeping Director who stated the facility had a cleaning schedule for the facility. The Housekeeping Director stated that the housekeeping staff were focusing on cleaning residents' rooms. There was a deep cleaning schedule utilized by the staff. The Regional Housekeeping Director stated rooms were always cleaned after the discharge of a resident and prior to the admission of the another resident. The Regional Housekeeping Director stated the nursing staff was responsible for packing the belongings of the residents when discharged or deceased . The nursing staff would then notify the Housekeeping staff that the room was ready to be cleaned. A copy of the cleaning schedule for the Residents' rooms was requested and received. The Regional Housekeeping Director stated she was in the facility 2-3 times per week because the facility's Housekeeping Manager was out on leave. She stated the housekeeping staff continued to follow its cleaning schedule.
Review of the Complete Room Schedule for February 2024 and March 2024 Complete Room Schedule revealed documentation that each Residents' room had been scheduled for cleaning.
Housekeeping staff members were observed working on all three units and in the common areas.
On 3/28/2024 at 3:20 p.m., interviews were conducted with the two Regional Nurse Consultants (Employee M and Employee N) regarding the condition of the blinds in the facility in several of the residents' rooms. They both stated the blinds should not be in disrepair. They also stated the expectation was that residents should have homelike environments and privacy in their rooms.
On 3/28/2024 at 3:23 p.m., both consultants toured the outside of the facility that faced the parking lot with Surveyor B. The two consultants stood on the sidewalk with Surveyor B and noted there were broken blinds and blinds in disrepair that were visible from the sidewalk. There was one room on the first floor( on Unit 2) with broken and warped blinds where the resident could clearly be seen through the window. The consultants were informed of observations through that window on 3/27/2024 of staff members providing assistance to that resident. Employee M and Employee N stated that the blinds needed to be repaired. They also stated that since some residents want the blinds to be open so they can see outside, they would look into purchasing some type of film to place over the windows to protect their privacy.
No further information was provided.
2. On 3-26-24 at approximately 11:45 a.m., an initial tour of the second floor of the facility was conducted (units 3 and 4). The main hallway was congested with linen carts, wheel chairs, and other equipment carts loaded with various supplies.
Residents in wheelchairs were trying to traverse the obstacles and having difficulty moving from room to room, and to the elevator, while bumping into each other, and the walls requiring staff assistance to disentangle their chairs.
There was a pervasive odor of urine. Resident rooms were noted to be cluttered with boxes, bags, resident clothing, trash, food, and personal items strewn around each room in a scattered manner,
The resident's beds were in disarray with linens partially on the floor and partially on some beds, with other beds stripped having no linen.
On the first floor other surveyors were making observations to include the (100 and 200), halls. Staff interviews with CNAs (certified nursing assistants) all revealed that frequently they do not have enough linen on one of the units. When asked what they do if a Resident has an accident, each of the CNAs reported they have to go to other units to see if they can find linen. One of the CNAs, who asked to remain anonymous, said that she has to sometimes use paper towels, because the facility just doesn't have adequate supplies to provide for Resident care needs, and had been told to use paper towels to clean Residents.
Ombudsman statements revealed that this has been an ongoing issue of concern for facility staff and Residents.
On 3-27-24, the above findings were shared with the facility Administrator and Director of Nursing (DON). The Administrator and DON stated staff were throwing away linens that had become heavily soiled, and had been counseled on the practice. The Administrator revealed a quality improvement plan to improve par levels for linens which is projected to be completed by 4-26-24.
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 F0624
(Tag F0624)
Could have caused harm · This affected 1 resident
Based on staff interview, facility documentation review and clinical record review, the facility staff failed to ensure a safe and orderly discharge for one resident (Resident # 1) in a survey sample ...
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Based on staff interview, facility documentation review and clinical record review, the facility staff failed to ensure a safe and orderly discharge for one resident (Resident # 1) in a survey sample of 16 residents.
Findings included:
For Resident # 1. the facility staff failed to provide any assistance with discharge instructions when the resident was discharged (AMA) against medical advice.
Resident # 1 was admitted to the facility on with diagnoses that included but were not limited to: Chronic Embolism and Thrombosis of the left femoral vein, , Acute Kidney Failure, Pressure Ulcer, Nontraumatic hematoma of soft tissue, Acute Embolism and Thrombosis of deep veins of lower extremity,Bipolar Disorder, History of falling, Acute Posthemorrhagic Anemia,Schizoaffective Disorder, Contracture of Muscle, Unspecified site.
The most recent MDS (minimum data set) assessment was a Quarterly assessment with an ARD (Assessment Review Date) of 7/1/2023. The MDS coded Resident # 1 with a BIMS (Brief Interview for Mental Status) score of 4 (of a possible 15 points) which indicated severe cognitive impairment. Resident # 1 required assistance with ADLs (activities of daily living.)
Review of the clinical record was conducted 3/26/2024-3/28/2024.
Review of the progress notes revealed documentation that the facility staff and nurse practitioner refused to provide any education, any list of medications,
The Progress Notes stated: 9/8/2023 2050 ( 8:50 p.m.):
Residents R/P (Responsible Party) ________ Name redacted (niece) came to the facility to discharge her and take her home, against medical advice, NP (nurse practitioner) was notified and made aware of her wanting to be discharge, ____ (name redacted) was informed of NP (nurse practitioner) not approving this resident to be discharged at this time, and that she would not be able to receive any discharge instructions from this facility r/t (related to) the residents continuing care at home, residents niece refused to sign the AMA (against medical advice) form, this nurse and the house supervisor signed the form to acknowledge the conversation, regarding the risks, All residents personnel (sic) belongings where gathered and packed by staff and sent with her, resident was escorted via wheelchair to the front entrance and transported by the nieces, personnel (sic) vehicle.
Another note stated:
Effective Date: 09/08/2023 14:11 Type: *Communication with Family/NOK (next of kin) /POA (power of attorney)
Note Text : Writer spoke with ________(Responsible Party's name redacted) who stated, They want me to pay $2000, no she will be coming with me, and Anthem don't want to pay for it.' Writer explained the risks of leaving AMA (Against Medical Advice) to ____(Responsible Party's name redacted), but she continued to demand discharge paperwork and meds for resident. Policy and procedures of leaving AMA were also explained unsuccessfully. ____(Responsible Party's name redacted) refused to sign AMA form and stated, 'I'll be back to get her in a while'. DON (Director of Nursing) and NP (Nurse Practitioner) notified.
Review of the facility's policy entitled Discharging a Resident Without a Physician's Approval revealed the following information:
SPECIFIC PROCEDURES/GUIDANCE
1. Should a resident, or his or her representative request a verbal or written discharge, the resident's attending physician will be promptly notified.
2. The nurse will document in the resident record the provider's response to the resident/resident representative's request to leave the facility.
3. If the resident or representative insists upon being discharged without the approval of the attending physician, the resident and/or representative must sign a Release of Responsibility form. Should either party refuse to sign the release, such refusal must be documented in the resident's medical record and witnessed by two staff members.
4. Should a resident and/or representative request a discharge from the facility during the time the resident is on isolation (transmission-based) precautions, the Charge Nurse must notify the Director of Nursing Services and the resident's Attending Physician of the discharge request.
a. The Director of Nursing Services, or Charge Nurse, shall inform the resident, and/or representative of the potential hazards involved in the early discharge of the resident and shall request that the resident remain in the facility until such time as the isolation/precautionary period has ended.
5. The facility respects the resident's right to discharge against medical advice and will offer education to the resident/resident representative on care needs post discharge.
a. Documentation of education and discharge instructions to the resident/resident representative will be made in the resident's medical record.
b. Discharge instructions may include, but is not limited to:
i. Prescribed medications/treatments
1. Where appropriate and available the physician/practitioner may provide prescriptions or call prescriptions into the desired pharmacy
2. With the physician's approval, the medications that are on hand, excluding narcotics, may be provided to the resident or the representative. The medications will be explained to the resident/representative including name, dose, time to be administered, any parameter requirements, risk associated, etc. The resident/representative and discharging nurse must sign a receipt noting
understanding of medication. A copy will be provided to the resident and original maintained in the resident record.
ii. Information on community resources [i.e., home health, therapy, equipment, etc.]
iii. Follow up appointments
iv. Safety precautions
c. If the resident/resident representative refuses to wait for or accept education and/or discharge instructions, such refusal will be documented in the resident's medical record.
6. If the facility feels that the resident's safety may be in jeopardy with the discharge, the facility may make a referral to Adult Protective Services or other community support system.
Review of the clinical record revealed no documentation of a referral to Adult Protective Services for Resident # 1 by the facility.
During the end of day debriefing on 3/28/2024, the Administrator, Director of Nursing and two Corporate Nurse Consultants (Employee-M and Employee-N) were informed of the findings.
No further information was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. For Resident # 1, the facility staff failed to develop a person-centered care plan regarding discharge planning.
The facilit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. For Resident # 1, the facility staff failed to develop a person-centered care plan regarding discharge planning.
The facility staff failed to tailor the care plan regarding discharge planning.
Resident # 1 was admitted to the facility on with diagnoses that included but were not limited to: Chronic Embolism and Thrombosis of the left femoral vein, , Acute Kidney Failure, Pressure Ulcer, Nontraumatic hematoma of soft tissue, Acute Embolism and Thrombosis of deep veins of lower extremity,Bipolar Disorder, History of falling, Acute Posthemorrhagic Anemia,Schizoaffective Disorder, Contracture of Muscle, Unspecified site.
The most recent MDS (minimum data set) assessment was a Quarterly assessment with an ARD (Assessment Review Date) of [DATE]. The MDS coded Resident # 1 with a BIMS (Brief Interview for Mental Status) score of 4 (of a possible 15 points) which indicated severe cognitive impairment. Resident # 1 required assistance with ADLs (activities of daily living.)
Review of the clinical record was conducted [DATE]-[DATE].
On [DATE] at 1:10 p.m., an interview was conducted with Registered Nurse B who stated care plans should reflect the residents and the plans to help them achieve their goals.
Review of the Care plan revealed a template had been utilized for focus area and had not been completed with the information specific to Resident # 1. :
CANCELLED: The resident wishes to (SPECIFY return/be discharged ) to (SPECIFY home, another facility)
Date Initiated: [DATE]
Revision on: [DATE]
Cancelled Date: [DATE]
CANCELLED: The resident will be able to verbalize/communicate required assistance post-discharge and the services required to meet
needs before discharge.
Date Initiated: [DATE]
Revision on: [DATE]
Target Date: [DATE]
Cancelled Date: [DATE]
CANCELLED: Evaluate/record the resident's abilities and strengths, with family/caregivers/IDT (Interdisciplinary team). Determine gaps in abilities which will affect discharge. Address gaps by (community referral to SPECIFY, pre-discharge PT/OT ) Physical Therapy/Occupational Therapy), internal referral to SPECIFY)
Date Initiated: [DATE]
Revision on: [DATE]
Cancelled Date: [DATE]
[DATE]
CANCELLED: Make arrangements with required community resources to support independence post-discharge (specify: homes care, PT, OT, MD, Wound Nurse)
Date Initiated: [DATE]
Revision on: [DATE]
Cancelled Date: [DATE]
[DATE]
CANCELLED: The resident needs (SPECIFY assistance/supervision) with: (SPECIFY communicate/describe needs, book appointments, ADLs, housekeeping, communication) on discharge to community.
Date Initiated: [DATE]
Revision on: [DATE]
Cancelled Date: [DATE]
Where the word specify was written, the staff did not include information tailored for Resident # 1. The careplan had the word cancelled written because Resident # 1 was already discharged at the time of survey
During the end of day debriefing on [DATE], the Administrator, Director of Nursing and two Corporate Nurse Consultants (Employee-M and Employee-N) were informed of the findings.
No further information was provided.
Based on staff interview, clinical record review, and facility document review, the facility staff failed to implement a comprehensive care plan for pressure ulcers for three Residents (Residents #10, #12 & #1) in a survey sample of 16 Residents.
The findings included:
1. For Resident #10, the facility staff failed to implement a care plan for a sacral pressure wound.
Resident #10 was admitted to the facility on [DATE] with diagnoses including; Diabetes, pulmonary embolism, stroke, aphasia, hypertension, contractures, syphilis, congestive obstructive pulmonary disorder (COPD), encephalopathy, carbon monoxide poisoning, and viral hepatitis C.
Resident #10's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 11-27-23 was a quarterly assessment. The MDS coded Resident #10 as needing extensive to total staff assistance with toileting, hygiene, and bathing. The Resident was also coded as unable to complete a brief interview for mental status (BIMS), indicating significant cognitive impairment. The Resident was coded as frequently incontinent of bowel and bladder.
On 1-27-23 a Braden scale skin assessment for admission was completed and indicated a score of 7 very high risk for skin breakdown. The Resident had no pressure wounds upon admission.
The Resident was no longer in the facility and a closed record review was conducted.
Resident #10's Activity of daily living sheets documented hygiene care given to the Resident. Review of those documents revealed that during the months of March, June and [DATE] personal hygiene was not given for the following dates and shifts;
3-2-23 (7am to 3pm), 3-4-23 (7am to 3pm), 3-21-23 (7am to 3pm), 3-22-23 (7am to 3pm), 3-30-23 (7am to 3pm)
3-4-23 (3pm to 11pm)
3-12-23 (11pm to 7am), 3-22-23 (11pm to 7am), 3-31-23 (11pm to 7am)
6-4-23 (7am to 3pm), 6-23-23 (7am to 3pm).
6-8-23 (3pm to 11 pm), 6-18-23 (3pm to 11pm), 6-19-23 3pm to 11pm).
6-11-23 (11pm to 7am), 6-17-23 (11pm to 7am)
7-15-23 (11pm to 7am).
Review of Resident #10's physician and nursing progress notes indicated a Resident who was total care and received peg tube liquid feedings through the abdomen.
The facility Incontinence care policy was reviewed and revealed that hygiene and incontinence care would be given in a timely manner.
The facility policy for Documentation of Wound Treatments was reviewed and revealed that
the following elements are;
1. Documented upon admission, weekly, and as needed if the Resident or wound condition deteriorates.
2. The following elements are documented as part of a complete wound assessment:
a. Type of wound (pressure injury, surgical, etc.) and anatomical location
b. Stage of the wound if pressure injury (stage 1, 2, 3, 4, deep tissue injury, unstageable pressure injury) or the degree of skin loss if non-pressure (partial or full thickness)
c. Measurements: height, width, depth, undermining, tunneling
d. Description of wound characteristics:
i. Color of the wound bed
ii. Type of tissue in the wound bed(i.e., granulation, slough, eschar, epithelium)
iii. Condition of the peri-wound skin (dry, intact, cracked, warm, inflamed, mascerated)
iiii. Presence, amount and characteristics of wound drainage/exudate
v. Presence or absence of odor
vi. Presence or absence of pain
3. Wound treatments are documented at the time of each treatment .
The Resident's care plan was reviewed and indicated the Resident would receive incontinence care after each incontinence episode. There was no care plan for wounds for Resident #10.
Physician's orders were reviewed and indicated a treatment for a sacral wound first ordered on 3-3-23 for cleanse with normal saline, pat dry, apply Medi honey, apply calcium alginate, and cover with a dry foam border dressing.
No measurements nor descriptions of the wound were every placed in the clinical record. Resident #10 was not afforded timely incontinence care as many times as was needed, as evidenced by the sacral wound actually acquired in the facility.
Weekly skin Evaluation documents were reviewed and revealed that only 4 existed in the clinical record. Those were as follows;
3-7-23 first weekly assessment sacrum wound. No further documentation nor description.
3-14-23 sacrum wound. No further documentation nor description.
3-21-23 sacrum wound. No further documentation nor description.
6-30-23 stated no open areas, however, the Resident continued to have treatments to her gluteal folds until the time of her discharge on [DATE]. There is no documentation of the sacrum improving, worsening, or healing.
A family interview and documentation revealed that the Resident still had a pressure injury to her bottom on 7-7-23.
Staff nurse and CNA interviews were conducted during the course of the survey on all units. Those interviews indicated that the expectation for incontinence rounds was every 2 hours and as often as needed, and skin would be assessed for breakdown during that care. If skin breakdown was found by CNA's (Certified Nursing Assistants), who typically completed incontinence care, they would then immediately report it to the nurse. the nurse would then assess the area, measure it, document a description of it, and seek physician's orders to treat and prevent worsening. The nursing staff stated all skin assessments were in the computerized record, and they had no paper assessments.
On 3-28-24 during the end of day meeting the Administrator and Director of Nursing (DON) were made aware of the above findings. The Administrator revealed a quality improvement plan to improve completion of skin assessments and education on proper assessment and staging wounds, which is projected to be completed by 3-29-24. No additional information was provided to the surveyor.
2. For Resident #12, the facility staff failed to implement a care plan for a sacral pressure wound.
Resident #12 was initially admitted to the facility on [DATE]. The most recent readmission was on 2-14-22 after a hospital stay. Diagnoses included; Diabetes, hypertension, stroke, end stage renal disease with dialysis, seizure, atrial fibrillation, anemia, sarcopenia, peripheral vascular disease, and obstructive sleep apnea with refusal to wear C-pap.
The Resident's most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 4-3-23 was coded as a quarterly assessment. Resident #12 was coded as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 of a possible 15 points, and was her own responsible party. The Resident required extensive to total dependant assistance from staff to perform activities of daily living, and was coded as always incontinent of bowel and bladder. The Resident was coded as at risk for pressure sores, however, had no pressure wounds.
During the time of survey the Resident was no longer in the facility, and was a closed record review.
Review of the clinical record revealed physician and nursing progress notes that documented the following time line;
On 5-23-23 (Tuesday) the Resident was sent to dialysis and was sent immediately to the hospital for care from the dialysis center after having no dialysis for 5 days.
On 6-4-23 the Resident returned to the nursing facility with a hospital discharge diagnosis of gangrene and pulmonary edema.
On 6-4-23 Nursing and physician progress notes revealed that a pressure ulcer was found on the Residents sacrum. A doctor's order was placed in the treatment record at 9:00 am for cleanse pressure area to sacrum with normal saline, pat dry, apply medi honey and cover with dry dressing every day and as needed.
On 6-7-23 a Bradens Scale assessment was completed for skin breakdown risk and scored the Resident with a 14.0, Moderate Risk.
On 6-9-23 The treatment for the pressure ulcer (ordered on 6-4-23) was finally implemented and started on this day, (6 days after the order was received) and was omitted on 6-10-23, 6-11-23, 6-12-23, 6-15-23, and 6-16-23. This revealed that in a 13 day period the treatment was only provided 3 times.
On 6-11-23 the progress notes documented that the Resident refused care stating I don't want nothing on it, it's killing me. The treatment administration records documented that the Resident did not receive the treatment on this day. There were no other refusals for the days in question. There were no other mentions of the sacral pressure ulcer.
On 6-13-23 there was a skin assessment document completed which documented sacrum wound. No further documentation nor description. This was the only skin evaluation found in the clinical record for the sacral pressure ulcer.
On 6-16-23 (Friday) the Resident went to the hospital again and she expired in the hospital on 6-21-23.
The Resident's care plan review for a sacral pressure ulcer revealed no care planning for the wound.
On 3-27-24, and 3-28-24 at the end of day debrief, the Administrator, and DON (director of nursing) were notified that the facility failed to provide care and services for pressure ulcers. The Administrator revealed a quality improvement plan to improve completion of skin assessments and education on proper assessment and staging wounds, which is projected to be completed by 3-29-24. No further information was provided by the facility.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
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 review and revise the care pl...
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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 review and revise the care plan for 1 Resident (#5) in a survey sample of 16 Residents.
The findings included:
For Resident #5, the facility staff failed to review and revise the care plan and add interventions after each fall the Resident had.
On 3/27/24 a review of the clinical record revealed that Resident #5 had 10 falls from the time of admission on [DATE] until her discharge on [DATE]. The dates of the falls are as follows:
7/21/22, 12/18/22, 1/7/23 (this fall happened while at the dialysis center), 1/16/23, 2/14/23, 4/16/23, 5/5/23, 5/10/23, 6/25/23, and 7/1/23.
A review of the care plan read as follows:
FOCUS - The Resident is at risk for falls r/t [related to] PVD [peripheral vascular disease], age related osteoporosis, cerebral infarction, - date initiated - 8/5/22.
GOAL - Minimize the risk of falls through the next review date - date initiated 8/5/22.
INTERVENTIONS:
Anticipate and meet the resident's needs - date initiated 8/5/22.
Be sure the resident's call light is within reach and encourage the resident to use it for assistance when needed. -date initiated 8/5/22.
PT eval and treat as ordered or PRN - date initiated 8/5/22.
FOCUS - Resident had an actual fall - date initiated 5/5/23.
GOAL - Free from injury related to falls through next review. date initiated 5/10/23.
INTERVENTIONS:
Fall mat to left side of the bed - date initiated 1/17/23.
Offer resident toileting after meals - date initiated 1/24/23.
Rehab to eval and TX as indicated - date initiated 2/16/23.
PT consult for strength and mobility - date initiated 5/8/23.
Fall mat - date initiated 5/11/23.
Keep items within reach - date initiated -5/16/23.
Scoop mattress & OT evaluate - date initiated 6/25/23.
OT evaluate -date initiated - 7/3/23.
Resident #5's first Actual Fall was on 7/21/22 at that time the care plan should have been updated to reflect the fall and any new interventions put in place. There were no new interventions put in place nor was the care plan updated when Resident #5 fell on [DATE]. On 1/7/23 Resident #5 sustained a fall while outside the facility at the dialysis center. The facility did not know of the fall until the Resident complained of pain on 1/8/23 and was found to have sustained a fractured pubic [NAME] after visit to the ER. The facility failed to update the care plan to include the fall with injury and put interventions in place. On 1/16/23 Resident #5 had a fall and they added fall mat as an intervention. On 1/24/23 Resident #5 had a fall and they added toileting after meals as an intervention. After Resident #5 fell on 2/14/23 they added Rehab to eval and treat as an intervention. This intervention was already in place as PRN since 8/5/22. On 4/16/23 there was no intervention added after the fall. On 5/5/23 after another fall, they added PT consult, which had been added on 8/5/22. On 5/11/23 they added Fall mat as an intervention after the 5/10/23 fall, however, this was already added on 1/17/23. On 5/16/23 they added Keep items in reach after a fall. On 6/24/23 they added, Scoop mattress and OT evaluate, after a fall on 6/25/23. On 7/3/23 the facility added OT consult, after a fall on 7/1/23 this is a duplicate intervention added on 6/25/23.
On the morning of 3/27/23 an interview with LPN D was conducted and LPN D was asked what the nurses do after a fall. LPN D stated first assess the Resident, then get vital signs and do the paperwork and notify the RP and Physician. When asked about the paperwork she stated that there are fall documents on the computer. She stated that a fall assessment and note have to be done in the electronic health record. When asked if this included updating the care plan, she stated that it did. When asked why how often care plans are updated, she stated that they are done quarterly unless there is a change in condition, or treatment or fall.
A review of the care plan policy read as follows:
Page 4
16. Thee care plan / interdisciplinary team is responsible for the review and updating of the care plans.
a. When requested by the resident / resident representative.
b. When there has been a significant change in the resident's condition.
c. When the desired outcome is not met.
d. When goals, needs, and preferences change.
e. When the resident has been readmitted to the facility from a hospital stay; and
f. At least quarterly and after each OBRA MDS assessment.
On 3/28/24 during the end of meeting the Administrator was made aware of the changes and no further I 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 F0660
(Tag F0660)
Could have caused harm · This affected 1 resident
Based on staff interview, facility documentation review and clinical record review, the facility staff failed to implement an effective discharge plan for one resident in a survey sample of 16 residen...
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Based on staff interview, facility documentation review and clinical record review, the facility staff failed to implement an effective discharge plan for one resident in a survey sample of 16 residents.
The findings include:
For Resident # 1, the facility staff failed to ensure the discharge needs were identified and implemented.
Resident # 1 was admitted to the facility on with diagnoses that included but were not limited to: Chronic Embolism and Thrombosis of the left femoral vein, , Acute Kidney Failure, Pressure Ulcer, Nontraumatic hematoma of soft tissue, Acute Embolism and Thrombosis of deep veins of lower extremity,Bipolar Disorder, History of falling, Acute Posthemorrhagic Anemia,Schizoaffective Disorder, Contracture of Muscle, Unspecified site.
The most recent MDS (minimum data set) assessment was a Quarterly assessment with an ARD (Assessment Review Date) of 7/1/2023. The MDS coded Resident # 1 with a BIMS (Brief Interview for Mental Status) score of 4 (of a possible 15 points) which indicated severe cognitive impairment. Resident # 1 required assistance with ADLs (activities of daily living.)
Review of the clinical record was conducted 3/26/2024-3/28/2024.
Review of the Progress notes was revealed the following notes:
The Progress Notes stated: 9/8/2023 at 2050 (8:50 p.m.):
Residents R/P (Responsible Party) ________ Name redacted (niece) came to the facility to discharge her and take her home, against medical advice, NP (nurse practitioner) was notified and made aware of her wanting to be discharge, ____ (name redacted) was informed of NP (nurse practitioner) not approving this resident to be discharged at this time, and that she would not be able to receive any discharge instructions from this facility r/t (related to) the residents continuing care at home, residents niece refused to sign the AMA (against medical advice) form, this nurse and the house supervisor signed the form to acknowledge the conversation, regarding the risks, All residents personnel (sic) belongings where gathered and packed by staff and sent with her, resident was escorted via wheelchair to the front entrance and transported by the nieces, personnel (sic) vehicle.
Another note stated:
Effective Date: 09/08/2023 14:11 Type: *Communication with Family/NOK (next of kin) /POA (power of attorney)
Note Text : Writer spoke with ________(Responsible Party's name redacted) who stated, They want me to pay $2000, no she will be coming with me, and Anthem don't want to pay for it.' Writer explained the risks of leaving AMA (Against Medical Advice) to ____(Responsible Party's name redacted), but she continued to demand discharge paperwork and meds for resident. Policy and procedures of leaving AMA were also explained unsuccessfully. ____(Responsible Party's name redacted) refused to sign AMA form and stated, 'I'll be back to get her in a while'. DON (Director of Nursing) and NP (Nurse Practitioner) notified.
Review of the clinical record revealed no documentation of a copy of the medical record being provided to the resident and/or family. Review revealed no copy of the Against Medical Advice form that was reportedly refused to be signed by the family/Responsible Party.
On 3/27/2024 at 10:27 a.m., an interview was conducted with the Administrator and Director of Nursing. They stated they had not been involved with the incident involving the discharge of Resident # 1. Both stated they had only been employed in their positions for four weeks at the time of the survey. The Administrator stated she had been informed about the incident when she was hired in February 2024. The Director of Nursing stated she had been employed as a Registered Nurse at the facility at the time of the incident but had no knowledge of the specifics of what happened.
The Administrator stated the facility's policy regarding AMA (Against Medical Advice) discharges was that residents were expected to be given assistance including discharge instructions, copies of the medications and referrals to physicians for follow up. She also stated the facility would notify Adult Protective Services to inform them of the AMA discharge. The Administrator stated she did not have any additional information other that which was documented in the clinical record.
The Director of Nursing stated the staff who were involved in the incident were no longer employed at the facility. The previous Director of Nursing, the Licensed Practical Nurse assigned to work with Resident # 1 on the day of discharge and the Nursing Supervisor were no longer employed at the facility. A list of the current employees was requested. A list of New Hires and Terminations for the previous 6 months was requested.
Review of the Current Employees list revealed documentation that none of the staff members involved in the incident were still employed at the time of the survey. However, the Nurse Practitioner was still a provider at the facility. The Administrator and Director of Nursing were informed that the survey team wanted to interview the Nurse Practitioner. The Nurse Practitioner did not contact the survey team prior to the end of the survey. The Medical Director met with the survey team on 3/28/2024 at approximately 2:45 p.m. The Medical Director stated he was informed about the incident involving the AMA discharge of Resident # 1. He stated the nursing staff should have provided the face sheet and discharge information to Resident # 1 and/or family at the time of the discharge. The Medical Director stated the staff should have given all of the medications for Resident #1 that were already at the facility to the family. The Medical Director stated the medications on the medication cart were already paid for by the Resident and could not be utilized by anyone else. He stated that would have been helpful to the Resident and family. The Medical Director stated it was not acceptable for the the facility's staff to refuse to provide assistance, education, discharge instructions and follow up appointments to residents who leave Against Medical Advice. The Medical Director stated the Nurse Practitioner was in a situation where the nursing staff informed her of the incident after everything had happened. The Medical Director stated Residents should be given copies of their medical records when requested.
Review of the facility's policy entitled Discharging a Resident Without a Physician's Approval revealed the following information:
SPECIFIC PROCEDURES/GUIDANCE
1. Should a resident, or his or her representative request a verbal or written discharge, the resident's attending physician will be promptly notified.
2. The nurse will document in the resident record the provider's response to the resident/resident representative's request to leave the facility.
3. If the resident or representative insists upon being discharged without the approval of the attending physician, the resident and/or representative must sign a Release of Responsibility form. Should either party refuse to sign the release, such refusal must be documented in the resident's medical record and witnessed by two staff members.
4. Should a resident and/or representative request a discharge from the facility during the time the resident is on isolation (transmission-based) precautions, the Charge Nurse must notify the Director of Nursing Services and the resident's Attending Physician of the discharge request.
a. The Director of Nursing Services, or Charge Nurse, shall inform the resident, and/or representative of the potential hazards involved in the early discharge of the resident and shall request that the resident remain in the facility until such time as the isolation/precautionary period has ended.
5. The facility respects the resident's right to discharge against medical advice and will offer education to the resident/resident representative on care needs post discharge.
a. Documentation of education and discharge instructions to the resident/resident representative will be made in the resident's medical record.
b. Discharge instructions may include, but is not limited to:
i. Prescribed medications/treatments
1. Where appropriate and available the physician/practitioner may provide prescriptions or call prescriptions into the desired pharmacy
2. With the physician's approval, the medications that are on hand, excluding narcotics, may be provided to the resident or the representative. The medications will be explained to the resident/representative including name, dose, time to be administered, any parameter requirements, risk associated, etc. The resident/representative and discharging nurse must sign a receipt noting understanding of medication. A copy will be provided to the resident and original maintained in the resident record.
ii. Information on community resources [i.e., home health, therapy, equipment, etc.]
iii. Follow up appointments
iv. Safety precautions
c. If the resident/resident representative refuses to wait for or accept education and/or discharge instructions, such refusal will be documented in the resident's medical record.
6. If the facility feels that the resident's safety may be in jeopardy with the discharge, the facility may make a referral to Adult Protective Services or other community support system.
Review of the Care plan revealed the following information:
CANCELLED: The resident wishes to (SPECIFY return/be discharged ) to (SPECIFY home, another facility)
Date Initiated: 01/24/2023
Revision on: 10/03/2023
Cancelled Date: 10/03/2023
CANCELLED: The resident will be able to verbalize/communicate required assistance post-discharge and the services required to meet
needs before discharge.
Date Initiated: 01/24/2023
Revision on: 10/03/2023
Target Date: 10/26/2023
Cancelled Date: 10/03/2023
CANCELLED: Evaluate/record the resident's abilities and strengths, with family/caregivers/IDT (Interdisciplinary team). Determine gaps in abilities which will affect discharge. Address gaps by (community referral to SPECIFY, pre-discharge PT/OT, internal referral to SPECIFY)
Date Initiated: 01/24/2023
Revision on: 10/03/2023
Cancelled Date: 10/03/2023
10/03/2023
CANCELLED: Make arrangements with required community resources to support independence post-discharge (specify: homes care, PT, OT, MD, Wound Nurse)
Date Initiated: 01/24/2023
Revision on: 10/03/2023
Cancelled Date: 10/03/2023
10/03/2023
CANCELLED: The resident needs (SPECIFY assistance/supervision) with: (SPECIFY communicate/describe needs, book appointments, ADLs, housekeeping, communication) on discharge to community.
Date Initiated: 01/24/2023
Revision on: 10/03/2023
Cancelled Date: 10/03/2023
Review of the clinical record revealed documentation that the facility's staff refused to provide any documentation of the medical record to the resident and/ family.
Review revealed no documentation of a copy of the medical record being provided to the resident and/or family. Review revealed no copy of the Against Medical Advice form that was reportedly refused to be signed by the family/Responsible Party.
On 3/27/2024 at 10:27 a.m., an interview was conducted with the Administrator and Director of Nursing. They stated they had not been involved with the incident involving the discharge of Resident # 1. Both stated they had only been employed in their positions for four weeks at the time of the survey. The Administrator stated she had been informed about the incident when she was hired in February 2024. The Director of Nursing stated she had been employed as a Registered Nurse at the facility at the time of the incident but had no knowledge of the specifics of what happened.
The Administrator stated the facility's policy regarding AMA (Against Medical Advice) discharges was that residents were expected to be given assistance including discharge instructions, copies of the medications and referrals to physicians for follow up. She also stated the facility would notify Adult Protective Services to inform them of the AMA discharge. The Administrator stated she did not have any additional information other that which was documented in the clinical record.
The Director of Nursing stated the staff who were involved in the incident were no longer employed at the facility. The previous Director of Nursing, the Licensed Practical Nurse assigned to work with Resident # 1 on the day of discharge and the Nursing Supervisor were no longer employed at the facility. A list of the current employees was requested. A list of New Hires and Terminations for the previous 6 months was requested.
Review of the Current Employees list revealed documentation that none of the staff members involved in the incident were still employed at the time of the survey. However, the Nurse Practitioner was still a provider at the facility. The Administrator and Director of Nursing were informed that the survey team wanted to interview the Nurse Practitioner. The Nurse Practitioner did not contact the survey team prior to the end of the survey.
The Medical Director met with the survey team on 3/28/2024 at approximately 2:45 p.m. The Medical Director stated he was informed about the incident involving the AMA discharge of Resident # 1. He stated the nursing staff should have provided the face sheet and discharge information to Resident # 1 and/or family at the time of the discharge. The Medical Director stated the staff should have given all of the medications for Resident #1 that were already at the facility to the family. The Medical Director stated the medications on the medication cart were already paid for by the Resident and could not be utilized by anyone else. He stated that would have been helpful to the Resident and family. The Medical Director stated it was not acceptable for the the facility's staff to refuse to provide assistance, education, discharge instructions and follow up appointments to residents who leave Against Medical Advice. The Medical Director stated the Nurse Practitioner was in a situation where the nursing staff informed her of the incident after everything had happened. The Medical Director stated Residents should be given copies of their medical records when requested.
During the end of day debriefings on 3/27/2024 and 3/28/2024, the facility's Administrator, Director of Nursing and two Corporate Nurse Consultants (Employee-M and Employee N) were informed of the findings.
No further information was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0675
(Tag F0675)
Could have caused harm · This affected 1 resident
Based on interview, clinical record review and facility documentation the facility staff failed to ensure that each resident receives care and services to attain or maintain the highest practicable ph...
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Based on interview, clinical record review and facility documentation the facility staff failed to ensure that each resident receives care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 resident in a survey sample of 16 Residents.
The findings included:
For Resident #6, the facility staff failed to speak with the Resident in a manner that preserved dignity and respect.
On 3/27/24 at approximately 3PM an interview was conducted with Resident #6 who stated that she felt that staff were uncaring. She stated that she felt that some staff were rude to Residents without provocation. When asked if she knew of any specific staff members, she declined to give names. She stated, You know I ' m not the only one who has seen this. It has been brought up at Resident Council and the supervisors are aware of it. I am trying to get transferred out of here to [facility name redacted].
A review of the Resident council minutes for the preceding 6 months revealed the following:
12/27/23 - Nursing - DON present - Resident Concern / Suggestions: Call lights are not being answered timely and having to wait a long time; Wing 4, all shifts & some staff get rude when they answer the call lights.
3/25/24 - Nursing - Concerns / Suggestions: Residents complained about waiting a long time for nursing assistance on evening shifts at night: On Weekends waiting a long time for assistance. Stating some staff are even rude.
On the morning of 3/27/24 an interview was conducted with the DON concerning the matter of respect and dignity and she stated that they have provided training and that they have ongoing training on timely answering of call lights and staff attitudes.
On 3/28/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident # 3, the facility staff failed to provide baths and showers as scheduled.
Resident # 3 was admitted to the faci...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident # 3, the facility staff failed to provide baths and showers as scheduled.
Resident # 3 was admitted to the facility in July 2023 with diagnoses that included but were not limited to: Major Depressive Disorder, Anoxic Brain Damage, Essential Hypertension, Hypothyroidism, Aphasia, Epilepsy, Unspecified Psychosis, Gastrostomy, Anxiety Disorder, Unspecified Mood [Affective] Disorder, Dysphagia, Unspecified Convulsions, Pruritis, Alternating Exotropia.
The most recent MDS (minimum data set) assessment was a Quarterly assessment with an ARD (Assessment Review Date) of 03/6/2024. The MDS coded Resident # 3 with severe cognitive impairment. Resident # 3 required extensive assistance of staff persons with ADLs (activities of daily living.) Resident # 3 was coded as always incontinent of bowel and bladder.
Review of the clinical record was conducted 3/26/2024-3/28/2024.
Certified Nursing Assistants (CNA's) were interviewed on all three units during survey, and indicated they documented all care in the Point of Care computerized system for each of their residents at the end of every shift.
Review of Resident # 3's physician orders, Treatment administration records (TAR's), Care plan, and progress notes indicated that Resident # 3 needed assistance with Activities of Daily Living.
The records indicated that Resident # 3 was totally dependent on staff for bathing and showering. The record further documented the following:
Review of the bathing records from September 2023 to March 2024 revealed the following documentation:.
September 2023-no missing documentation
October 2023-1 day missing
November 2023-1 day missing
December 2023-3 days missing
January 2024- 4 days missing
February 2024-3 days missing
March 2024- 7 days missing
Review of the Progress Notes revealed no documentation of a reason for the missing documentation of bathing.
Scheduled showers were documented as not being administered included but were not limited to: September 2023-twice, December 2023- 6 times, January 2024-3 times, February 2024-4 times, March 2024-3 times.
On 3/27/2024, the Director of Nursing (DON), and Administrator were interviewed and asked about their expectation for bathing and showering. They stated all residents should receive showers twice a week and bed baths on the other days, and that the provision of care must be documented afterwards.
Staff stated that the facility's policy was for residents to receive showers twice a week and bed baths on they days they did not get a shower.
On 3/28/2024 at 3:05 p.m., an interview was conducted with the Director of Nursing who stated the expectation was for all residents to receive a bed bath on the days they did not receive a shower. The Director of Nursing stated the staff should document all baths and showers in the clinical record.
A review was conducted of the facility policy titled, Activities of Daily Living (ADLs). The policy read, .4. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); i. Each resident shall receive tub or shower baths as often as needed, but not less than twice weekly or as required by state law .
During the end of day debriefing on 3/28/2024, the facility's Administrator, Director of Nursing and two Corporate Nurse Consultants (Employee-M and Employee N) were informed of the findings.
No further information was provided.
Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure incontinence hygiene care was provided timely for 2 residents (Resident #10 & # 3) of 16 residents in the survey sample.
The findings included:
1. For Resident #10 the facility staff did not provide incontinence hygiene care timely.
Resident #10 was admitted to the facility on [DATE] with diagnoses including; Diabetes, pulmonary embolism, stroke, aphasia, hypertension, contractures, syphilis, congestive obstructive pulmonary disorder (COPD), encephalopathy, carbon monoxide poisoning, and viral hepatitis C.
Resident #10's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 11-27-23 was a quarterly assessment. The MDS coded Resident #10 as needing extensive to total staff assistance with toileting, hygiene, and bathing. The Resident was also coded as unable to complete a brief interview for mental status (BIMS), indicating significant cognitive impairment. The Resident was coded as frequently incontinent of bowel and bladder.
The Resident was no longer in the facility and a closed record review was conducted.
Resident #10's Activity of daily living sheets documented hygiene care given to the Resident. Review of those documents revealed that during the months of March, June and July 2023 personal hygiene was not given for the following dates and shifts;
3-2-23 (7am to 3pm), 3-4-23 (7am to 3pm), 3-21-23 (7am to 3pm), 3-22-23 (7am to 3pm), 3-30-23 (7am to 3pm)
3-4-23 (3pm to 11pm)
3-12-23 (11pm to 7am), 3-22-23 (11pm to 7am), 3-31-23 (11pm to 7am)
6-4-23 (7am to 3pm), 6-24-23 (7am to 3pm).
6-8-23 (3pm to 11 pm), 6-18-23 (3pm to 11pm), 6-19-23 3pm to 11pm).
6-11-23 (11pm to 7am), 6-17-23 (11pm to 7am)
7-15-23 (11pm to 7am).
Review of Resident #10's physician and nursing progress notes indicated a Resident who was total care and received peg tube liquid feedings through the abdomen.
The facility incontinence care policy was reviewed and revealed that hygiene and incontinence care would be given in a timely manner.
The Resident's care plan was reviewed and indicated the Resident would receive incontinence care after each incontinence episode. The Resident experienced a wound on her sacrum, and there was no care plan for wounds for Resident #10.
Staff nurse and CNA interviews were conducted during the course of the survey on all units. Those interviews indicated that the expectation for incontinence rounds was every 2 hours and as often as needed, and skin would be assessed for breakdown during that care. If skin breakdown was found by CNA's (Certified Nursing Assistants), who typically completed incontinence care, they would then immediately report it to the nurse. the nurse would then assess the area, measure it, document a description of it, and seek physician's orders to treat and prevent worsening.
Physician's orders were reviewed and indicated a treatment for a sacral wound first ordered on 3-3-23. No measurements nor descriptions of the wound were every placed in the clinical record. Resident #10 was not afforded timely incontinence care as many times as was needed, as evidenced by the sacral wound actually acquired in the facility.
On 3-28-24 during the end of day meeting the Administrator and Director of Nursing (DON) were made aware of the above findings and no additional information was provided to the surveyor.
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
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. For Resident #8 the facility staff failed to consistently provide pressure injury care per physician orders.
Resident #8 was...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. For Resident #8 the facility staff failed to consistently provide pressure injury care per physician orders.
Resident #8 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, paraplegia, osteomyelitis of left ankle and foot, pressure ulcer of left heel, pressure ulcer left ankle, stage 4, pressure ulcer of right ankle, stage 3 and osteomyelitis of the vertebra. The resident was discharged to the hospital on [DATE] and did not return .
Resident #8's MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of [DATE] was an admission assessment. The MDS coded Resident #8 with a brief interview for mental status (BIMS) score of 7, indicating significant cognitive impairment as needing extensive to staff assistance with toileting, hygiene, and bathing. Section M for pressure ulcers indicated the resident was admitted with several Stage IV pressure ulcers.
Resident #8's Care Plan dated [DATE] revealed Resident #8 had potential for impairment to skin integrity related to quadriplegia, diabetes mellitus, wounds, and abrasion. Resident #8 had documentation of pressure wounds upon admission.
The Resident was no longer in the facility and a closed record review was conducted.
The physician orders were reviewed and revealed the following:
- Left heal wound: Cleanse with normal saline wound cleaner, apply Santyl and cover with border foam only for thirty days, every day shift for unstageable wound. Start [DATE]-End [DATE].
- Left lateral leg: cleanse with wound cleaner (may sub normal saline) pat dry, apply Santyl and cover with dry dressing every day shift for wound care. Start [DATE]-D/C Date [DATE].
-Right Leg: Cleanse with Wound cleanser, pat dry, apply Santyl then calcium alginate and cover with dry dressing (foam border if available) every day shift for wound care-Start Date: [DATE]-D/C Date [DATE].
- Sacrum: cleanse with wound cleaner pat dry, apply Santyl then calcium alginate and cover with dry dressing (foam border if available) every day shift for wound care. -Start Date [DATE]-D/C Date[DATE].
- Santyl External Ointment 250 UNIT/GM (Collagenase) Apply to left heel topically every day shift for wound care related to Pressure Ulcer of Left Heal, unstageable (L89.620) Left Heel: Cleanse with Wound cleanser, pat dry, apply thin layer of Santyl then calcium alginate and cover with dry dressing (foam border if available).-Start Date[DATE] 0700 -D/C Date[DATE] 1436
Review of the [DATE] Treatment Administration Record (TAR) revealed wound care was not signed off by the licensed nurse as provided to one of Resident #8's (unable to identify which of the 4 pressure ulcers) pressure ulcers per physician order on [DATE]. The local advocate for the aged was visiting on [DATE] and identified that one of the pressure ulcer dressings was dated [DATE] which corroborated the [DATE] pressure ulcer wound care was omitted on [DATE].
SANTYL Ointment (SANTYL) is indicated for debriding chronic dermal ulcers and severely burned areas and is the only FDA-approved enzymatic debridement agent indicated for debriding both chronic dermal ulcers and severely burned areas. Its unique mechanism of action selectively removes necrotic tissue without harming healthy tissue (https://santyl.com/).
Calcium alginate dressings are used primarily for the granulating phase of wound repair. The calcium in the dressing interacts with sodium in the wound, providing a wound exudate that stimulates myofibroblasts and epithelial cells and speeds wound homeostasis (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4525879/).
Review of the nurses' notes did not reveal or document why the wound care was not performed on the above date.
Resident #8's care plan revealed Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate, Date Initiated: [DATE] Revision on: [DATE] Resolved Date: [DATE].
On [DATE] at 3:14 p.m., the Administrator and the Director of Nursing were informed that there was a lack of documentation that pressure ulcer wound care was consistently signed off as provided by a licensed nurse during the month of [DATE] for Resident #8 . We discussed, the wound care policy, and what is to be expected of the staff. The director of nursing stated that wound care orders are to be carried out per the physician's order .
No further information was provided by the facility staff.
Based on family interview, staff interview, clinical record review, and facility document review, the facility staff failed to provide treatment and services for pressure sores for three Residents (Residents #10, 12, & #8) in a survey sample of 16 Residents.
The findings included:
1. For Resident #10, the facility staff failed to give incontinence hygiene care timely, failed to assess, describe and document a sacral pressure wound, and further failed to provide a care plan for the sacral pressure wound.
Resident #10 was admitted to the facility on [DATE] with diagnoses including; Diabetes, pulmonary embolism, stroke, aphasia, hypertension, contractures, syphilis, congestive obstructive pulmonary disorder (COPD), encephalopathy, carbon monoxide poisoning, and viral hepatitis C.
Resident #10's most recent MDS (Minimum Data Set Assessment) with an ARD (Assessment Reference Date) of 11-27-23 was a quarterly assessment. The MDS coded Resident #10 as needing extensive to total staff assistance with toileting, hygiene, and bathing. The Resident was also coded as unable to complete a brief interview for mental status (BIMS), indicating significant cognitive impairment. The Resident was coded as frequently incontinent of bowel and bladder.
On 1-27-23 a Braden scale skin assessment for admission was completed and indicated a score of 7 very high risk for skin breakdown. The Resident had no pressure wounds upon admission.
The Resident was no longer in the facility and a closed record review was conducted.
Resident #10's Activity of daily living sheets documented hygiene care given to the Resident. Review of those documents revealed that during the months of March, June and [DATE] personal hygiene was not given for the following dates and shifts;
3-2-23 (7am to 3pm), 3-4-23 (7am to 3pm), 3-21-23 (7am to 3pm), 3-22-23 (7am to 3pm), 3-30-23 (7am to 3pm)
3-4-23 (3pm to 11pm)
3-12-23 (11pm to 7am), 3-22-23 (11pm to 7am), 3-31-23 (11pm to 7am)
6-4-23 (7am to 3pm), 6-23-23 (7am to 3pm).
6-8-23 (3pm to 11 pm), 6-18-23 (3pm to 11pm), 6-19-23 3pm to 11pm).
6-11-23 (11pm to 7am), 6-17-23 (11pm to 7am)
7-15-23 (11pm to 7am).
Review of Resident #10's physician and nursing progress notes indicated a Resident who was total care and received peg tube liquid feedings through the abdomen.
The facility Incontinence care policy was reviewed and revealed that hygiene and incontinence care would be given in a timely manner.
The facility policy for Documentation of Wound Treatments was reviewed and revealed that
the following elements are;
1. Documented upon admission, weekly, and as needed if the Resident or wound condition deteriorates.
2. The following elements are documented as part of a complete wound assessment:
a. Type of wound (pressure injury, surgical, etc.) and anatomical location
b. Stage of the wound if pressure injury (stage 1, 2, 3, 4, deep tissue injury, unstageable pressure injury) or the degree of skin loss if non-pressure (partial or full thickness)
c. Measurements: height, width, depth, undermining, tunneling
d. Description of wound characteristics:
i. Color of the wound bed
ii. Type of tissue in the wound bed(i.e., granulation, slough, eschar, epithelium)
iii. Condition of the peri-wound skin (dry, intact, cracked, warm, inflamed, mascerated)
iiii. Presence, amount and characteristics of wound drainage/exudate
v. Presence or absence of odor
vi. Presence or absence of pain
3. Wound treatments are documented at the time of each treatment .
The Resident's care plan was reviewed and indicated the Resident would receive incontinence care after each incontinence episode. There was no care plan for wounds for Resident #10.
Physician's orders were reviewed and indicated a treatment for a sacral wound first ordered on 3-3-23 for cleanse with normal saline, pat dry, apply Medi honey, apply calcium alginate, and cover with a dry foam border dressing.
No measurements nor descriptions of the wound were every placed in the clinical record. Resident #10 was not afforded timely incontinence care as many times as was needed, as evidenced by the sacral wound actually acquired in the facility.
Weekly skin Evaluation documents were reviewed and revealed that only 4 existed in the clinical record. Those were as follows;
3-7-23 first weekly assessment sacrum wound. No further documentation nor description.
3-14-23 sacrum wound. No further documentation nor description.
3-21-23 sacrum wound. No further documentation nor description.
6-30-23 stated no open areas, however, the Resident continued to have treatments to her gluteal folds until the time of her discharge on [DATE]. There is no documentation of the sacrum improving, worsening, or healing.
A family interview and documentation revealed that the Resident still had a pressure injury to her bottom on 7-7-23.
Staff nurse and CNA interviews were conducted during the course of the survey on all units. Those interviews indicated that the expectation for incontinence rounds was every 2 hours and as often as needed, and skin would be assessed for breakdown during that care. If skin breakdown was found by CNA's (Certified Nursing Assistants), who typically completed incontinence care, they would then immediately report it to the nurse. the nurse would then assess the area, measure it, document a description of it, and seek physician's orders to treat and prevent worsening. The nursing staff stated all skin assessments were in the computerized record, and they had no paper assessments.
On 3-28-24 during the end of day meeting the Administrator and Director of Nursing (DON) were made aware of the above findings. The Administrator revealed a quality improvement plan to improve completion of skin assessments and education on proper assessment and staging wounds, which is projected to be completed by 3-29-24. No additional information was provided to the surveyor.
2. For Resident #12, the facility staff failed to assess, describe and document a sacral pressure wound, and further failed to provide a care plan for the sacral pressure wound.
Resident #12 was initially admitted to the facility on [DATE]. The most recent readmission was on 2-14-22 after a hospital stay. Diagnoses included; Diabetes, hypertension, stroke, end stage renal disease with dialysis, seizure, atrial fibrillation, anemia, sarcopenia, peripheral vascular disease, and obstructive sleep apnea with refusal to wear C-pap.
The Resident's most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 4-3-23 was coded as a quarterly assessment. Resident #12 was coded as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 of a possible 15 points, and was her own responsible party. The Resident required extensive to total dependant assistance from staff to perform activities of daily living, and was coded as always incontinent of bowel and bladder. The Resident was coded as at risk for pressure sores, however, had no pressure wounds.
During the time of survey the Resident was no longer in the facility, and was a closed record review.
Review of the clinical record revealed physician and nursing progress notes that documented the following time line;
On 5-23-23 (Tuesday) the Resident was sent to dialysis and was sent immediately to the hospital for care from the dialysis center after having no dialysis for 5 days.
On 6-4-23 the Resident returned to the nursing facility with a hospital discharge diagnosis of gangrene and pulmonary edema.
On 6-4-23 Nursing and physician progress notes revealed that a pressure ulcer was found on the Residents sacrum. A doctor's order was placed in the treatment record at 9:00 am for cleanse pressure area to sacrum with normal saline, pat dry, apply Medi honey and cover with dry dressing every day and as needed.
On 6-7-23 a Braden's Scale assessment was completed for skin breakdown risk and scored the Resident with a 14.0, Moderate Risk.
On 6-9-23 The treatment for the pressure ulcer (ordered on 6-4-23) was finally implemented and started on this day, (6 days after the order was received) and was omitted on 6-10-23, 6-11-23, 6-12-23, 6-15-23, and 6-16-23. This revealed that in a 13 day period the treatment was only provided 3 times.
On 6-11-23 the progress notes documented that the Resident refused care stating I don't want nothing on it, it's killing me. The treatment administration records documented that the Resident did not receive the treatment on this day. There were no other refusals for the days in question. There were no other mentions of the sacral pressure ulcer.
On 6-13-23 there was a skin assessment document completed which documented sacrum wound. No further documentation nor description. This was the only skin evaluation found in the clinical record for the sacral pressure ulcer.
On 6-16-23 (Friday) the Resident went to the hospital again and she expired in the hospital on 6-21-23.
The Resident's care plan review for a sacral pressure ulcer revealed no care planning for the wound.
On 3-27-24, and 3-28-24 at the end of day debrief, the Administrator, and DON (director of nursing) were notified that the facility failed to provide care and services for pressure ulcers. The Administrator revealed a quality improvement plan to improve completion of skin assessments and education on proper assessment and staging wounds, which is projected to be completed by 3-29-24. No further information was provided by the facility.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, Ombudsman interview, clinical record review, and facility documentation review, the facility staff fai...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, Ombudsman interview, clinical record review, and facility documentation review, the facility staff failed to provide necessary dialysis services and transportation for 1 Resident (Resident's #12) in a survey sample of 16 residents.
The findings included:
For Resident #12, the facility staff failed to provide timely transportation to receive dialysis treatment from 5-18-23 until 5-23-23 (5 days).
Resident #12 was initially admitted to the facility on [DATE]. The most recent readmission was on 2-14-22 after a hospital stay. Diagnoses included; Diabetes, hypertension, stroke, end stage renal disease with dialysis, seizure, atrial fibrillation, anemia, sarcopenia, peripheral vascular disease, and obstructive sleep apnea with refusal to wear C-pap.
The Resident's most recent quarterly MDS (minimum data set) with an ARD (assessment reference date) of 4-3-23 was coded as a quarterly assessment. Resident #12 was coded as cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 of a possible 15 points, and was her own responsible party. The Resident required extensive to total dependant assistance from staff to perform activities of daily living, and was coded as always incontinent of bowel and bladder. The Resident was coded as at risk for pressure sores, however, had no pressure wounds.
During the time of survey the Resident was no longer in the facility, and was a closed record review.
Review of the clinical record revealed physician and nursing progress notes that documented the following time line;
4-17-23 discharged to hospital with fever and altered mental status. The Resident was diagnosed with an abdominal abscess and sepsis.
On 4-25-23 while in the hospital the Resident was also diagnosed with osteomyelitis and sepsis secondary to Gangrene, and under went amputation of her left leg below the knee, and her right partial foot and toes.
On 5-5-23 the Resident was readmitted to the facility from the hospital, and stayed for 2 days when she was readmitted to the hospital with altered mental status on 5-7-23.
On 5-17-23 (Wednesday) the Resident returned to the nursing facility from the hospital after receiving dialysis, which had been historically scheduled for Mondays, Wednesdays, and Fridays, every week.
On 5-19-23 (Friday) the Resident did not go to dialysis as she had no transportation, and progress notes described swelling on left side.
On 5-22-23 (Monday) the Resident was unable to receive dialysis because transportation was late arriving.
On 5-23-23 (Tuesday) the Resident was sent to dialysis and was sent immediately to the hospital for care from the dialysis center after having no dialysis for 5 days.
On 6-4-23 the Resident returned to the nursing facility with a hospital discharge diagnosis of gangrene and pulmonary edema.
On 6-7-23 (Wednesday) the Resident went to dialysis.
On 6-9-23 (Friday) the Resident's surgical wounds were infected and antibiotics were ordered to treat.
On 6-12-23 (Monday) the Resident went to dialysis and was again sent from dialysis directly to the hospital where she was treated and discharged back to the nursing facility the same day.
On 6-14-23 (Wednesday) the Resident went to dialysis, and on 6-16-23 (Friday) the Resident went back to the hospital and did not return.
The Resident's care plan review for dialysis revealed facility provides transportation, Aetna Logisticare transportation.
The facility policy review for Transportation revealed Social Services - Transportation, Our facility shall help arrange transportation for Residents as needed.
On 3-27-24, and 3-28-24 at the end of day debrief, the Administrator, and DON (director of nursing) were notified that the facility failed to provide transportation to dialysis for 5 days for Resident #12. They stated that the expectation was that the Residents will keep all dialysis appointments, and will be sent to the hospital to receive dialysis if needed, and appointments are missed. No further information was provided by the facility.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
Based on observation, interview, clinical record review and facility documentation the facility staff failed to ensure that food is palatable and served at an appetizing temperature for all Residents ...
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Based on observation, interview, clinical record review and facility documentation the facility staff failed to ensure that food is palatable and served at an appetizing temperature for all Residents receiving meals from the kitchen.
The findings included:
1. For all Residents receiving meals from the kitchen, the dietary staff failed to ensure food was consistently served in a manner that maintained appropriate temp for that food item (hot items served hot and cold items served cold).
On 3/27/24 at approximately 12:20 PM an interview was conducted with Resident #6 who stated that she complained many times about the food since her admission. She stated, It's getting better now that the elevator is fixed. When asked what the elevator has to do with the food being cold, she said, Well the kitchen is in the basement, and they have to bring the trays up to the 2 floors. The elevator was broken for months and now its fixed but sometimes we still have a problem if they don't use the hot plates in the trays.
Although a test tray was done during the survey and this issue was not found during the survey process, interviews with Resident # a review of the Resident council minutes revealed the following:
10/23/23 - Dietary - Residents stated that the food is cold all meals; States they fries, potatoes, and hash browns are raw/not fully cooked.
11/27/23 - Dietary - Meal tray times are late, food cold.
12/27/23 - Dietary - more variety with meals, Expired milk received by several Residents.
1/29/24 - Dietary - Cold food, getting wrong items on tray and no condiments provided on meal trays. Requested representative from dietary come to Resident Council.
2/26/24 - Dietary - Food is cold, requested representative from dietary come to Resident Council. Requested cartons of milk back instead of milk poured into cups. Not getting snacks at night on all wings.
3-7-24 - Food Committee Meeting - Staff present: Dietary manager, Activities Director and Social Worker.
# of Residents present -20.
Concerns Addressed: [Name Redacted] Dietary Manager, explained the food was cold due to issues with the elevator continuously breaking down [and the kitchen being located in the basement.] and the hot pallets in the kitchen are broke. She apologized to the Residents and informed them that maintenance has fixed the hot plate pallets. And the elevator is being repaired.
On 3/28/24 at 3:30 PM an interview was conducted with the Administrator who stated that the elevator repairs took a long time due to the age of the system and the difficulty obtaining parts for it. She stated that during the time she has been at the facility she looked for creative ways to ensure food was served at the right temperatures, including Styrofoam clamshell, fixing the hot pallets, instead of carrying trays up she had dietary set up food on the first floor and those able to ambulate could come and get meals in the dining room. [Please notes she has been in this role for 4 weeks and the food issue has been ongoing for 6 months].
On 3/28/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.
2. For Resident # 3, the facility staff failed to ensure that food had an appetizing temperature.
Resident # 3 was admitted to the facility in July 2023 with diagnoses that included but were not limited to: Major Depressive Disorder, Anoxic Brain Damage, Essential Hypertension, Hypothyroidism, Aphasia, Epilepsy, Unspecified Psychosis, Gastrostomy, Anxiety Disorder, Unspecified Mood [Affective] Disorder, Dysphagia, Unspecified Convulsions, Pruritis, Alternating Exotropia.
The most recent MDS (minimum data set) assessment was a Quarterly assessment with an ARD (Assessment Review Date) of 03/6/2024. The MDS coded Resident # 3 with severe cognitive impairment. Resident # 3 required extensive assistance of staff persons with ADLs (activities of daily living.) Resident # 3 was coded as always incontinent of bowel and bladder.
Review of the clinical record was conducted 3/26/2024-3/28/2024.
Review of the Grievance logs revealed documentation of complaints about food being cold.
Review of the Resident Council Committee minutes revealed documentation of complaints of cold food.
Tour of the Dietary department revealed the kitchen was located in the basement of the facility. The Service Elevator was located in close proximity to the kitchen door where service carts exit the kitchen area.
On 3/27/2024 at 1:10 p.m., an interview was conducted with the Dietary Assistant who stated the elevator was broken for a while. She stated the Dietary staff and nursing staff had to lift the individual trays up the stairs in order to distribute the trays to residents. Since the elevator was broken, the delivery carts could not be utilized. The trays could not be placed on the cart for storage and distribution. The Dietary Assistant stated it was difficult getting the trays up the stairs from the basement to the first and second floor. She also stated there were complaints from residents of food being cold.
On 3/27/2024 at 1:15 p.m., the temperature of a test tray was tested on Unit 4. The temperatures of the food was within the acceptable range. The meat was at 166 degrees, the vegetables were at 138 degrees.
On 3/27/2024 at 1:18 p.m., an interview was conducted with the Dietary Manager who stated she was aware of some complaints about the food at the facility. The Dietary Manager stated she utilized the menus obtained from the Corporate office which were for four cycles. The Dietary Manager stated she had to discuss with the Regional Dietary Manager the Residents' requests for changes within the cycle of menus to see if changes could be made. The Dietary Manager stated she always had an alternate menu. She stated she incorporated food preferences and included likes and dislikes on the bottom of the tickets. The food preferences were located on the top of the tickets. The Dietary Manager stated the food was always hot when it left the kitchen. She stated the trays were distributed by the nursing staff when the serving carts arrived on the units. The Dietary Manager stated the expectation was for food trays to be distributed as soon as possible so the appropriate temperature of the food would be maintained.
On 3/27/2024 at 3:00 p.m., an interview was conducted with the Administrator and Director of Nursing. The Administrator stated there had been numerous complaints about food regarding the presentation. She stated there were Styrofoam containers being used because of missing hot plates. The Administrator also stated there were complaints about the temperature of the food.
The Administrator state the Service Elevator located near Dietary was broken for a period of time. The staff had to used the stairwell to carry the trays from the kitchen in the basement to the first floor and second floor. The Administrator stated they attempted to have the majority of residents eat in the first floor dining room so trays could be delivered faster. The Administrator stated it was strenuous, time consuming and entailed utilization of multiple staff members carrying trays up the stairs. Dietary staff, Nursing staff and ancillary staff all helped to get the trays up the stairs to be distributed to the residents.
Pellet warmers were inoperable. It was stated that several warmers were dropped and broken while lifting trays up the stairs when the elevator was broken.
The Director of Nursing stated the expectation was that the nursing staff would distribute the trays on the carts promptly upon arrival on the units.
On 3/28/2024 at 9:40 a.m., an meeting was conducted with the Administrator and Director of Nursing. They stated they had been in their roles for about 4 weeks at the time of the survey and had identified areas of concern. They stated one of the areas was regarding food. The Administrator stated she had put a Council in place to determine how to best handle the multiple complaints about food. The Administrator stated the Council was interdisciplinary. The Administrator presented documentation of a scheduled QAPI (Quality Assurance Performance Improvement) Committee meeting that was scheduled on 3/28/2024 which happened to be during the time of the survey. The documentation revealed that weeks prior to the survey, the meeting had been scheduled on that date. The Administrator stated the staff members were working on a plan to present to the QAPI Committee on 3/28/2024.
During the end of day debriefings on 3/27/2024 and 3/28/2024, the facility's Administrator, Director of Nursing and two Corporate Nurse Consultants (Employee-M and Employee N) were informed of the findings. Evidence revealed residents did receive cold food due to several factors including but not limited to a broken elevator, inoperable pellet warmers and delayed distribution of trays delivered on the units.
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
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interview, clinical record review and facility documentation the facility staff failed to maintain clinical records that were accurate for 1 Resident (#7) in a survey sample of 16 Residents.
...
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Based on interview, clinical record review and facility documentation the facility staff failed to maintain clinical records that were accurate for 1 Resident (#7) in a survey sample of 16 Residents.
The findings included:
For Resident #7 the facility staff failed to ensure that code status, and Power of Attorney information was consistently and accurately maintained in the clinical record.
On 3/26/24 a review of the clinical record revealed that Resident #7 had orders for Full Code, dated since admission. Further review of records revealed that in Physician Progress Notes, Resident #7 was referred to as DNR (Do Not Resuscitate).
12/17/23 - 7:09 PM Resident declined additional episodes of hemodialysis. Advanced directive was discussed, and resident is a full code.
The clinical record contained an order for Resident #7 that stated, FULL CODE, however, the physician's notes dated 12/13, 12/14, 12/18, 12/20 & 12/23 refer to the Resident as being DNR On 3/28/24 an interview was conducted with the DON and Administrator who were asked if they were aware of the conflicting documentation of code status for Resident #7. They stated that they were not aware of it.
(** Please note both the Administrator and the DON have been in those roles for a little more than 4 weeks.)
On 3/28/24 at approximately 4 PM, an interview was conducted with the Medical Director who stated that Resident #7 was a Resident at another facility where he also worked, and that the Resident was a DNR at that facility. The Medical Director stated that Resident #7 rescinded his code status when he was admitted to the hospital and was now a Full Code. The Medical Director stated that when he pulled the Resident up in the computer it automatically pulled in his former code status. When asked if this is indicative of a computer systems error the Medical Director stated that it was.
On 3/28/24 at approximately 5 PM the Administrator admitted there was a delay in getting the medical records to the Resident #7's mother. The Administrator stated that the mother was not the power of attorney the girlfriend / significant other was the power of attorney. When surveyor mentioned the name of the Resident's power of attorney the Administrator stated That is not who we have listed as the POA. The clinical record had the POA (mothers name) but in the relationship box it said girlfriend / or significant other.
The following excerpt if from the hospital discharge summary given to the facility on admission:
12/5/23 -Mother has copies of POA and advanced directives that have been placed in patient chart.
The following excerpt is from the Physician Progress notes written by the Medical Director:
12/13/23 - He is a poor historian and according to nursing staff his mother is his power of attorney. All of his medications and extensive medical records have been reviewed.
On 3/28/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
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 ensure a safe and functional...
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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 ensure a safe and functional environment for all residents who reside in room [ROOM NUMBER], reside on Wing 2, utilize the Sunroom, or receive meals from the dietary staff.
The findings included:
On 3/26/24 a review of the maintenance logs was conducted. The following are excerpts from the maintenance logs.
Created 1/2/24 at 9:19 AM - NO HEAT - Resident Room wing 2 Updated 1/3/24 10:40 AM Completed.
Created 1/4/24 at 12:49 PM - Power is out in [NAME] River Sunroom - Updated 1/4/24 1:30 PM - Completed.
Created 1/5/24 a -t 2:48 PM - Power is Out in [NAME] River Sunroom. Updated 1/11/24 at 10:27 AM Completed
(Please note no power for 6 days)
Radiator Heat Common Area 300 - 2/6/24- Created 1:15 PM Updated 3:03 PM - Messed with valves at the end of the hall to give more air to memory care unit, messing with the one 1/3 to give more heat as well.
Created 2/19/24 at 8:05 AM- room [ROOM NUMBER] C Heating unit - Residents in room [ROOM NUMBER] are stating it is very cold in their room at night. Can we check the heating unit to be sure it is flowing properly? Updated status 2/20/24 at 5:02 PM Completed.
(** Please Note: Residents stayed in their rooms with heating system not functioning properly for 32 hours.)
Created 3/21/24 at 1:23 PM - Wires hanging out of heating unit - Completed 3/21/24 at 2:43 PM
The following is an excerpt from the food committee in response to Resident Council complaints of cold food. The facility stated the issues were the hot plate pallets and elevator in need of repairs.
3-7-24 - Food Committee Meeting - Staff present Dietary manager, Activities Director and Social Worker # of Residents present -20.
Concerns Addressed: [Name Redacted] Dietary Manager, explained the food was cold due to issues with the elevator continuously breaking down [and the kitchen being located in the basement.] and the hot pallets in the kitchen are broke. She apologized to the Residents and informed them that maintenance has fixed the hot plate pallets. And the elevator is being repaired.
On 3/28/24 at approximately 3:00 PM an interview was conducted with the Maintenance Director and the Regional Maintenance Director who were asked about the elevator being broken, as well as the heat and hot water issues. The facility submitted work logs of repairs and a timeline of the elevator repairs. Excerpt from the elevator repairs are as follows:
3/12/23 - Significant oil loss noticed on freight elevator [note this is how dietary gets food to the floors. There is another elevator however it does not go to the basement where dietary is located.]
8/7/23 - Parts arrived.
9/1/23 - [NAME] installation complete - Pending City inspection
9/11/23 - Inspection passed.
9/29/23 - Both door mods arrived with vendor.
10/9/23 Door mod project started.
10/16/23 - Door mod project stopped due to failed county inspection for oil loss in main elevator diagnosed as oil leak.
[Please note this put a halt to the door project on the freight elevator because they had to focus on the main elevator]
11/3/23 - Hydraulic line replaced on main elevator.
11/6/23 - Door project on freight elevator Re-Starts
11/13/23 - Doors finished on freight elevator.
12/14/23 - new door equipment failed- vendor orders replacement.
12/29/23 - New equipment installed.
2/23/24 - Door equipment failed again - Contract cancelled with vendor.
3/1/24 - New vendor on site full assessment of both elevators
3/8/24 - Tech on site for 2 days to go over all equipment recommendation for both elevators.
3/15/24 - All work completed both elevators are in working order.
3/27/24 - [during survey] Met with the vendors for any additional recommendations - None at this time.
On 3/28/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review and clinical record review, the facility staff failed to follow standard...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review and clinical record review, the facility staff failed to follow standards of practice affecting one resident (Resident #1) in a survey sample of 16 residents.
The findings included:
For Resident # 1, the facility staff refused to provide education and resources to the resident who was discharging against medical advice. They failed to serve as an advocate for the resident. They failed to show practice the tenets of nursing .
Resident # 1 was admitted to the facility on with diagnoses that included but were not limited to: Chronic Embolism and Thrombosis of the left femoral vein, , Acute Kidney Failure, Pressure Ulcer, Nontraumatic hematoma of soft tissue, Acute Embolism and Thrombosis of deep veins of lower extremity,Bipolar Disorder, History of falling, Acute Posthemorrhagic Anemia,Schizoaffective Disorder, Contracture of Muscle, Unspecified site.
The most recent MDS (minimum data set) assessment was a Quarterly assessment with an ARD (Assessment Review Date) of 7/1/2023. The MDS coded Resident # 1 with a BIMS (Brief Interview for Mental Status) score of 4 (of a possible 15 points) which indicated severe cognitive impairment. Resident # 1 required assistance with ADLs (activities of daily living.)
The Progress Notes stated: 9/8/2023 at 8:50 p.m.:
Residents R/P (Responsible Party) ________ Name redacted (niece) came to the facility to discharge her and take her home, against medical advice, GNP (nurse practitioner) was notified and made aware of her wanting to be discharge, ____ (name redacted) was informed of GNP (nurse practitioner) not approving this resident to be discharged at this time, and that she would not be able to receive any discharge instructions from this facility r/t (related to) the residents continuing care at home, residents niece refused to sign the AMA (against medical advice) form, this nurse and the house supervisor signed the form to acknowledge the conversation, regarding the risks, All residents personnel (sic) belongings where gathered and packed by staff and sent with her, resident was escorted via wheelchair to the front entrance and transported by the nieces, personnel (sic) vehicle.
Another Progress Note stated:
Effective Date: 09/08/2023 14:11 Type: *Communication with Family/NOK (next of kin) /POA (power of attorney)
Note Text : Writer spoke with ________(Responsible Party's name redacted) who stated, They want me to pay $2000, no she will be coming with me, and Anthem don't want to pay for it.' Writer explained the risks of leaving AMA (Against Medical Advice) to ____(Responsible Party's name redacted), but she continued to demand discharge paperwork and meds for resident. Policy and procedures of leaving AMA were also explained unsuccessfully. ____(Responsible Party's name redacted) refused to sign AMA form and stated, 'I'll be back to get her in a while'. DON (Director of Nursing) and GNP (Nurse Practitioner) notified.
There was no documentation of the nurse's response to the family's request for discharge paperwork and medication when requested at 2:11 p.m. The nurse did not follow the procedures for residents leaving AMA which included but were not limited to: providing education, medications and resources.
Review of the facility's policy entitled Discharging a Resident Without a Physician's Approval revealed the following information:
SPECIFIC PROCEDURES/GUIDANCE
1. Should a resident, or his or her representative request a verbal or written discharge, the resident's attending physician will be promptly notified.
2. The nurse will document in the resident record the provider's response to the resident/resident representative's request to leave the facility.
3. If the resident or representative insists upon being discharged without the approval of the attending physician, the resident and/or representative must sign a Release of Responsibility form. Should either party refuse to sign the release, such refusal must be documented in the resident's medical record and witnessed by two staff members.
4. Should a resident and/or representative request a discharge from the facility during the time the resident is on isolation (transmission-based) precautions, the Charge Nurse must notify the Director of Nursing Services and the resident's Attending Physician of the discharge request.
a. The Director of Nursing Services, or Charge Nurse, shall inform the resident, and/or representative of the potential hazards involved in the early discharge of the resident and shall request that the resident remain in the facility until such time as the isolation/precautionary period has ended.
5. The facility respects the resident's right to discharge against medical advice and will offer education to the resident/resident representative on care needs post discharge.
a. Documentation of education and discharge instructions to the resident/resident representative will be made in the resident's medical record.
b. Discharge instructions may include, but is not limited to:
i. Prescribed medications/treatments
1. Where appropriate and available the physician/practitioner may provide prescriptions or call prescriptions into the desired pharmacy
2. With the physician's approval, the medications that are on hand, excluding narcotics, may be provided to the resident or the representative. The medications will be explained to the resident/representative including name, dose, time to be administered, any parameter requirements, risk associated, etc. The resident/representative and discharging nurse must sign a receipt noting understanding of medication. A copy will be provided to the resident and original maintained in the resident record.
ii. Information on community resources [i.e., home health, therapy, equipment, etc.]
iii. Follow up appointments
iv. Safety precautions
c. If the resident/resident representative refuses to wait for or accept education and/or discharge instructions, such refusal will be documented in the resident's medical record.
6. If the facility feels that the resident's safety may be in jeopardy with the discharge, the facility may make a referral to Adult Protective Services or other community support system.
The Administrator stated that the facility used [NAME] for their nursing standards.
According to [NAME], nursing ethics are the values and principles governing nursing practice,conduct and relationships. there are 10 tenets of Nursing. They include: advocacy, autonomy, beneficence, fidelity. The respect for autonomy focuses on allowing others to make their own decisions.
Also [NAME] stated:
beneficence in nursing refers to making sure patients best interest are considered. It also states that nurses have an obligation to promote their patient's well being and interests. And, The primary duty of the nurse is to care for the patient.
During the end of day debriefing on 3/28/2024, the Administrator, Director of Nursing and two Corporate Nurse Consultants (Employee-M and Employee-N) were informed of the findings. They stated the facility staff should have provided education, information, resources and medications to Resident # 1 who was being discharged against medical advice. The staff failed to follow the professional standards of nursing practice. The family requested information and the facility's staff refused to provide that information.
No further information was provided.
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
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on interview, clinical record review and facility documentation review, the facility staff failed to provide adequate ADL (activities of daily living) care for 1 Resident in a survey sample of 3...
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Based on interview, clinical record review and facility documentation review, the facility staff failed to provide adequate ADL (activities of daily living) care for 1 Resident in a survey sample of 3 Residents.
The findings include:
On 4/20/23 during clinical record review it was discovered that Resident #1's point of care record (the Certified Nurses Assistant documenting system), did not have any entries documented for 4/15/23.
On 4/20/23 an interview with the Director of Nursing (DON) was conducted and she stated she was not aware of the care not being documented for 4/15/23. When asked the expectation for the nurses and Certified Nurses Assistants (CNA) when providing care she stated that it was to be documented during the shift. The DON stated that Resident #1 had a lot of behavioral issues and did refuse care at times, however she stated it is the expectation of the DON that the CNAs document the refusal of care as well.
On 4/20/23 during the end of day meeting the Administrator was made aware of the concern and no further information was provided.
Jul 2022
34 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 observation, interview, clinical record review, facility documentation review and in the course of a complaint investig...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, facility documentation review and in the course of a complaint investigation, the facility staff failed for one of 48 sampled residents (#75) to ensure the Resident received ordered wound physician visits, care, and failed to identify a pressure wound to the heel before it reached an advanced stage. This is harm.
The Findings Include:
Resident # 75 was admitted to the facility on [DATE], her diagnoses included, quadriplegia, diabetes type 2, and pressure ulcers.
Resident # 75's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/29/22, coded the Resident as follows:
Section G - Resident #75 was coded as requiring #3- Extensive Assistance of #3 - 2 Person Physical Assistance for bed mobility and dressing. For transfers and toileting she was coded as requiring #4 -Total Assistance (requiring a mechanical lift) and #3 - 2 Person Physical Assistance Walking was coded as #8 -Activity did not occur. Resident required a wheelchair for locomotion on and off the unit.
Section H - Coded Resident #75 as having and indwelling catheter and being always incontinent
Section M - Coded Resident #75 as at risk for developing pressure ulcers.
Excerpts from the admission note read as follows:
Resident was admitted to the hospital R/T [related to] abuse / neglect. History of diabetes type 2, neurogenic bladder, has Foley catheter in place, depression, quadriplegic spinal paralysis, . , abrasion to great toe and left foot. Turn every 2 hours, resident needs air mattress. Resident is incontinent.
Resident #75 was seen by the wound physician on 5/25/22 for Initial Wound Evaluation and Management. The document did not list any wounds to the heel and included the following: Follow up evaluation by wound care specialist within seven days with further interventions as indicated.
Resident #75 was seen again by the wound physician on 6/1/22 (7 days later) and no wounds to the heel were documented.
The next time Resident #75 was seen by the wound physician was on 7/8/22 (over 1 month since the last visit) and the following wound was documented: Unstageable Left Heel - Wound size - 6 cm X 8.5 cm X unmeasurable
There were no other entries in the Resident's clinical record concerning the wound to the heel.
On 7/6/22 an observation of Resident #75's wound was made by Surveyor B. The following was noted: Wound to Left heel and side of foot - 9cm X 10.5cm, open with black necrotic tissue, yellow slough. and active bleeding at the time of observation.
A review of the Resident's care plan revealed the following: Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate Date Initiated: 06/02/2022
The Nutrition Evaluation Annual and Significant Change was completed by the dietician on 5/27/22 with recommendations for vitamins and Prostat for wound healing.
On 7/12/22 a review of the clinical record revealed that these recommendations were never implemented.
On 7/13/22 at approximately 1:50 PM, the Nurse Practitioner (NP) was interviewed and asked if she was aware that the RD had put in a recommendation for Pro-Stat for wound healing. The NP stated that she was not aware. The NP stated they have not been having the meetings where the DON would bring those things to my attention.
On 7/14/22 at approximately 945 am, an interview with the Corporate RN was conducted. The Cooperate RN stated that she had looked in the records and could not find consistent documentation of the progression of Resident #75's wound and could not locate consistent accurate weekly skin assessments. She stated that she had only been in the facility a couple of days and did not know what happened to the documentation and did not know why the Resident was only seen once in June.
A review of the policies and procedures document WC - 130 Pressure Injury Record revealed the following:
Policy: To document the president of skin impairment/new skin impairment related to pressure when first observed and weekly thereafter until the side is resolved. One site will be recorded per page.
Procedure:
1. Residents will have a pressure injury record completed for each skin impairment that is related to pressure.
2. [NAME] the pressure area on the body description identifying the site
3. Enter the date.
4. Enter the stage of the pressure injury.
5. Enter the size of the pressure injury - length X width X depth in centimeters
6. Enter the tissue type in color.
7. Enter the wound edges and drainage
8. Enter the peri-wound information.
9. Licensed nurse to sign the appropriate area.
On 7/14/22 the Interim Administrator was made aware and no further information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, Resident interview, staff interview, and clinical record review, the facility staff failed to maintain dignity for one Resident (Resident #142) in a sample size of 48 Residents. ...
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Based on observation, Resident interview, staff interview, and clinical record review, the facility staff failed to maintain dignity for one Resident (Resident #142) in a sample size of 48 Residents. Specifically, the facility staff did not assist Resident #142 to obtain clothes/get dressed for approximately 2 months.
The findings included:
On 07/11/2022 at 2:35 P.M., Resident #142 was observed lying in bed wearing a hospital gown. When asked if it was their preference to be in bed in a hospital gown at this time of day, Resident #142 stated they would like to be dressed but they do not have clothes to wear. Resident #142 indicated that out of respect for other Residents, they really want to wear pants. When asked if the facility staff have assisted with getting clothes, Resident #142 stated that some clothes were ordered but were too small so other clothes needed to be ordered. Resident #142 stated it has been a few months since then. Resident #142 stated they have not received any clothes yet.
On 07/12/2022, Resident #142's clinical record was reviewed. Resident #142's most recent Minimum Data Set with an Assessment Reference Date of 07/01/2022 was coded as an annual assessment. The Brief Interview for Mental Status was coded as 15 out of possible 15 indicative of intact cognition.
On 07/13/2022 at approximately 10:30 A.M., Certified Nursing Assistant N (CNA N) was interviewed. CNA N verified they care for Resident #142 on a regular basis. When asked about Resident #142's clothes, CNA N stated the social worker brought him clothes a few months ago but they were too small so they took the clothes back. CNA N confirmed Resident #142 does not have clothes to wear.
On 07/13/2022 at approximately 10:35 A.M., Employee T, a social worker, was interviewed. When asked how long she worked at the facility, the social worker stated she worked for a sister facility and was only filling in because the previous social worker quit. When informed that Resident #142 had no clothes and asked about the expectation for assisting Residents to obtain clothes, the social worker indicated that something should be done to assist (Resident #142) obtain clothes.
On 07/13/2022 at approximately 5:00 P.M., the Administrator was notified.
O 07/14/2022 at 2:45 P.M., the corporate nurse entered the conference room and stated that the facility staff were going to get Resident #142 some pants today.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
Based on observation, interview, facility documentation and clinical record review the facility staff failed to promote self determination through support of resident choice, for Resident # 84 in a su...
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Based on observation, interview, facility documentation and clinical record review the facility staff failed to promote self determination through support of resident choice, for Resident # 84 in a survey sample of 48 Residents.
The findings included:
For Resident # 84 the facility staff told the Resident he must go to bed between 9:00 PM and 10:00 PM.
On 7/11/22 at approximately 2:00 PM Resident # 84 was interviewed about his stay at the facility and he stated They told me I have to go to bed between 9:00 and 10:00 o'clock. I am not a child, I am a grown man I don't need a bedtime.
On 7/12/22 at 4 PM an interview was conducted with CNA B, (a staff member working 3-11 shift ) who stated We try to get the Residents in bed by 10:00 PM so that the night shift doesn't have to get them to bed. We have more staff on 3-11 than nights so we try to make sure everyone is in bed, in a gown by 10:00. When asked what is done if a Resident refuses to go to bed, CNA B said, Well we try at 9:00 and then give them more time like until 9:30. Then at 9:30 we remind them we will be back at 10:00 to get them in bed. They usually don't fuss if you say it like that.
On 7/12/22 an interview was conducted with RN A who stated The Residents have the right to go to bed when they want to however the CNA's like to get them changed into night clothes by 10:00 PM. When asked why that was she stated They don't want nights to complain that people were left up. I guess because nights has less staff.
On 7/13/22 during end of day meeting with facility acting Administrator was informed of this practice and asked his opinion on Resident going to bed at specific times. The Acting Administrator stated that the Residents have the right to stay up as late as they want and get up at the time they want to. He stated that he would use this as a learning opportunity for his staff.
On 7/14/22 during the end of day meeting the Acting Administrator was made aware of concerns and no further information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0563
(Tag F0563)
Could have caused harm · This affected 1 resident
Based on staff interview, clinical record review and facility documentation review, the facility staff failed to allow a Resident to have visitors at the time of their choosing, for one Resident (#127...
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Based on staff interview, clinical record review and facility documentation review, the facility staff failed to allow a Resident to have visitors at the time of their choosing, for one Resident (#127) in a survey sample of 48 Residents.
The findings included:
For Resident #127, the facility staff had her daughter removed from the facility for visiting beyond visiting hours.
On 7/12/22, during a clinical record review a nursing note was noted that read, Late Entry: Note Text: Daughter [name redacted] c/o [complained of] Nurse called security previous night and walked sister out of building for staying past visiting hours. Reassured daughter that family was welcomed to visit with patient, as long as they wished to without being loud and interfering with other residents care. Daughter very appreciative and patient is currently alone in room. No further complaints voiced at this time. Patient resting comfortably in bed with eyes closed. No distress noted at this time. This entry was made on 7/10/22, by Employee C, the Assistant Director of Nursing (ADON) and noted as a late entry for 7/5/22.
Resident #127 was unable to be interviewed regarding the incident.
On 7/12/22, during the morning, the Regional Administrator and the facility Administrator were asked about the above nursing note entry and both said they had no knowledge of the incident and would have to look into it.
On 7/12/22 at 2:16 PM, an interview was conducted with Employee C, the writer of the progress note. Employee C was asked about the progress note and events of Resident #127's daughter being removed. Employee C said, [Resident #127's name redacted] daughter had approached me and said the other daughter was escorted out by security. Employee C said she was not able to find out who had escorted the family member out but, I did interview the nurse who called security and the nurse reported they were visiting after visiting hours had ended and she wanted them out of the building. I reached out to [Regional Administrator name redacted] and told him and he said we can't be uptight about visiting hours due to the business we are in, unless they are being noisy or disturbing resident care. The nurse said they weren't causing problems and in this case [Resident name redacted] was alone in the room.
On 7/13/22 at 3:15 PM, an interview was conducted with LPN F. LPN F was asked about the facility security and she said, We have someone at the desk that monitors entry and enforces visiting hours. When asked what time visiting hours were, she said usually 8 AM to 8 PM. LPN F was asked to discuss the events regarding Resident #127's family being removed. LPN F said, All I asked was that security go knock on the door and let them know that visiting hours were over. LPN F was asked who the security person was and she gave Employee S's name. LPN F went on to say that she wasn't working that unit and was just helping out another nurse, therefore she didn't observe when Resident #127's family left the facility.
LPN F was asked what her understanding of visiting rights are. LPN F said, The only time family can extend or stay beyond visiting hours is if the resident is actively dying and she [Resident #127] wasn't in that condition and I'm not aware of her having any special privileges. LPN F was asked if it is her current understanding of when visitors are permitted. LPN F said, Visiting hours are 8 AM to 8 PM. LPN F was asked if Resident #127's family was causing any problems or disturbances on the night the family was asked to leave. LPN F said, No, there were no issues.
LPN F was asked if she had received any training regarding Resident Rights. LPN F said, Yes. When asked what the nature of that training included with regards to visitation she said If there is a situation such as the Resident's condition changes and they are dying, they have the right to have visitors then. LPN F was asked if it was ever discussed that Residents have the right to receive visitors at any time, LPN F said, They only time we have that is if a change in condition and they are actively dying, I was told the visiting hours are 8 AM to 8 PM.
A review of the facility policy titled, Access and Visitation was conducted. This policy read, The resident has the right to receive visitors of his or her choosing at the time of his or her choosing, subject to the resident's right to deny visitation when applicable, and in a manner that does not impose on the rights of another resident.2. The center will provide immediate access to a resident by immediate family and other relative of the resident, subject to the resident's right to deny or withdraw consent at the time.
On 7/13/22, the facility Administrator was asked to provide any Resident Rights training LPN F had since her hire on 1/2/2018. The facility Administrator reported they did not have any evidence to submit.
On 7/13/22, during an end of day meeting the facility Administrator and Assistant Director of Nursing and Corporate staff were made aware of the above findings.
No further information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview, facility record review and clinical record review the facility staff failed to report allegations of abuse to the State Agency (VDH Office of Licensure and Certification) for 1 Res...
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Based on interview, facility record review and clinical record review the facility staff failed to report allegations of abuse to the State Agency (VDH Office of Licensure and Certification) for 1 Resident (# 64) in a survey sample of 48 Residents.
The findings included:
For Resident #64 the facility staff failed to report allegation of sexual abuse by a CNA.
On 7/11/22 during review of FRI's (Facility Reported Incidents) for this facility it was discovered that on 8/27/21 APS (Adult Protective Services) reported to the OLC an allegation of sexual abuse of Resident # 64 that they were investigating. The alleged abuse occurred on 8/21/21 by a CNA, employee O. The report from APS states that the local Police were notified, APS was notified and that the Resident was taken to the hospital for an examination.
On 7/12/22 at approximately 1:00 PM the facility was asked to see any and all FRI's for 2021. Employee Q submitted the FRI Book for the surveyors to examine. The FRI Book did not contain any FRI's for alleged sexual abuse of Resident #64. The acting Administrator and the Regional Administrator searched the records and could not find the FRI. The Regional Administrator stated that he talked to the former DON who stated that she remembers doing the investigation but does not know where the paperwork would be.
The facility was given an additional 2 days until end of survey to find the documents however none were found.
On 7/14/22 during the end of day meeting the Interim Administrator was made aware and no further information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
Based on electronic health record (EHR) review the facility failed ensure the preadmission screening (PASARR) evaluation for an individual with a mental disorder was conducted for one resident (Reside...
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Based on electronic health record (EHR) review the facility failed ensure the preadmission screening (PASARR) evaluation for an individual with a mental disorder was conducted for one resident (Resident #45) in a sample of 48.
The findings include:
On 07/13/22 at approximately 4:30 p.m., while conducting EHR review observed that Resident #45 did not have a PASARR on record.
Administrator was made known that the PASARR for Resident #41 could not be located.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to develop a resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to develop a resident-centered baseline care plan that met professional standards of quality care for one resident (Resident #127) in a sample of 48 Residents.
The findings included:
For Resident #127, the facility staff failed to develop a baseline care plan to direct the Residents care upon admission.
On 7/11/22 and 7/12/22, a clinical record review was conducted. This review revealed the following:
1. Resident #127, was admitted to the facility on [DATE].
2. There was no evidence of a baseline care plan being developed.
3. The comprehensive care plan was not initiated until 6/30/22.
On 7/12/22, the facility Administrator was asked to provide Resident #127's baseline care plan.
On 7/12/22, the facility Administrator advised the survey team that a base line care plan for Resident #127 was not available.
On 7/13/22, the facility's Corporate Clinical Consultant confirmed that a base line care plan for Resident #127 was not located and not available.
On 7/13/22 at 11:31 AM, an interview was conducted with Employee P, the MDS (care plan) Nurse. Employee P was asked when and who initiates baseline care plans. Employee P said, The nursing staff initiate the baseline care plan within 24 hours of a patient being admitted . Employee P was asked, what is the purpose of the baseline care plan? Employee P said, To let the staff know how to properly care for the patient and things to look out for.
During the above interview with Employee P, she was asked, what are the risks if a care plan is not developed or doesn't include items? Employee P said, If it is not on the care plan, the patient may not be cared for properly.
The facility staff provided a copy of their Policy titled, Plans of Care. The policy was received and reviewed. It read, Develop and implement an Individualized Person-Centered baseline plan of care within 48 hours of admission that includes, but not limited to, initial goals based on the admission orders, physician orders, dietary orders, therapy services, social services, PASARR recommendations, if applicable, and other areas needed to provide effective care of the resident that meets professional standards of care to ensure that the resident's needs are met appropriately until the Comprehensive plan of care is completed.
On 07/13/2022 at approximately 10:45 AM, the Administrator and Assistant Director of Nursing (DON), Corporate Clinical Consultant, and Regional Administrator were notified of the findings.
No further information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, and clinical record review, the facility staff failed to supervise one Resident during meal time to ensure safety (Resident #49) in a sample size of 48 Residents...
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Based on observation, staff interview, and clinical record review, the facility staff failed to supervise one Resident during meal time to ensure safety (Resident #49) in a sample size of 48 Residents. Specifically, Resident #49 was observed eating her lunch in an unsafe position presenting a potential choking hazard on 07/11/2022.
The findings included:
On 07/11/2022 at 1:25 P.M., Resident #49 was observed in her bed eating lunch. The head of the bed was elevated approximately 45 degrees but Resident #49's upper back was in the fold of the bed where the head of the bed begins to rise. Resident #49's head was at the level of the tray table with the lunch tray on it. Resident #49 was not seated upright to safely consume food without the risk of choking. There was no staff in the room. At approximately 1:28 P.M., this surveyor and Certified Nurse Assistant H (CNA H) observed (from the hall) Resident #49 eating their lunch. When asked if any concerns were identified, CNA H stated that the room floor looked dirty. When asked if there were any concerns related to positioning, CNA H stated yes and entered Resident #49's room. CNA H talked with Resident #49 about repositioning. Resident #49 stated, No and continued to eat. CNA H explained it wasn't safe to eat in that position and Resident #49 was agreeable when CNA H elevated the head of the bed to approximately 60 degrees and repositioned Resident #49 to a seated upright position. CNA H then exited the room and explained to this surveyor that they repositioned (Resident #49) so that (Resident #49) won't choke.
On 07/12/2022, Resident #49's clinical record was reviewed. Resident #49's most recent Minimum Data Set with an Assessment Reference Date of 05/13/2022 was coded as a quarterly assessment. Resident #49's Brief Interview for Mental Status was coded as 4 out of possible 15 indicative of severe cognitive impairment. Functional status for eating was coded as 1 meaning requiring supervision- oversight, encouragement, or cueing for eating.
Resident #49's physician's orders were reviewed. An active order dated 03/24/2021 documented, Regular diet Dysphagia pureed texture, nectar thickened fluids consistency, fortified foods.
Resident #49's care plan was reviewed. A focus with a revision date of 10/20/2021 entitled, At risk for nutrition risk r/t [related to] anxiety, HLD [hyperlipidemia], GERD [gastroesophageal reflux disease], constipation, dysphagia [difficulty swallowing], nausea, vitamin D defiency [sic], dementia, schizophrenia, hx [history] of low weight. On mechanically altered diet and thickened liquids.
An intervention for this focus included but was not limited to the following:
-
Monitor/document/report PRN any s/sx of worsening dysphagia: Pocketing,
Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing,
Refusing to eat, Appears concerned during meals.
On 07/13/2022 at approximately 11:15 A.M., Certified Nursing Assistant H (CNA H) was interviewed. When asked about Resident #49's appetite, CNA H stated (Resident #49 eats well and usually eats about 50% of her food and drinks all of her fluids. When asked about swallowing difficulties, CNA H stated (Resident #49) does not have any problems with swallowing.
On 07/13/2022 at approximately 5:00 P.M., the Administrator was notified of findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to identify, monitor, and treat significant weight loss for one Resident (Re...
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Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to identify, monitor, and treat significant weight loss for one Resident (Resident #49) in a sample size of 48 Residents. Specifically, Resident #49 experienced an 18.91% weight loss over a 3 month time period (January 2022 through April 2022).
The findings included:
On 07/11/2022 at 1:25 P.M., Resident #49 was observed in her bed eating lunch. Resident #49 appeared small-framed and thin.
On 07/12/2022, Resident #49's clinical record was reviewed. According to the weight flow chart, Resident #49 was weighed twice since 01/13/2022. Resident #49 weighed 110 pounds on 01/13/2022 and 89.2 pounds on 04/18/2022 which represented an 18.91% weight loss in 3 months.
The nursing progress notes around 04/18/2022 were reviewed. There were no progress notes addressing the significant weight loss nor notification of provider or responsible party.
The following excerpts of a provider progress note dated 04/19/2022 documented the following:
.currently tolerating a regular diet, dysphagia pureed texture, nectar thickened fluid consistency and has had a stable weight. Weight: 89.2 pounds. Height: 62 inches.
The dietary progress notes were reviewed. There was one dietary note written since 04/18/2022. A dietary note dated 06/01/2022 at 12:16 P.M. documented, Note Text: Weight Note:
Weight loss noted. Additional weights requested in order to establish new baseline. BMI 16.3 [underweight]. On a pureed diet with nectar thick liquids and fortified foods eating variably 0-100%. Recommend MD consult r/t [related to] weight loss and possible benefit from appetite stimulant and add Med Pass 120mL TID [three times a day].
The physician's orders were reviewed. There were no orders for an appetite stimulant or Med Pass (or any similar supplement).
Resident #49's care plan was reviewed. There was no focus addressing actual significant weight loss as recorded on the weight flow sheet on 04/18/2022. A focus with a revision date of 10/20/2021 entitled, At risk for nutrition risk r/t [related to] anxiety, HLD [hyperlipidemia], GERD [gastroesophageal reflux disease], constipation, dysphagia [difficulty swallowing], nausea, vitamin D defiency [sic], dementia, schizophrenia, hx [history] of low weight. On mechanically altered diet and thickened liquids.
Interventions for this focus included but were not limited to the following:
-
Monitor/document/report PRN any s/sx of worsening dysphagia: Pocketing,
Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing,
Refusing to eat, Appears concerned during meals.
-
Weight monitoring as ordered and as indicated.
On 07/13/2022 at approximately 11:15 A.M., Certified Nursing Assistant H (CNA H) was interviewed. When asked about Resident #49's appetite, CNA H stated (Resident #49 eats well and usually eats about 50% of her food and drinks all of her fluids. When asked about swallowing difficulties, CNA H stated (Resident #49) does not have any problems with swallowing.
On 07/13/2022 at approximately 11:20 A.M., the unit manager for the 400 hall was interviewed. When asked about the process for obtaining weights, the unit manager stated monthly weights are divided by shifts. The expectation is that staff will record the weights on paper and then give the paper to her to put in her book. The unit manager stated she would then enter the weight values into each clinical record. When asked about Resident #49's most recent weight, the unit manager stated that the staff on the previous evening shift did all the weights but the unit manager was unable to locate the sheet of paper with the weights on it. When asked about the policy for obtaining weights, the unit manager stated that an order is needed to obtain weights but by policy, everyone gets weighed monthly. When asked about the process for ordering the registered dietitian recommendations, the unit manager stated that the nurses will let the physician/provider know what the dietitian recommended and either the nurse or the provider will enter the orders into the clinical record. When asked about Resident #49's weight, the unit manager referred to the clinical record and stated Resident #49's last weight was 89.2 pounds on 04/18/2022. The unit manager then stated I don't see where we were monitoring weights [for Resident #49]. When asked about the orders for the appetite stimulant and Med Pass as recommended by the dietitian, the unit manager stated she did not see an order for the appetite stimulant and Med Pass has been on back order from the manufacturer. When asked if there were other options similar to Med Pass, the unit manager stated it could be substituted with Ensure. A current weight for Resident #49 was requested.
On 07/13/2022 at approximately 11:35 A.M., this surveyor observed Certified Nursing Assistant M (CNA M) obtain Resident #49's weight on the standing scale. Resident #49 weighed 91.8 pounds.
On 07/13/2022 at 2:00 P.M., the nurse practitioner was interviewed. When asked about the process for tracking weights, the nurse practitioner stated that there are dietary and weight meetings and usually with weight changes, the nurses would let me know. When asked if she was aware of Resident #49's significant weight loss, the nurse practitioner stated that No one brought it to my attention and They [nurses] have to let me know. The nurse practitioner also indicated the dietary meetings have not been happening for about a year. When asked if she has access to weight values and dietitian notes in the clinical record, the nurse practitioner stated that she could look at them But it's a lot. When asked what she would've ordered if she was aware of the weight loss, the nurse practitioner stated she would've ordered Ensure with every meal, weekly weights, a dietary referral for food preference assessment and possibly look at labs.
On 07/13/2022, the facility staff provided a copy of their policy entitled, Weighing the Resident. Under the header, Policy, it was documented, Residents will be weighed unless ordered otherwise by the physician: Admission/readmission x 3 days [for three days]; weekly x [for] 4 weeks; monthly thereafter; as needed. Under the header Procedure an excerpt of the last paragraph documented, Record weight and alert nurse to any significant change. Nurse to notify the physician of any significant weight change.
On 07/13/2022 at approximately 5:00 P.M., the Administrator was notified of findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0745
(Tag F0745)
Could have caused harm · This affected 1 resident
Based on observation, interview, facility record review and clinical record review the facility staff failed to provide medically related social services to maintain highest practicable well-being for...
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Based on observation, interview, facility record review and clinical record review the facility staff failed to provide medically related social services to maintain highest practicable well-being for 1 Resident (#34) in a survey sample of 48 Residents.
The findings included:
For Resident #34 the facility staff failed to provide needed prescription eye glasses to enable Resident # 34 to pursue reading and other leisure activities that require adequate vision.
On 7/6/22 at approximately 1:45 PM an interview was conducted with Resident #34 who explained that he needed eyeglasses and had not had his vision checked in some time. He stated he was not aware of the exact date he last had an eye exam but he knew it was more than a year ago. Resident #34 stated that he had his eyes examined and the doctor recommended a certain type of eyeglasses and the facility staff told him They are too expensive we won't buy them.
On 7/12/22 at approximately 11:00 AM an interview was conducted with Employee T (a Social Worker) who stated that she was not from this building she had been called from a sister facility to assist because the Social Worker assigned to the building was no longer employed by the company. She stated she would research and find out what happened with obtaining Resident #34's glasses.
On 7/12/22 at approximately 1:50 PM Employee T returned to inform this Surveyor that Resident #34 has not had an eye exam since 2016 and it the Resident was correct in saying that the facility did not purchase his glasses. They were not covered under his insurance (Medicaid). When asked what is usually done in cases like this Employee T stated we usually get the bill and submit it to the Business Office Manager to do a MAP adjustment. There is no reason the Resident should be without his glasses. Employee T stated she had arranged for Resident #34 to be seen by the eye doctor on July 26th 2022 when they are scheduled to come to the building. She further stated that they will get his eyeglasses ordered once the eye exam is done.
On 7/14/22, during the end of day meeting, the Interim Administrator was made aware of the concerns and no further information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
Based on observation, interview, facility documentation and during the course of a complaint investigation the facility staff failed to follow the menus for the facility in general and for Resident #3...
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Based on observation, interview, facility documentation and during the course of a complaint investigation the facility staff failed to follow the menus for the facility in general and for Resident #34.
The findings included:
For the facility in general, it was reported in an anonymous complaint that the facility did not follow the menus and ordered pizza for Residents on 6/21/22, also during survey it was noted that Resident #34 received turkey sandwich instead of what was on his meal ticket and had some food items missing from his lunch tray.
On 7/5/22 at approximately 1:00 PM the Social Worker was interviewed and she stated that she was aware of the incident involving having to order pizza for Residents. She stated that the allegation was true and that she was present at the time. She stated that the Acting Administrator was called in and he called a sister facility to get a kitchen staff member to prepare the puree foods and he then ordered pizza for the Residents who could eat regular consistency.
On 7/7/22 at approximately 9:00 AM an interview was conducted with Resident # 34 who stated Oh yeah last month we had pizza from a restaurant because they didn't have enough staff to cook.
On 7/7/22 at approximately 9:15 AM an interview was conducted with Resident # 83 who stated that she felt one slice of pizza, a cookie and some juice was not sufficient
On 7/7/22 at approximately 10:15 an interview was conducted with Employee Q (Regional Administrator) who stated that on 6/21/22 he was called by the facility staff to inform him that only 2 dietary staff had shown up for work, no cook had shown up. Employee Q stated that he called employee D (the Regional Dietary Manager) and told him We have to get these folks fed. He stated that he also called Employee J, the cook from the sister facility in close proximity, and that employee J the facility to prepare the puree diet for the residents that could not eat regular consistency, and he ordered pizza from a local restaurant for those with regular consistency diets.
On 7/7/22 at approximately 10:45 Employee J, the [NAME] from the sister facility was interviewed and he stated that on 6/21/22 he did receive a call asking him to come to this facility to prepare puree foods for those who could not eat pizza. When asked what he prepared he stated they were given pureed herb chicken, pureed mixed veggies, mashed potatoes and applesauce
On 7/11/22 at approximately 1:00 PM while speaking with Resident #34 the CNA came in to bring his lunch tray. The CNA knocked on the door announced herself and set the tray on the table asked the Resident if he needed anything else and then left the room. Resident # 34 looked at his tray and said Why do they give me turkey sandwiches when I don't eat the fake turkey roll they serve I only eat real turkey carved from a turkey not the deli meat.
A review of the Resident's lunch ticket revealed that Resident #34 was supposed to receive herbed chicken breast, sauteed spinach with garlic, whipped sweet potatoes, dinner roll and margarine, pineapple tidbits and coffee and 16 oz whole milk.
The tray contained 8 oz whole milk, no coffee, no herbed chicken. The vegetable, the potato, the pineapple and the dinner roll were all on the tray along with the cold turkey sandwich.
The Resident asked the CNA to please ask the kitchen for a Tomato Sandwich with mayonnaise which was provided at 1:30 PM.
On 7/11/22 at approximately 3:00 PM an interview was conducted with Employee X (the Dietary Manager) who stated that Resident #34 has an extensive list of likes and dislikes. She stated it is hard to know what he likes and it can vary from day to day. A review of the dietary preferences did reveal that the Resident does not like turkey sandwiches.
During the end of day meeting on 7/13/22 the Interim Administrator was made aware and no further information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on observation, interview, clinical record review and facility documentation the facility staff failed to maintain accurate clinical records for 2 Residents (#'s 75) in a survey sample of 48 Res...
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Based on observation, interview, clinical record review and facility documentation the facility staff failed to maintain accurate clinical records for 2 Residents (#'s 75) in a survey sample of 48 Residents.
The findings included:
For Resident # 75 the facility staff failed to maintain accurate and consistent information on catheter.
On 7/6/22 at approximately 11:45 AM an interview was conducted with Resident #75 when asked if she has had her catheter since admission. The resident stated she had gotten the catheter at the hospital prior to admission. Observation was made of Resident with Foley Catheter in privacy bag attached to wheelchair.
On 7/6/22 during clinical record review it was noted that Resident #75 has had an indwelling catheter since admission for a diagnosis of neurogenic bladder. Excerpts from skilled nurses notes are as follows:
5/24/22 at 402 AMCatheter is not noted
5/25/22 at 2:31 PM Catheter is in dwelling
5/25/22 at 7:05 PM Catheter not noted
5/25/22 at 9:30 PM Catheter not noted
5/26/22 at 3:30 AM Catheter not noted
5/26/22 at 10:36 AM Catheter is indwelling
5/26/22 at 6:36 PM Catheter not noted
5/27/22 at 6:43 AM Catheter not noted
5/27/22 at 12:43 PM Catheter not noted
5/28/22 at 12:39 PM Catheter not noted
5/28/22 at 11:40 PM Catheter is indwelling
5/29/22 at 2:40 AM Catheter in dwelling draining yellow urine no signs or symptoms of infection noted
This documentation continues on through June and July as well with some shifts and nurses writing Catheter not noted, and others writing Catheter is indwelling.
On 7/11/22 at 10:00 AM an interview was conducted with RN B who stated that Resident #75 has had an indwelling Foley Catheter since admission. When asked about the documentation she stated that it was inaccurate
On the morning of 7/12/22 during clinical record review of Resident # 75 it was discovered that the Resident had been admitted with wounds from the hospital. The Residents weekly skin assessments had not been accurately completed, and there were only 2 notes by the wound physician in spite of the fact that the wound physician clearly wrote in the notes that Resident #75 was to be seen weekly by the wound physician.
On 7/14/22 after requesting all wound documentation and a timeline of progression of wounds Employee N stated that since she had only been there for 2 days she had not been able to locate the former wound nurse's notes or tracking. She stated that since the wound nurse quit, the DON and the ADON had only been employed for a short time, she did not feel the documentation was consistent with regards to wound care.
On 7/14/22 during the end of day meeting the Interim Administrator was made aware of concerns and no further information was provided,
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
Based in observation, interview, facility documentation and clinical record review the facility staff failed to maintain patient care equipment for 1 Resident #34 in a survey sample of 48 Residents.
T...
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Based in observation, interview, facility documentation and clinical record review the facility staff failed to maintain patient care equipment for 1 Resident #34 in a survey sample of 48 Residents.
The findings included:
For Resident #34 the facility staff failed to ensure the proper working order of his CPAP machine.
On 7/13/22 at approximately 9:00 AM an interview was conducted with Resident #34 who stated I didn't sleep at all last night, this CPAP was worse than ever. It doesn't work right and I was up all night. When asked if the Resident had told the staff he stated We don't have a DON we don't have a Social Worker we don't have an Administrator. I told all of them a bunch of times before they quit and nothing was done. Now I have told the nurses but half of them don't care and the other half are agency staff, what are they going to do.
After leaving the Resident's room this surveyor went to the ADON's office and reported the concerns of the Resident and how he stated that he has complained repeatedly about this issue. The ADON stated she would check on it.
On the afternoon of 7/13/22 the following note was entered in Resident #34's chart:
7/13/22 at 1:07 PM - Nursing Progress Note: Patient stated he felt C-Pap not working well. On assessment lung sounds clear to auscultations. No cyanosis noted on fingers and toes. No SOB observed at this time. Respirations even, non-labored. Chest expansion even bilaterally. RT [Respiratory Therapist] notified and will arrive later today and access machine. MD notified with none/o [orders] at this time. Patient resting in bed with eyes open. HOB elevated
On the morning of 7/14/22 the Corporate RN brought this surveyor a copy of the shipping receipt for a new CPAP machine and stated, The Respiratory Therapist would be in to set it up this afternoon when it arrives.
On 7/14/22 at approximately 2:00 PM during an interview with Resident #34 the Resident stated Thank you so much for your help in getting my CPAP. The Respiratory Therapist is coming today to set it up. I know it's been months since it has worked right and now I can get a good night's sleep with a new machine.
On 7/14/22 the Administrator was made aware of the concerns and no further information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0909
(Tag F0909)
Could have caused harm · This affected 1 resident
Based on observation, interview, and facility documentation the facility staff failed to ensure the bed frame and the mattress are compatible, for 1 Resident # 34 in a survey sample of 48 Residents.
T...
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Based on observation, interview, and facility documentation the facility staff failed to ensure the bed frame and the mattress are compatible, for 1 Resident # 34 in a survey sample of 48 Residents.
The findings included:
For Resident #34 the facility staff failed to supply the appropriate sized mattress for the bariatric bed Resident #34 was using.
On 7/11/22 at approximately 12:30 AM Resident #34 was interviewed and he stated that the bed he has is uncomfortable and that he had to order feather pillows from [name of company redacted] to put under his back and bottom because the mattress was not comfortable. In visualizing the mattress there was a 3 inch gap on either side of the mattress where it did not meet the edge of the bed frame or the top rails. When asked about this the Resident stated he has always had this problem with the mattress not being wide enough, and stated I have complained a number of times but nothing is done about it.
On the afternoon of 7/11/22 during clinical record review it was discovered that Resident # 34 has resided at the facility since 7/23/15 and has a current BIMS (Brief Interview of Mental Status) score of 15 out of 15, indicating no cognitive impairment. The Resident is extensive assistance for all aspects of ADL care to include turning and positioning, this Resident cannot ambulate without a wheelchair and requires staff assistance for mobility.
On 7/11/22 at approximately 1:45 PM, the Maintenance Director was interviewed about Resident # 34's bed. The Maintenance Director was asked if this was the appropriate sized mattress for this bed. He indicated that there are 2 size bariatric mattresses and that he felt this mattress was appropriate for this bed. The manufacture instructions and recommendations for the bed were requested at this time.
On the morning of 7/12/22 the Corporate RN notified this surveyor that Maintenance had put wedges in the bed. Upon visualization of the bed it was noted that wedges were placed between the mattress and the top rails of the bed however there was still a 3 inch gap on either side of the bed from the end of the wedge to the foot of the bed (from end of top rail to foot of bed).
When asked, Resident #34 stated he was not happy with the wedges because it was uneven, not the same depth as the mattress.
After observing the bed, once again the manufacture instructions and recommendations for the bed were requested.
On 7/13/22 The Corporate RN stated the Maintenance Director could not find the manufacture instructions and were indeed ordering a new bed for Resident #34.
On 7/14/22 the Administrator was made aware of the concerns and no further information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
Based on observation, Resident interview, staff interview, and facility documentation review, the facility staff failed to ensure a working call light for one Resident (Resident #91) in a sample size ...
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Based on observation, Resident interview, staff interview, and facility documentation review, the facility staff failed to ensure a working call light for one Resident (Resident #91) in a sample size of 48 Residents. Resident #91's call light was not working for a number of days in June and July 2022.
The findings included:
On 07/11/2022 at approximately 12:05 P.M., Resident #91 was observed lying in her bed. When asked if there were any concerns about the care received at the facility, Resident #91 stated that the call light has not been working. Resident #91 indicated staff was notified about it. This surveyor observed Resident #91 press the button on the call light several times and the light and sound were not activated.
On 07/11/2022 at approximately 12:15 P.M., the Regional Administrator was notified Resident #91's call light was not working. The Regional Administrator stated he would let maintenance staff know.
On 07/12/2022 at 9:30 A.M., Resident #91 was interviewed. Resident #91 stated that the call light was now working.
On 07/12/2022, a grievance for Resident #91 was reviewed. The grievance, dated 06/21/2022 indicated that Resident #91's call light was not working. According to the grievance document, the grievance was not addressed/resolved.
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 observation, Resident interview, and staff interview, the facility staff failed to provide a clean, comfortable, and ho...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, Resident interview, and staff interview, the facility staff failed to provide a clean, comfortable, and homelike environment for Residents on one unit (the 400 unit) out of 4 units. Specifically, observations of the 400 unit shower room and Resident rooms included the following:
1) The shower room had no hot water from 2 out of 3 shower heads
2) One shower head was detached from the hose and inoperable so the water temperature could not even be tested.
3) The shower room sink had a leaky faucet and there were rust stains in the sink basin.
4) There were rust spots on the floor in various places in the shower room and black spots on the floor in one of the shower stalls.
5) There was a dry, white, crusty substance covering the entire base plate of the shower handle in one of the three shower stalls.
6) For Resident #50, the paper towel dispenser in the bathroom was on the bathroom floor
7) For Resident #111 and in Resident room [ROOM NUMBER], the floors were sticky to walk upon, stained, scuffed, and had debris on the floor.
The findings included:
On 07/11/2022 at approximately 12:55 P.M., Resident #110 was interviewed. When asked about any concerns identified, Resident #110 stated the only concern was that the shower room (on the 400 unit) was a mess.
On 07/11/2022 at approximately 1:25 P.M., the shower room on the 400 unit was observed. This surveyor observed that one of three shower heads were detached/inoperable; the sink was leaking and had rust in the basin; there were rust spots on the floor in various areas and black spots on the floor in one of the shower stalls; and there was a dry, white, crusty substance covering the entire base plate of the shower handle in one of the shower stalls.
On 07/11/2022 at 3:45 P.M., Resident #50 was interviewed. When asked about concerns, Resident #50 stated the showers (on the 400 unit) were not working. Resident #50 was unable to say how long the showers weren't working. Also, Resident #50 indicated he told staff that the paper towel dispenser was off the wall in their room bathroom. This surveyor observed the paper towel dispenser on the bathroom floor up against the wall.
On 07/11/2022 at approximately 3:55 P.M., this surveyor and Certified Nurse Assistant M (CNA M) observed the shower room on the 400 hall. When asked about the broken shower head, CNA M stated that it wasn't like that on Friday (3 days ago). When asked to test the water temperature, CNA M turned on the water for one of the shower stalls and let the water run for approximately 3 minutes. The water temperature did not rise above 80 degrees according to the temperature gauge on the wall. The water was tepid to touch. When asked about the rust and black spots on the floor, CNA M stated, They need to clean up in here.
On 07/11/2022 at approximately 4:10 P.M., this surveyor and the unit manager for the 400 hall, Licensed Practical Nurse H (LPN H) observed the shower room. When asked to test the water temperature for the third shower stall, LPN H turned on the water and let it run. After approximately 3 minutes, LPN H stated the water was not heating up. LPN H also stated that staff usually just use the other 2 showers.
On 07/12/2022 at approximately 9:10 A.M., the paper towel dispenser in Resident #50's bathroom was still on the bathroom floor as observed on 07/11/2022.
On 07/12/2022 at approximately 9:15 A.M., Resident #111 and two family members were interviewed. When asked about concerns, one of Resident #111's family members stated housekeeping staff have not been mopping the floor and the floor appears dirty. This surveyor observed the floor in Resident #111's room to have debris on the surface, dried spill stains, and sticky to walk upon.
On 07/13/2022 at approximately 8:50 A.M., Employee U, a housekeeper, was interviewed. Employee U verified she works on the 400 hall. When asked about her process for cleaning Resident rooms, Employee U stated she sweeps and mops each Resident room daily, among other things. When asked about Resident #111's room, Employee U stated she had not gotten to that room yet today. Employee U verified she did clean room [ROOM NUMBER] already today. This surveyor and Employee U observed room [ROOM NUMBER]. There were particles of debris on floor (looking unswept) and a coin on the floor in the center of the room. There were dried spill stains and the floor was sticky to walk upon. When asked about the floor being sticky, Employee U stated she didn't notice the floor was sticky.
On 07/13/2022 at 3:30 P.M., three maintenance employees (Employee K, (Maintenance Director) Employee F, and Employee G) were interviewed. When asked about Resident #50's paper towel dispenser, Employee F stated he saw it in the sink this morning and will be fixing it. When asked about the shower head in the 400 hall shower room, Employee K stated they just found out about the shower head yesterday and fixed it.
On 07/13/2022 at approximately 5:00 P.M., the administrator was notified of findings.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
Based on observation, staff interview, facility documentation review, and clinical record review, the facility staff failed to review and revise care plans for 6 Residents (Resident #127, 93, 4, 49, 7...
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Based on observation, staff interview, facility documentation review, and clinical record review, the facility staff failed to review and revise care plans for 6 Residents (Resident #127, 93, 4, 49, 75, and 34) in a survey sample of 48 Residents.
The findings included:
1. For Resident #127 the facility staff failed to revise the care plan to include an unstageable wound (a wound where the wound bed is not able to be visualized and therefore the extent of the wound cannot be determined) that required debridement.
On 7/11/22 and 7/12/22, a clinical record review was conducted. This review revealed that on 6/30/22, the nurse practitioner ordered for a wound consult and would culture. On 7/8/2022, Resident #127 was seen by a wound specialist and a surgical debridement procedure was performed at the bedside on the unstageable sacral wound.
Review of the care plan for Resident #127 revealed that the sacral wound had not been addressed on the care plan.
2. For Resident #93, the facility staff failed to review and revise the nutritional care plan to capture an 82 lb. weight gain.
On 7/12/22, the clinical record for Resident #93 was reviewed. This review revealed the following with regards to weights. On 1/3/22, Resident #93 weighed 251.1 lbs. On 3/28/22, Resident #93 weighed 333.2 lbs. There were entries into the clinical record from the dietician requesting the physician be consulted for the significant weight gain.
Review of the nutritional care plan for Resident #93 revealed that a nutritional care plan was implemented on 11/3/2021. All of the interventions on the care plan were dated 11/3/2021, and the significant weight gain had not been addressed on the care plan.
3. For Resident #4, who had a fall on 5/29/22, the facility staff failed to review and revise the fall care plan since 1/10/22.
On 7/12/22, during a clinical record review the nursing notes revealed an entry on 5/29/22, which indicated Resident #4 was found on the floor beside her bed. This was an unwitnessed fall.
Review of the care plan revealed she had been identified as a fall risk and a fall care plan initiated on 3/5/2019. Review of the interventions revealed the most recent intervention was entered into the fall care plan on 7/15/2021. The care plan was not reviewed or revised following the fall on 5/29/22, to implement any interventions to prevent a reoccurrence.
On 7/13/22, the facility Administrator was made aware of the findings and confirmed that the care plan had not been revised following the fall and had not been revised quarterly with the assessments as required. The Administrator indicated they would update the care plan that day.
On 7/13/22 at 11:31 AM, an interview was conducted with Employee P, the care plan nurse. Employee P stated that the comprehensive care plan is developed when a Resident has their admission assessment and with each subsequent assessment or change in condition that warrants a change in treatment. When asked what the purpose of the care plan is, Employee P said, It guides the daily care. When asked who uses the care plan, she said, The nursing staff. When asked if a Resident has a change such as a significant weight change or develops a wound or has a fall when the care plan would be reviewed and revised, she said, It would go on the care plan the day of occurrence, the same day. Employee P went on to say, If it is not on the care plan the patient may not be cared for properly.
During the above interview with Employee P, she accessed the clinical chart for Resident #127 and #93 and confirmed the above findings. When asked if these are items that should warrant a revision of the care plan, Employee P said, Absolutely.
Review of the facility policy titled Plan of Care was conducted. This policy read, .Review, update and/or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident and in response to current interventions after the completion of each OBRA MDS assessment (except discharge assessments), and as needed. The interdisciplinary team shall ensure the plan of care addresses any resident needs and that the plan is oriented toward attaining or maintaining the highest practicable physical, mental and psychosocial well-being.
On 7/13/22, the facility Administrator and Corporate Clinical Consultant were made aware of the above findings for Residents #127, #93, and #4.
No further information was received.
4. Resident #49 experienced an 18.91% weight loss over a 3 month time period (January 2022 through April 2022) and the care plan was not revised to include goals and interventions addressing the significant weight loss.
On 07/11/2022 at 1:25 P.M., Resident #49 was observed in her bed. Resident #49 appeared small-framed and thin.
On 07/12/2022, Resident #49's clinical record was reviewed. According to the weight flow chart, Resident #49 was weighed twice since 01/13/2022. Resident #49 weighed 110 pounds on 01/13/2022 and 89.2 pounds on 04/18/2022 which represented an 18.91% weight loss in 3 months.
The nursing progress notes around 04/18/2022 were reviewed. There were no progress notes addressing the significant weight loss.
The following excerpts of a provider progress note dated 04/19/2022 documented the following:
.currently tolerating a regular diet, dysphagia pureed texture, nectar thickened fluid consistency and has had a stable weight. Weight: 89.2 pounds. Height: 62 inches.
The dietary progress notes were reviewed. There was one dietary note written since 04/18/2022. A dietary note dated 06/01/2022 at 12:16 P.M. documented, Note Text: Weight Note:
Weight loss noted. Additional weights requested in order to establish new baseline. BMI 16.3 [underweight]. On a pureed diet with nectar thick liquids and fortified foods eating variably 0-100%. Recommend MD consult r/t [related to] weight loss and possible benefit from appetite stimulant and add Med Pass 120mL TID [three times a day].
The physician's orders were reviewed. There were no orders for an appetite stimulant or Med Pass (or any similar supplement).
Resident #49's care plan was reviewed. There was no focus addressing actual significant weight loss as recorded on the weight flow sheet on 04/18/2022.
On 07/13/2022 at 2:00 P.M., Employee R, the nurse practitioner was interviewed. When asked about the process for tracking weights, the nurse practitioner stated that there are dietary and weight meetings and usually with weight changes, the nurses would let me know. When asked if she was aware of Resident #49's significant weight loss, the nurse practitioner stated that No one brought it to my attention and They [nurses] have to let me know. When asked what she would've ordered if she was aware of the weight loss, the nurse practitioner stated she would've ordered Ensure with every meal, weekly weights, a dietary referral for food preference assessment and possibly look at labs.
On 07/13/2022, the facility staff provided a copy of their policy entitled, Plans of Care. In the Section entitled, Procedure paragraph 4, an excerpt documented, Review, update and/or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident and in response to current interventions .as needed.
5. For Resident #75 the facility staff failed to review and revise the care plan to include changes in wounds and wound treatments.
On 7/12/22 during clinical record review it was discovered that Resident # 75's Care Plan was not updated to include the sacral wound that was labeled Moisture Associated Dermatitis.
On 7/12/22 at approximately 3:00 PM an interview was conducted with Employee N who was asked when the care plan should be updated and she stated that at least quarterly but also PRN as changes occur. When asked should wounds or skin breakdown be included she stated that they should. When asked who can update the care plan she stated that Nursing staff have access to the care plans.
On 7/14/22 during the end of day meeting the Interim Administrator was made aware of the concerns and no further information was provided.
6. For Resident #34 the facility staff did not review and revise the care plan include Resident #34's need to wear eyeglasses.
On 7/6/22 at approximately 1:45 PM an interview was conducted with Resident #34 who explained that he needed eyeglasses and had not had his vision checked in some time. He stated he was not aware of the exact date he last had an eye exam but he knew it was more than a year ago. Resident #34 stated that he had his eyes examined and the doctor recommended a certain type of eyeglasses.
On 7/12/22 at approximately 1:50 PM Employee T was interviewed and she stated that Resident #34 has not had an eye exam since 2016 and it the Resident was correct in saying that he did require eyeglasses and that his care plan was not updated to include that information.
On 7/14/22 during the end of day meeting the Interim Administrator was made aware of the concerns and no further information was provided.
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** Based on staff interviews, facility documentation review and clinical record review, the facility staff failed to follow the nur...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, facility documentation review and clinical record review, the facility staff failed to follow the nursing standards of practice, for two Residents (Resident #106 & #127) in a survey sample of 48 Residents.
The findings included:
1. For Resident #106, the facility staff failed to follow physician orders and obtain weekly weights as ordered by the physician.
On 7/11/22 and 7/12/22, a clinical record review was conducted of Resident #106's clinical chart. This review revealed an active physician orders which read, Weekly weights with an effective date of 2/16/2021.
Review of Resident #106's weights revealed a weight had not been obtained since 4/29/22.
On 7/13/22 at 11:04 AM, an interview was conducted with the Nurse Practitioner (NP)/Employee R. The NP was asked what her expectations are when she writes or gives an order regarding a Resident. The NP said, To execute it as soon as possible or as soon as available, at least within 24 hours. When asked what is the importance of monitoring someone's weight? The NP said, The majority I monitor is if they had significant weight loss, I will also order med pass, ensure or something to increase their appetite because we want to make sure they don't diminish their protein or calorie malnutrition.
The NP was asked specifically about the monitoring of Resident #106's weight on a weekly basis. The NP said, He has bilateral lymphedema, I have him on diuretics and he has kidney disease so I want to make sure if he has a significant weight change I am notified and can work on plan B. The NP was asked if she was aware that the despite the order for weekly weights that the facility staff had not recorded a weight on this Resident since 4/29/22. The NP said she was not aware and added, They used to have meetings and would discuss Residents with weight changes and would give me a list but they haven't been having those meetings in some time now.
2. For Resident #127, the facility staff failed to obtain a wound culture as ordered by the physician.
On 7/11/22 and 7/12/22, a clinical record review was conducted of Resident #127's chart. This review revealed that on 6/30/22, an order was entered that said to obtain a wound culture from the sacral wound and wound specialist consult. Further review revealed that the wound culture had not been obtained as of the time of review.
On 7/12/22, the Corporate Clinical Consultant/Employee N was asked to access Resident #127's chart and confirmed the order for a wound culture. Employee N stated she would need to look into if it was obtained.
On 7/13/22 at 10:44 AM, a video call was held between Surveyor F and the Corporate Clinical Consultant, facility Administrator, and Regional Administrator. Employee N confirmed, We did not get that [referring to the wound culture ordered on 6/30/22], we spoke with the NP and got a new order yesterday and they will be obtaining that culture today if they didn't get it last night.
On 7/13/22 at 11:04 AM, an interview was conducted with the Nurse Practitioner (NP)/Employee R. The NP was asked about Resident #127's wound. The NP said, It was brought to my attention when it was bad, that's why I consulted a wound specialist and ordered a wound culture. When asked if she was aware that the wound culture was not obtained as ordered, the NP said, I was not aware until they told me yesterday that they didn't get it.
The facility Administrator confirmed that the facility follows Potter & [NAME] for their standards of nursing practice.
Review of Potter & [NAME] Fundamentals of Nursing eighth edition was conducted. On page 302, Box 23-2 Common Negligent Acts it read, Failure to notify the health care provider of problems, failure to follow orders, failure to follow the six rights of medication administration, failure to follow policy and procedures .
Review of the facility policy titled, Physician Orders was conducted. This policy read, A Nurse may accept a telephone order from the Physician, Physician Assistant or Nurse Practitioner (as permitted by state law). The order will be repeated back to the physician, PA or ARNP for his/her verbal confirmation. The order is transcribed to all appropriate areas of the electronic health record (eMar/eTAR). For pharmacy orders, the nurse will notify the pharmacy per pharmacy policy by telephoning, faxing or completing the order electronically. The ordering physician or physician extender will review and confirm orders. Confirmation of routine orders requires that the physician sign and date the order as soon as practicable after it is provided to maintain an accurate medical record.
On 7/13/22, during an end of day meeting the facility Administrator, Assistant Director of Nursing and Corporate staff were made aware of the findings.
No further information was provided.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
Based on observation, Resident interview, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility failed to ensure sufficie...
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Based on observation, Resident interview, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility failed to ensure sufficient nursing staff to provide nursing and related services to meet the resident's needs safely, timely, and in a manner that promotes each residents rights, physical, mental, and psychosocial well being.
The Findings included:
On 7-5-22 Staffing schedules were requested for the week, and were reviewed each day. A tour of the entire building to ascertain all staff currently providing care to the Residents and working during the shift was conducted on 7-5-22. The census on this day was 143 Residents. There was no Infection Preventionist (IP), nor Director of Nursing (DON), and no MDS (Minimum Data Set)/care plan Coordinator present.
Nursing staff were interviewed during initial tour and asked who the Administrator, DON, IP, and MDS Coordinators were for the building. All answered that none of those positions were filled and that Employee Q was the only one they had seen, and that had been seldom as he only came a couple times per week because his facility and home were hours away from this facility.
There was an Assistant Director of Nursing present (ADON) on 7-5-22 who stated she was very new to the role and facility, and had worked there less than a month, and was getting to know the residents and facility. She continued to say that she was not acting as the Director of Nursing in an interim capacity. She stated that there was no Director of Nursing at that time.
The Social Worker was also interviewed on 7-5-22, and stated it was her last week to work, as she was working out her notice, and that she had resigned her position with the facility. The Social Worker stated there was no DON, no MDS Coordinator, and no IP. She stated they all left about the same time which was Weeks ago.
The Area Ombudsman came to the conference room on 7-5-22 to talk with surveyors about her concerns of no administrative personnel in the building, and restated that there was no DON, nor IP in the building for weeks, as she had visited several times for resident advocacy issues regarding staff guidance and lack of leadership, and found no one in charge to discuss the incidents with.
Employee Q indicated there was no DON, nor IP at the time of survey, however, that a sister facility was going to share a DON next week, and an MDS Coordinator was already being shared as there also was not an MDS Coordinator for the facility. He went on to state that the IP position was going to be filled temporarily by the Corporate IP professional until an IP could be hired.
On 7-5-22 (7:00 a.m., to 3:00 p.m., shift) during entrance to the survey there were 3 CNA's (Certified Nursing Assistants) for all resident care on the 4 wings in the facility, for 143 Residents. There were also 5 Residential Aides who the CNA's stated may only pass water, meal trays, and get supplies, as they are not trained and certified to provide physical care to a Resident. Staffing for that shift indicated that each CNA would be responsible for the care of 47.6 Residents in one 7.5 hour shift with one 30 minute staff meal break.
This allows 9.45 minutes for each resident to receive care.
Resident interviews were conducted individually and in a resident council group meeting during the course of the survey. The interviews revealed complaints from the residents regarding staffing. Those complaints voiced consisted of; Wait too long for call bells to be answered, not enough staff to get a shower., My bed gets wet because no one will come take me to the bathroom. there is not enough staff to take care of us.
On 7-13-22 and 7-14-22 at the end of day debrief, the Regional Administrator and newly started facility Administrator, were made aware of the findings. No further information was submitted by the facility.
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 observation, Resident interview, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility failed to ensure a Regist...
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Based on observation, Resident interview, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility failed to ensure a Registered Nurse (RN) Director of Nursing (DON) was present and overseeing resident care, and staff competencies on a full time basis.
The Findings included:
On 7-5-22 Staffing schedules were requested for the week, and were reviewed each day. A tour of the entire building to ascertain all staff currently providing care to the Residents and working during the shift was conducted on 7-5-22. The census on this day was 143 Residents. There was no Director of Nursing (DON) present.
Nursing staff were interviewed during initial tour and asked who the Administrator, DON, IP, and MDS Coordinators were for the building. All answered that none of those positions were filled and that Employee Q was the only one they had seen, and that had been seldom as he only came a couple times per week because his facility and home were hours away from this facility.
There was an Assistant Director of Nursing present (ADON) on 7-5-22 who stated she was very new to the role and facility, and had worked there less than a month, and was getting to know the residents and facility. She continued to say that she was not acting as the Director of Nursing in an interim capacity. She stated that there was no Director of Nursing at that time, nor Administrator, but that the Administrator of a sister building was helping out a couple days a week. The ADON directed surveyors to talk with the Social Worker who can tell you more, I just don't know.
The Social Worker was also interviewed on 7-5-22. The Social Worker stated there was no DON. She stated they left Weeks ago.
The Area Ombudsman came to the conference room on 7-5-22 to talk with surveyors about her concerns of no administrative personnel in the building, and restated that there was no full time DON in the building for weeks, as she had visited several times for resident advocacy issues regarding staff guidance and lack of leadership, and found no one in charge to discuss the incidents with.
Human resources records, and state agency records were reviewed and no documentation had been sent from the facility notifying of the loss nor reassignment of the DON position.
Employee Q indicated there was no DON, at the time of survey, however, that a sister facility was going to share a DON next week.
On 7-13-22 and 7-14-22 at the end of day debrief, the Regional Administrator and newly started facility Administrator, were made aware of the findings. No further information was submitted by the facility.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected multiple residents
Based on observation, Resident interview, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility failed to ensure competen...
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Based on observation, Resident interview, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility failed to ensure competent nursing staff to provide nursing and related services to meet the resident's needs for 4 of five record reviews.
The Facility failed to provide performance competency reviews to ensuring skilled and competently trained staff, able to provide for Resident care needs.
The Findings included:
On 7-5-22 Staffing schedules were requested for the week, and were reviewed each day. A tour of the entire building to ascertain all staff currently providing care to the Residents and working during the shift was conducted on 7-5-22. The census on this day was 143 Residents. There was no Administrator, no Infection Preventionist (IP), nor Director of Nursing (DON), and no MDS (Minimum Data Set)/care plan Coordinator present.
Staff members (2 LPN's, and all 3 CNA's) were asked during initial tour if they had received training and had annual competencies evaluated. All responded they could not remember any training other than a recent first CNA licensing course, and long ago abuse training that they had ever received. They were asked who provided training and evaluations, and all responded I don't know, some are on the computer.
A sample of 5 employee records was requested for performance competency and education review. The review of nursing staff documentation revealed the lack of required training for baseline staff. Competencies were not completed to assess ability to care for the residents.
CNA (B) - all education or competencies.
CNA (P) - Abuse education only.
CNA (H) - all education or competencies.
CNA (Q) - all education or competencies.
On 7-14-22 the Administrator stated We have no more education/documentation to provide.
On 7-13-22 and 7-14-22 at the end of day debrief, the Regional Administrator and newly started facility Administrator, were made aware of the findings. No further information was submitted by the facility.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, and interview the facility failed to properly store drugs on two medication carts in a sample of four medication carts.
The findings included:
On 7/13/22 at approximately 11:04...
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Based on observation, and interview the facility failed to properly store drugs on two medication carts in a sample of four medication carts.
The findings included:
On 7/13/22 at approximately 11:04 a.m. while conducting a review of medication cart(S) observed the following:
1.
On Unit 1 the medication cart was reviewed with LPN F. The following medications routes were commingled in the up left corner pocket of drawer one: topical patches (catapres), transdermal (rivastigmine), suppositories (bisacodyl), oral medications (alendronate).
LPN F acknowledged that medications of various route are to be stored with dividers separating each medication route. However, the aforementioned medications were not stored in such a manner.
2.
On Unit 2 the medication cart was reviewed with RN D. The following medication route were commingled: injectable (single dose of medroxyprogesterone syringe with needle), multi-dose vial (medroxyprogesterone), and oral medications (aspirin, Motrin).
RN D acknowledged that medications of various route are to be stored with dividers separating each medication route. However, the aforementioned medications were not stored in such a
manner.
The facility's medication storage policy states: Facility should ensure that external use medications and biologicals are stored separately from internal use medications and biologicals.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected multiple residents
Based on observation, interview, facility record review and in the course of a complaint investigation, the facility staff failed to employ sufficient staff to carry out the functions of the food and ...
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Based on observation, interview, facility record review and in the course of a complaint investigation, the facility staff failed to employ sufficient staff to carry out the functions of the food and nutrition services for the facility as a whole.
The findings included:
For the facility, on 6/21/22 the facility staff failed to ensure the proper number of staff including a cook as well as dietary aids to prepare and serve dinner.
On 7/5/22 at approximately 1:00 PM the Social Worker was interviewed and she stated that she was aware of the incident involving having to order pizza for Residents. She stated that she was present at the time. She stated that the Acting Administrator was called in and he called a sister facility to get a kitchen staff member to prepare the puree foods and he then ordered pizza for the Residents who could eat regular consistency.
On 7/7/22 at approximately 9:00 AM an interview was conducted with Resident # 34 who stated Oh yeah last month we had pizza from a restaurant because they didn't have enough staff to cook.
On 7/7/22 at approximately 9:15 AM an interview was conducted with Resident # 83 who stated that the kitchen staff had not shown up for work on 6/21/22 and that the facility ordered pizza. She also stated that she felt one slice of pizza, a cookie and some juice was not sufficient.
On 7/7/22 at approximately 10:15 AM, an interview was conducted with Employee Q (the Regional Administrator) who stated that on 6/21/22 he was called by the facility staff to inform him that only 2 dietary staff had shown up for work, no cook had shown up. The the Regional Administrator stated that he called the contracted Dietary District Manager ( Employee D) and told him, We have to get these folks fed. He stated that he also called the cook from the sister facility to this facility to prepare the puree diet for the residents that could not eat regular a consistency. For the Residents that could have a regular consistency he ordered pizza from a local restaurant.
On 7/7/22 at approximately 2:00 PM an interview was conducted Employee D who was asked if they were experiencing staffing challenges he stated that they had enough staff and that dietary was contracted through an agency, however that day in particular the cook just did not show up for work.
On 7/7/22 at approximately 10:45 AM, Employee J (the [NAME] from the sister facility) was interviewed and he stated that on 6/21/22 he did receive a call asking him to come to this facility to prepare puree foods for those who could not eat pizza. When asked what he prepared he stated they were given pureed herb chicken, pureed mixed veggies, mashed potatoes and applesauce.
A review of the employee file for Dietary Manager Employee X revealed that on 6/30/22 the dietary manager was given an Employee Corrective Action write excerpts are as follows:
To date you have established a pattern of failure to meet performance expectation, and the following issues were identified:
Failed to maintain proper staffing levels. Your non aggressive approach towards recruiting has put [facility name redacted] in critical staffing mode. After reviewing ICISMS your last employee ad posted on 5/30/22 this should be accessed/updated.
Has not provided leadership, support and guidance to ensure that food quality standards, safety guidelines and customer service expectations are met. Numerous complaints regarding plate presentation, and cold food. Utilizing paper service ware for meal service has negatively impacted the unit financially and residents overall satisfaction.
Additionally our client feels you lack the commitment to improve your performance and the performance of your staff and has noted several concerns including frequently no staff, missed and late meals. During the week of June 23, 2022 the entire staff was out on 3-11, requiring facility staff to work the line and call out for pizza. This is not only a regulatory issue but a safety concern.
The Employee signed the document on 7-5-22.
On 7/14/22 during the end of day meeting the Acting Administrator was made aware of the concerns and no further information was provided.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected multiple residents
Based on staff interview and facility documentation review, the facility staff failed to maintain an ongoing antibiotic stewardship program to monitor the use of antibiotics which had the ability to i...
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Based on staff interview and facility documentation review, the facility staff failed to maintain an ongoing antibiotic stewardship program to monitor the use of antibiotics which had the ability to impact numerous Residents throughout the facility on all nursing units/resident care units.
The findings included:
On 7/12/22 at 8:09 AM, a request was made for the facility administration to provide the survey team with, the Antibiotic surveillance tracking from Jan-July, 2022.
On 7/12/22 at approximately 11 AM, a video call was conducted with the facility interim Infection Preventionist (IP)/Employee N, who was also the Corporate Clinical Consultant. The IP stated, I have gone through the binders and can't find antibiotic surveillance, I will keep looking for it. The IP was asked to provide the infection line listing, which was noted in the facility policy. The IP again said, I'm having difficulty finding it.
On 7/12/22 at 4:20 PM, another video call was held with the IP. She stated, I did locate the binder and they did not do antibiotic surveillance/infection investigations for June, we are in the process of catching it up. When asked what the purpose of an antibiotic stewardship program is and the importance, the IP said, We need to keep a line listing so we can track and trend and identify if we have an issue. We need to look at antibiotics, are we prescribing in the right way, is the treatment appropriate and make sure we don't have poor practices- we review in QA (quality assurance) and with the doctors, you don't want to prescribe unnecessarily- there are a lot of purposes for keeping a log. If you try to catch up at the end of the month you are missing the boat.
Review of the facility policy titled, Antibiotic Stewardship- Review and Surveillance of Antibiotic Use and Outcomes, was conducted. This policy read, 1. As part of the facility Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist, or designee. 2. The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics 3. At the conclusion of the review, the provider will be notified of the review findings. 4. All resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form .
On 7/12/22 and again on 7/13/22, the facility Administrator, Corporate Clinical Consultant/IP, and Regional Administrator were made aware that the facility had failed to provide evidence of an ongoing antibiotic stewardship program.
No further information was provided.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to implement their immunization policy and ensure each Resident is offered influenza and pneumococcal immunization, for 3 Resident (Resident #121, 23, 140), in a sample of 5 Residents reviewed for immunizations.
The findings included:
On 7/11/22 and 7/12/22, clinical record reviews were conducted for the sampled Residents with regards to immunization for flu and pneumonia. This review revealed the following:
1. Resident #121 had been admitted to the facility on [DATE]. On the immunization tab of the electronic health record (EHR) it read, No immunizations found. Review of the misc. (miscellaneous) tab, assessment tab, and progress notes revealed no evidence of vaccine administration or offering of such. There was a document scanned into the EHR on the misc. tab that was titled, COVID vaccines no record. This document was reviewed and contained immunization information accessed from VIIS (Virginia Immunization Information System) which revealed Resident #121 had not received any doses of the flu or pneumonia immunizations. Review of the Medication Administration Records (MAR) revealed no evidence of the flu or pneumonia immunization being provided to Resident #121.
2. Resident #23 had been admitted to the facility on [DATE], during flu season. On the immunization tab of the electronic health record (EHR) there was no documentation with regards to the flu vaccine status of Resident #23. Physician orders revealed an order that read, Flu vaccine annually. Review of the misc. (miscellaneous) tab, assessment tab, and progress notes revealed no evidence of vaccine administration or offering of such. Review of the admission agreement that had been scanned into the EHR under the miscellaneous tab revealed that Resident #23 had consented to receive the flu vaccine. Review of the Medication Administration Records (MAR) revealed no evidence of the flu immunization being provided to Resident #23.
3. Resident #140 had been admitted to the facility on [DATE], which was during flu season. On the immunization tab of the electronic health record (EHR) there was no documentation with regards to the pneumonia or flu vaccine status of Resident #140. Review of the misc. (miscellaneous) tab, assessment tab, and progress notes revealed no evidence of vaccine administration or offering of such. Review of the admission agreement that had been scanned into the EHR under the miscellaneous tab revealed that Resident #140 had consented to receive the flu vaccine. Review of the Medication Administration Records (MAR) revealed no evidence of the flu or pneumonia immunization being provided to Resident #140.
On 7/12/22, an interview was conducted with Employee N, the Infection Preventionist (IP)/Corporate Clinical Consultant. The IP was asked to explain the process when a Resident is admitted , with regards to immunizations. The IP said, When a Resident is admitted we should get their immunization status, ideally we should document in [name of the EHR software redacted], sometimes we have to go back and research and the nurse doesn't always enter it. During flu season we get authorization when they come in, see their pneumonia status and if eligible we offer it to them.
Employee N was asked where all of the immunization information such as education and offering of a vaccine get documented. Employee N said, The consent should be scanned into the miscellaneous file and additionally 1 or 2 things happen, we scan the vaccine information sheet and check the box on the immunization tab that they were educated.
During the above interview with the IP/Employee N, she was asked to access the EHR for Resident #121. She observed and confirmed the immunization tab had no data recorded. She reviewed the misc. tab and nursing notes and confirmed there was no information in the EHR. Employee N then accessed Resident #23 and #140's EHR and confirmed the above findings that no information was available to indicate they had been educated on or offered the immunizations.
Review of the facility policy titled, Pneumococcal Vaccine was conducted. This policy read, .1. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 2. Assessments of pneumococcal vaccination status will be conducted within five (5) working days of the resident's admission if not conducted prior to admission .
The facility policy titled, Influenza, Prevention and Control of Seasonal was reviewed. This policy was noted to read, .Vaccination. 1. The Infection Preventionist organizes and oversees an annual influenza vaccine campaign. 2. All residents and staff are offered the vaccine unless there is a medical contraindication .
On 7/12/22 and again on 7/13/22, the facility interim Administrator, Assistant Director of Nursing and Infection Preventionist/Corporate Clinical Consultant were made aware of the above findings.
No further information was provided prior to the conclusion of the survey on 7/14/22.
Complaint related deficiency.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0886
(Tag F0886)
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 review, the facility staff failed to conduct COVID-...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and facility documentation review, the facility staff failed to conduct COVID-19 testing in accordance with the Centers for Disease Control and Prevention (CDC) guidance for 4 Residents (Residents #46, #23, #92, and #83) in a sample of 5 Residents reviewed for testing and for 9 staff (Employee K, CNA J, RN C, LPN C, Employee C, Employee L, CNA K, LPN E, and Employee M) in a sample of 9 employees reviewed for COVID testing.
The findings included:
1. For Residents #46, #23, and #92, the facility staff failed to conduct COVID-19 testing upon their admission to the facility.
On 7/11/22 and 7/12/22, a clinical record review was conducted and revealed the following:
1a. Resident #46 was readmitted to the facility on [DATE]. Resident #46 was not tested for COVID until 5/9/22.
1b. Resident #23 had been readmitted to the facility on [DATE]. The first instance of COVID testing for Resident #23 following readmission was 7/4/2022. Resident #23 had been tested in the hospital on 6/17/22.
1c. Resident #92 was admitted to the facility on [DATE]. There was no evidence in the clinical chart of Resident #92 that he/she had been tested for COVID-19 at the facility until 7/4/22.
On 7/12/22, a video call was conducted with the facility Interim Infection Preventionist (IP)/Employee N. When asked about COVID testing of admissions, she stated, When admitted they are tested upon admission then again on day 5-7. When asked if they accept testing conducted at the hospital in lieu of being tested in the facility upon admission, the IP said, No, we shouldn't be, if it is a few days old then we can't accept the hospital test. The IP confirmed that the facility has a pandemic plan which is based upon CDC guidance, which they follow.
Review of the CDC document entitled, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated February 2, 2022, and was reviewed. This document read on page 4, Testing, item 3, Newly-admitted residents and residents who have left the facility for (greater than) 24 hours, regardless of vaccination status, should have a series of two viral tests for SARS-CoV2 infection; immediately and, if negative, again 5-7 days after their admission. Accessed online at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html
The facility policy titled, COVID-19 - Pandemic Plan with a revision date of 3/11/22, was reviewed. This policy read, .13.
New admissions/re-admissions: Newly admitted or re-admitted residents, regardless of their vaccination status will have a series of two viral COVID-19 test, immediately and if negative, again in 5-7 days after admission. Residents not up to date with all recommended COVID-19 vaccines (even those with a negative test upon admission) will be quarantined for 10 days (if they do not develop symptoms). Quarantine may be shortened to 7 days if the resident does not develop symptoms AND a viral test for COVID-19 is negative. The specimen will be collected and tested within 48 hours before planned discontinuation of TBP.
2. The facility staff failed to conduct COVID-19 testing of Resident #83, who reported COVID symptoms.
On 7/11/22 at 2:45 PM, Surveyor B was informed by Resident #83 that she has had cold symptoms since Friday, 7/8/22. During the interactions Surveyor B observed Resident #83's voice was hoarse and it hard for the Resident to talk. Resident #83 reported that she did not get COVID tested yet and she was concerned since she was supposed to be leaving on Friday (7/15/22). Resident #83 reported that the Nurse on duty (RN B) told her she did not have a test (COVID test) over the weekend and therefore could not perform the test.
On 7/11/22 at 3:00 PM, Surveyor B interviewed Employee N, the Interim Infection Preventionist (IP) who stated that she was unaware there was someone in the building that had COVID-like symptoms since Friday that had not been tested.
On 7/11/22 at 3:15 PM, Employee N reported back to Surveyor B that she had spoken to the Resident and the nurse (RN B) and that the nurse stated she could not find a test in the med room but did not call the supervisor or search elsewhere for the test.
On 7/12/22, a video call was conducted with Employee N/ the Interim IP. She was asked about Resident #83's report of COVID symptoms and she confirmed that the facility has an abundance of COVID tests and should have been tested when she/he reported symptoms. The IP stated that Resident #83 had now been tested. The IP confirmed that the facility has a pandemic plan which is based upon CDC guidance, which they follow.
Review of the CDC document entitled, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated February 2, 2022, and was reviewed. This document read, .Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test as soon as possible . Accessed online at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html
The facility policy titled, COVID-19 - Pandemic Plan with a revision date of 3/11/22, was reviewed. This policy read, .6. Testing: Symptomatic testing: Test staff or residents who have signs or symptoms of COVID-19 (regardless of their vaccination status) i.
Staff experiencing signs or symptoms should be excluded from work pending results. If COVID-19 test is positive refer to the Employee Health section of this plan
ii. Residents experiencing signs or symptoms are placed on transmission-based precautions pending test results.
Note: Follow CDC Guidance on interpretation of Antigen testing- If the patient is asymptomatic and the antigen test is positive confirm with PCR If the patient is symptomatic and the antigen is negative confirm with a PCR .
3. The facility staff failed to conduct routine and outbreak testing of for 9 staff (Employee K, CNA J, RN C, LPN C, Employee C, Employee L, CNA K, LPN E, and Employee M) who were not vaccinated and/or up to date with COVID vaccines.
On 7/11/22 and 7/12/22, the facility submitted staff vaccination matrix was reviewed and a sample of employees was selected for review.
On 7/12/22, a video call was held with the Interim Infection Preventionist/Employee N. Employee N was given each of the employee's names and asked to provide evidence of COVID testing for the months of May, June and July.
Employee N reported the following as testing occurrences/dates: 5/23/22- routine testing, 5/30/22- outbreak testing, 6/6/22- outbreak testing, 6/13/22- outbreak testing, 6/20/22- outbreak testing, 6/27/22- routine testing, 7/4/22- outbreak testing, and 7/11/22- outbreak testing. Review of the facility submitted tracking of community transmission rates revealed the community rate of transmission had been high for the months of May, June and July. There was no evidence of routine testing for staff not up-to-date being conducted twice weekly as per the CDC recommendations and facility policy.
The findings were as follows for the specific staff members:
3a. Employee K, who was noted as having a religious exemption had evidence of COVID testing on 5/23/22, 6/27/22, and 7/11/22. Employee K's name was highlighted on the 7/4/22, listing of staff as having been tested but the facility staff had no evidence of Employee K's test results for that date of testing.
Employee K was missing testing occurrences on 5/30/22, 6/6/22, 6/13/22, 6/20/22, and 7/4/22.
3b. CNA J, was noted as having had a religious exemption. Testing occurrences were noted as: 5/23/22, 6/20/22, 6/27/22, and 7/11/22. CNA J's name was highlighted on the 7/4/22, listing of staff as having been tested but the facility staff had no evidence of CNA J's test results for that date of testing.
CNA J was missing testing occurrences on: 5/30/22, 6/6/22, 6/13/22, and 7/4/22.
3c. RN C, was noted as having had a religious exemption. Testing occurrences were noted as: 5/23/22, 6/20/22, 6/27/22, and 7/11/22. RN C's name was highlighted on the 7/4/22, listing of staff as having been tested but the facility staff had no evidence of RN C's test results for that date of testing.
RN C was missing testing on the following dates: 5/30/22, 6/6/22, 6/13/22, and 7/4/22.
3d. LPN C, was noted as having had a religious exemption. Testing occurrences were noted as: 5/23/22, 6/20/22, and 7/11/22. The Infection Preventionist reported that LPN C was on vacation the week of 7/4/22.
LPN C was missing testing on the following dates: 5/30/22, 6/6/22, 6/13/22, and 7/4/22.
3e. Employee C, who was not up-to-date with COVID vaccines was noted as having been tested for COVID-19 on 6/20/22, 7/4/22, and 7/11/22.
Employee C was missing testing on the following dates: 5/23/22, 5/30/22, 6/6/22, and 6/13/22.
3f. Employee L, who was not up-to-date with COVID vaccination, was noted to have COVID testing occurrences on the following dates: 6/20/22, 7/4/22, and 7/11/22.
Employee L was missing testing on the following dates: 5/23/22, 5/30/22, 6/6/22, 6/13/22, and 6/27/22.
3g. CNA K, who was not up to date with COVID immunizations, was tested on [DATE], 7/4/22, and 7/11/22.
CNA K was missing testing on the following dates: 5/23/22, 5/30/22, 6/6/22, 6/13/22, and 6/27/22.
3h. LPN E, who was not up to date with COVID immunizations was tested on : 6/20/22, 7/4/22, and 7/11/22.
LPN E was missing testing on the following dates: 5/23/22, 5/30/22, 6/6/22, 6/13/22, and 6/27/22.
3i. Employee M who was not up to date with COVID immunizations, was tested on : 7/4/22 and 7/11/22.
Employee M was missing testing on the following dates: 5/23/22, 5/30/22, 6/6/22, 6/13/22, 6/20/22, and 6/27/22.
On 7/12/22, during a video call with the facility Infection Preventionist she confirmed that there were multiple testing occurrences missing for staff as noted above. When the Surveyor notified the IP there was not evidence of twice a week testing for routine testing when not in outbreak, the IP said, That's a fair statement to say.
On 7/12/22 at 4:20 PM, the facility Infection Preventionist stated she had found some additional testing information and provided evidence of LPN E, Employee C, LPN C, and CNA K being tested on [DATE]. She stated she had no further information to provide.
Review of the CDC document entitled, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated February 2, 2022, and was reviewed. This document read, .In nursing homes, HCP who are not up to date with all recommended COVID-19 vaccine doses should continue expanded screening testing based on the level of community transmission as follows: In nursing homes located in counties with substantial to high community transmission, these HCP should have a viral test twice a week . Accessed online at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html
The facility policy titled, COVID-19 - Pandemic Plan with a revision date of 3/11/22, was reviewed. This policy read, .6. Testing: .Outbreak Investigation: A single new case of COVID-19 infection in any staff or a nursing home -onset COVID-19 infection in a resident should be evaluated as a potential outbreak A resident admitted to a center with COVID-19 does not constitute a center outbreak. Testing should begin immediately, and the center can perform outbreak investigation using either, contact tracing or broad-base (e.g. facility -wide) testing (unless otherwise directed by the local health department) .Expanded Screening Testing of Asymptomatic Staff: Test all staff who are not up to date with the recommended COVID-19 vaccine doses based on the extent of the virus in the community, using the community transmission level available from the CDC.
i. Centers should begin testing based on the community transmission level reported for the past week.
ii. Center should monitor their community transmission level every other week and adjust the frequency of testing accordingly. Level of COVID-19 Community Transmission Minimum Testing Frequency, Staff Not Up to Date with ALL Recommended Vaccine Doses ONLY
Low (blue)-Not Recommended; Moderate (yellow)- Once a Week; Substantial (orange)- Twice a week; High (red)- Twice a Week .
On 7/12/22 and again on 7/13/22, the facility Administrator, Assistant Director of Nursing, Corporate Clinical Consultant and Regional Administrator were made aware of the above findings. The Administrator confirmed the facility should be following CDC guidance.
No further information was provided.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility staff failed to offer COVID vaccination(s) to four Residents (Resident #121, 23, 140 and 92), in a sample of 5 Residents reviewed for immunizations.
The findings included:
1. The facility staff failed to provide evidence that Resident #121 was offered, educated and provided/or declined COVID vaccination.
Review of the facility submitted listing of Resident's COVID vaccination status revealed Resident #121 was not vaccinated for COVID-19.
On 7/11/22 and 7/12/22, a clinical record review for Resident #121 was conducted. This review revealed the following: Resident #121 had been admitted to the facility on [DATE]. On the immunization tab of the electronic health record (EHR) it read, No immunizations found. Review of the misc. (miscellaneous) tab, assessment tab, and progress notes revealed no evidence of vaccine administration or offering of such. There was a document scanned into the EHR on the misc. tab that was titled, COVID vaccines no record. This document was reviewed and contained immunization information accessed from VIIS (Virginia Immunization Information System) which revealed Resident #121 had not received any doses of the COVID vaccine.
The progress notes for Resident #121 were reviewed, which included social work, nursing and medical providers, to include from admission through the date of review. There was no indication of Resident #121 being offered or educated on the benefit of immunization for COVID.
Review of the Medication Administration Records (MAR) and Treatment Administration Records (TAR), revealed no evidence of the COVID immunization being provided to Resident #121.
2. The facility staff failed to provide evidence that Resident #23 was educated about the COVID vaccination.
Review of the facility provided listing of Resident's vaccination status revealed Resident #23 had received one dose of the [NAME] COVID vaccine on 2/9/22.
On 7/11/22 and 7/12/22, a clinical record review for Resident #23 was conducted. This review revealed the following: Resident #23 was admitted to the facility on [DATE], with a readmission on [DATE]. On the immunization tab of the electronic health record (EHR) there was documentation that Resident #23 received one dose of the COVID vaccine on 2/9/22.
All of the progress notes for Resident #23 were reviewed, which included social work, nursing and medical providers, to include from admission through the date of review. There was no indication of Resident #23 being offered or educated on the benefit of immunization for COVID.
Review of the Medication Administration Records (MAR) and Treatment Administration Records (TAR), revealed no evidence of the COVID immunization being provided to Resident #23.
3. The facility staff failed to provide evidence that Resident #140 was offered, educated and provided/or declined COVID vaccination.
On 7/11/22 and 7/12/22, a clinical record review for Resident #140 was conducted. This review revealed the following: Resident #20 was admitted to the facility on [DATE]. On the immunization tab of the electronic health record (EHR) there was no documentation with regards to the COVID vaccine status of Resident #20.
All of the progress notes for Resident #140 were reviewed, which included social work, nursing and medical providers, to include from admission through the date of review. There was no indication of Resident #140 being offered or educated on the benefit of immunization for COVID.
Review of the Medication Administration Records (MAR) and Treatment Administration Records (TAR), revealed no evidence of the COVID immunization being provided to Resident #140.
4. The facility staff failed to provide evidence that Resident #92 was offered, educated and provided/or declined COVID booster vaccination.
On 7/11/22 and 7/12/22, a clinical record review for Resident #92 was conducted. This review revealed the following: Resident #20 was admitted to the facility on [DATE]. On the immunization tab of the electronic health record (EHR) there was documentation that Resident #92 had received the primary vaccination series for COVID on 7/30/21 and 8/27/21, and was eligible for a vaccine booster.
All of the progress notes for Resident #92 were reviewed, which included social work, nursing and medical providers, to include from admission through the date of review. There was no indication of Resident #92 being offered or educated on the benefit of a COVID booster.
Review of the Medication Administration Records (MAR) and Treatment Administration Records (TAR), revealed no evidence of the COVID immunization being provided to Resident #140.
On 7/12/22, a video call was held with the Interim Infection Preventionist (IP)/Employee N. The IP confirmed that Resident immunizations are documented on the immunization tab of the electronic health record of each Resident. She stated that Anyone we admit we have to know their COVID vaccination status and we offer immunizations and boosters if needed.
During the above video call Employee N accessed the EHR for each of the Residents (Resident #121, 23, 140 and 92) and confirmed that she saw no evidence within the clinical record of the Residents being offered COVID immunizations and/or booster doses.
Review of the facility policy titled, COVID-19 Pandemic Plan was conducted. This policy read, .COVID-19 Vaccine. Residents, employees/contractors/community members will be offered the COVID-19 vaccine when vaccine supplies are available to the center .Vaccine emergency use authorization fact sheet will be provided and reviewed with the resident/resident representative, employee and community member (including the risk/benefit and potential side effects), Consent (including the screening questions) will be obtained, Monitor for allergic reaction post administration for 15 minutes up to 30 minutes for those with previous reaction to vaccines (per the CDC)
Residents: Obtain physician order, Document in the medical record, Monitor the resident for 72 hours post vaccine and document in the medical record .
The facility policy titled, COVID-19 Vaccination- Residents was reviewed. This policy read, 1. COVID-19 vaccinations will be offered to residents per CDC and/or FDA guidelines unless such immunization is medically contraindicated, the individual has already been immunized during this time period or the individual refuses to receive the vaccine. 2. Residents/representatives will be educated on the COVID-19 vaccine they are offered, in a manner they can understand . This policy went on to read, .Documenting COVID-19 Vaccine. 5. Review the COVID-19 consent with the resident/resident representative or community member a) obtain signature indicating acceptance or declination .b) file the consent form in resident electronic health record. 6. Documentation includes but is not limited to: Residents (in the electronic health record) a) Whether the resident/representative consented or declined the vaccine .
CDC (Centers for Disease Control and Prevention) provides the following guidance to nursing facilities in their document titled Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes. This document read, .New Admissions and Residents who Leave the Facility: Create a Plan for Managing New Admissions and Readmissions In general, all residents who are not up to date with all recommended COVID-19 vaccine doses and are new admissions and readmissions should be placed in quarantine .COVID-19 vaccination should also be offered. Accessed online 7/13/22, at web address: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#anchor_1631030153017
On 7/13/22, during an end of day meeting held, the interim facility Administrator, Assistant Director of Nursing, Corporate Clinical Consultant and Regional Administrator were made aware of concerns regarding COVID immunizations for Residents noted above.
No further information was provided.
Complaint related deficiency.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0888
(Tag F0888)
Could have caused harm · This affected multiple residents
Based on staff interview and facility documentation review, the facility staff failed to complete exemption documents for 10 of 10 exemptions requested by staff (Employee K, Employee Y, Employee G, CN...
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Based on staff interview and facility documentation review, the facility staff failed to complete exemption documents for 10 of 10 exemptions requested by staff (Employee K, Employee Y, Employee G, CNA J, CNA F, CNA H, CNA G, LPN C, LPN J, and RN C)
The findings included:
On 7-6-22, the facility staff was requested to provide the survey team with a copy of the staff vaccination matrix and as worked schedule. The as worked schedule was used to check that all facility employees were included on the staff vaccination matrix.
On 7-8-22 after several revisions to omissions of staff, between the schedule and the matrix, a final copy was received. The final copy included all exemption forms (10) that had been requested by the staff. None of the (10) exemption documents were complete, to include; Dates, signatures, approved or denied status for the requested exemptions, and mitigation strategies to be adhered to by unvaccinated staff.
On 7-8-22 at 2:00 p.m., a conference call was placed with the onsite survey team and the Regional Administrator, who was the only leadership in the building.
During that meeting, the facility Administrator confirmed that the staff vaccination log provided to the survey team was current, complete and inclusive of all facility staff and agency staff. The Regional Administrator was asked why the exemption forms were incomplete and the staff who had applied for, but were not yet approved for exemptions, were unvaccinated, and actively working on the floors. He was asked what mitigating precautions the staff who were unvaccinated were required to follow to protect the resident population from contracting COVID-19. The Regional Administrator stated he was unsure, however, he would look into it.
On 7-8-22 at 3:00 p.m., The Regional Administrator was asked for the staff vaccination and exemption policy, and it was supplied. The Regional Administrator confirmed that the exemption forms were incomplete, and the documents would be corrected immediately, and unvaccinated staff made aware of the need to wear N-95 respirator masks, and CDC required weekly testing.
Review of the facility policy titled, COVID-19 Vaccinations, was reviewed. This policy read, .2. Personnel will submit their request for religious exemption on the company's form to the location executive, or their designee, at the individual's primary work location. 3. Care center employees who regularly work in, or provide services to, the care center will submit appropriate .proof of an approved exemption to the Infection Preventionist or their designee by the regulatory deadline. All documentation will be maintained confidentially and in compliance with applicable record keeping requirements.
The facility was experiencing an active outbreak of COVID-19, however, no hospitalizations as a result of the outbreak had occurred.
On 7-8-22, during the end of day meeting, the Regional Administrator was made aware of the concern that the staff vaccination exemptions policy and tracking system in use, was not implemented and not complete and accurate.
No additional information was received during the course of the survey, and by the time of exit on 7-14-22.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0943
(Tag F0943)
Could have caused harm · This affected multiple residents
Based on observation, Resident interview, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility failed to ensure completi...
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Based on observation, Resident interview, staff interview, facility documentation review, clinical record review, and in the course of a complaint investigation, the facility failed to ensure completion of staff abuse training for 3 of 5 sampled records
The Findings included:
On 7-5-22 Staffing schedules were requested for the week, and were reviewed each day. A tour of the entire building to ascertain all staff currently providing care to the Residents and working during the shift was conducted on 7-5-22. The census on this day was 143 Residents. There was no Administrator, no Infection Preventionist (IP), nor Director of Nursing (DON), and no MDS (Minimum Data Set)/care plan Coordinator present.
Staff members (2 LPN's, and all 3 CNA's) were asked during initial tour if they had received training and had annual competencies evaluated. All responded they could not remember any training other than a recent first CNA licensing course, and long ago abuse training that they had ever received. They were asked who provided training and evaluations, and all responded I don't know, some are on the computer.
A sample of 5 employee records was requested for performance competency and education review which is required upon hire and at least annually. Competencies were not completed for the following:
CNA (B) - No education on abuse documented.
CNA (H) - No education on abuse documented.
CNA (Q) - No education on abuse documented.
On 7-14-22 the Administrator stated We have no more education/documentation to provide.
On 7-13-22 and 7-14-22 at the end of day debrief, the Regional Administrator and newly started facility Administrator, were made aware of the findings. They stated at that time there were no more education documents for those staff on record. No further information was submitted by the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected most or all residents
Based on observation, resident interview, staff interview, clinical record review, facility document review, and in the course of a complaint investigation the facility was not administered in a manne...
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Based on observation, resident interview, staff interview, clinical record review, facility document review, and in the course of a complaint investigation the facility was not administered in a manner that enabled it to use it's resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. This has the potential to affect all residents.
The Directors and Officers of the facility's parent company knew of the absence of leadership in the facility, as the Regional Administrator had been tasked with assisting in the capacity of Administrator for 2 buildings and they did not act to allocate effective full time leadership to the facility.
The findings included;
On 7-5-22 Staffing schedules were requested for the week, and were reviewed each day. A tour of the entire building to ascertain all staff currently providing care to the Residents and working during the shift was conducted on 7-5-22. The census on this day was 143 Residents. There was no Administrator, no Infection Preventionist (IP), nor Director of Nursing (DON), and no MDS (Minimum Data Set)/care plan Coordinator present.
Nursing staff were interviewed during initial tour and asked who the Administrator, DON, IP, and MDS Coordinators were for the building. All answered that none of those positions were filled and that Employee Q (name) was the only one they had seen, and that had been seldom as he only came a couple times per week because his facility and home were hours away from this facility.
There was an Assistant Director of Nursing present (ADON) on 7-5-22 who stated she was very new to the role and facility, and had worked there less than a month, and was getting to know the residents and facility. She continued to say that she was not acting as the Director of Nursing in an interim capacity. She stated that there was no Director of Nursing at that time, nor Administrator, but that the Administrator of a sister building was helping out a couple days a week. The ADON directed surveyors to talk with the Social Worker who can tell you more, I just don't know.
The Social Worker was also interviewed on 7-5-22, and stated it was her last week to work, as she was working out her notice, and that she had resigned her position with the facility. The Social Worker stated there was no Administrator, no DON, no MDS Coordinator, and no IP. She stated they all left about the same time which was Weeks ago.
The Area Ombudsman came to the conference room on 7-5-22 to talk with surveyors about her concerns of no administrative personnel in the building, and restated that there was no full time Administrator, DON, nor IP in the building for weeks, as she had visited several times for resident advocacy issues regarding staff guidance and lack of leadership, and found no one in charge to discuss the incidents with.
Human resources records, and state agency records were reviewed and documented that the Administrator of record (Employee Administrator) had started immediately after the resignation of the former Administrator (before 6-14-22), as the previous Administrator was documented as having become the Administrator of record at another facility. This was incorrect. Interviews with the facility staff, ADON, Social Worker, and Ombudsman, as well as the Regional Administrator (Employee Q) confirmed that the Administrator of record had not yet been in the facility and was on vacation until 8-1-22, when he would join the facility on a full time basis.
Employee Q stated that there had been several Administrators assisting during this time, however, all of the other interviews stated no one with the exception of employee Q had acted as an Administrator since the former Administrator left. Employee Q stated he was the Administrator of record for a sister facility 2 hours from this facility, and came a few days a week to help since there previous Administrator left.
Employee Q indicated there was no DON, nor IP at the time of survey, however, that a sister facility was going to share a DON next week, and an MDS Coordinator was already being shared as there also was not an MDS Coordinator for the facility. He went on to state that the IP position was going to be filled temporarily by the Corporate IP professional until an IP could be hired.
On 7-7-22 an interview was requested with the Social Worker. Employee Q stated that the Social worker was as of yesterday no longer employed by the facility. When surveyors asked why the termination and early departure as the Social Worker had self scheduled for 2 more days, no answer was given.
On 7-11-22 the Administrator of record entered the position, building, and survey.
On 7-12-22 The social worker from a sister facility (Employee T) was present during survey, and upon interview stated she was joining the facility from a sister facility to help out for 2 or 3 days a week until a replacement could be found. She was asked if she was familiar with the resident population and she stated no, and stated that she was fairly new with the sister facility as well.
The former Social Worker had given a 2 week notice of resignation, yet no replacement had been obtained, and she was not allowed to work out her notice. The sharing of Social workers between facilities with 120 beds is not permitted by federal regulation. Both facilities had greater than 120 beds.
From 7-6-22 through 7-14-22 at the time of survey exit, the facility had no full time Social Worker.
In conclusion, the lack of sufficient and competent staffing, and leadership, resulted in the outcome of a Substandard Level of Care finding. Extensive other deficiency findings were cited and an extended survey ensued for multiple system failures which impacted the delivery of care and services to the resident population in a negative manner.
On 7-13-22 and 7-14-22 at the end of day debrief, the Regional Administrator and newly started facility Administrator, were made aware of the findings. No further information was submitted by the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Social Worker
(Tag F0850)
Could have caused harm · This affected most or all residents
Based on observation, staff interview, facility document review, and in the course of a complaint investigation, the facility failed to ensure employment of a qualified Social worker on a full time ba...
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Based on observation, staff interview, facility document review, and in the course of a complaint investigation, the facility failed to ensure employment of a qualified Social worker on a full time basis. This has the potential to affect all residents. This is Substandard Quality of Care.
The Facility failed to provide a full time Social worker for the second week of survey, and planned to use another facility's Social worker to help out 2-3 days per week.
The Findings included:
The Social Worker was interviewed on 7-5-22, and stated it was her last week to work, as she was working out her notice, and that she had resigned her position with the facility.
On 7-7-22 an interview was requested with the Social Worker. Employee Q stated that the Social worker was as of yesterday no longer employed by the facility. When surveyors asked why the termination and early departure as the Social Worker had self scheduled for 2 more days, no answer was given.
On 7-12-22 The social worker (Employee T) from a sister facility, which had greater than 120 beds, was present during survey, and upon interview stated she was joining the facility from a sister facility to help out for 2 or 3 days a week until a replacement could be found. She was asked if she was familiar with the resident population and she stated no, and stated that she was fairly new with the sister facility as well.
The former Social Worker had given a 2 week notice of resignation, yet no replacement had been obtained, and she was not allowed to work out her notice.
From 7-6-22 through 7-14-22 at the time of survey exit, the facility had no full time Social Worker.
On 7-13-22 and 7-14-22 at the end of day debrief, the Regional Administrator and newly started facility Administrator, were made aware of the findings. No further information was submitted by the facility.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on observation, staff interviews, facility documentation review, and clinical record review, the facility staff failed to maintain an infection prevention and control program for the prevention,...
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Based on observation, staff interviews, facility documentation review, and clinical record review, the facility staff failed to maintain an infection prevention and control program for the prevention, identifying, reporting, and investigating infections.
The findings included:
1. The facility staff failed to maintain an infection prevention and control program to include infection surveillance, infection investigation and system to prevent the development and transmission of communicable diseases within the facility.
On 7/12/22 at 8:09 AM, the facility administration was asked to provide the survey team with evidence of infection surveillance logs/line listing (for COVID and non-COVID infections) Jan-July 2022.
On 7/12/22 at approximately 11 AM, a video call was conducted with the facility interim Infection Preventionist (IP)/Employee N, who was also the Corporate Clinical Consultant. During this video call the IP was asked to show evidence of the infection line listing and she said, I'm having difficulty finding it. When asked about their COVID infections and recent outbreaks, Employee N had difficulty providing details on when and who had tested positive for COVID-19.
On 7/12/22 at 4:20 PM, another video call was held with the IP and Surveyor F. Also present was the facility Administrator and Regional Administrator. The IP stated, I found the binder and they did not keep it current, we are in the process of doing June's now, we are trying to catch it up. For the infection line listing, the IP showed Surveyor F that the line listing ended on 5/20/22. The facility staff confirmed that they had COVID cases in June as well as July and were currently in outbreak but that the infections were not currently being tracked/surveilled, investigated, etc.
The IP confirmed that the previous IP had left around June 23-26, and she assumed the role of interim IP on 6/26/22. The IP further confirmed that prior to her arrival at the facility this week (week of survey) she had been overseeing from a distance, and was not aware that infection surveillance, tracking, etc. had not been maintained.
When asked what is the purpose and importance of infection line listings and surveillance, etc. the IP said, We need to be keeping a line listing so we can track and trend and identify if we have an issue. Ideally Monday through Friday when they go through the orders during clinical meeting they should be discussing infections and adding to the line listing. In June it wasn't done. We are having to run a report of antibiotics and treatments prescribed in June to try to catch it up. We should be investigating infections, if you are trying to catch it up at the end of the month you are missing the boat, it is a living document.
A review of the facility policy titled, Policies and Practices- Infection Control, was conducted. This policy read, .2. The objectives of our infection control policies and practices are to: a. Prevent, detect, investigate, and control infections in the facility .
The facility policy titled, Monitoring Compliance with Infection Control was received and reviewed. This policy stated, Routine monitoring and surveillance of the workplace are conducted to determine compliance with infection prevention and control policies and practices. 1. The infection preventionist or designee monitors the compliance and effectiveness of our infection prevention and control policies and practices. 2. Monitoring includes regular surveillance of adherence to hand hygiene practices and availability of hand hygiene supplies, and the availability of personal protective equipment and its appropriate use .
The policy titled, Surveillance for Infections was received and reviewed. This policy read, 1. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and Healthcare-Associated Infections, to guide appropriate interventions, and to prevent future infections . Gathering Surveillance Data: 1. The infection preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data .5. In addition to collecting data on the incidence of infections, the surveillance system is designed to capture certain epidemiologically important data that may influence how the overall surveillance data is interpreted .
On 7/12/22 and again on 7/13/22, the facility Administrator, Corporate Clinical Consultant/IP, and Regional Administrator were made aware of the findings that they did not have an ongoing infection prevention program.
No further information was provided.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected most or all residents
Based on staff interviews and facility documentation review, the facility staff failed to have a designated individual to serve as the Infection Preventionist (IP) which has the potential to affect al...
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Based on staff interviews and facility documentation review, the facility staff failed to have a designated individual to serve as the Infection Preventionist (IP) which has the potential to affect all 143 Residents residing in the facility.
The findings included:
On 7/5/2022, the Regional Administrator reported to the survey team that the Infection Preventionist for the facility had quit. He (the Regional Administrator) said they were going to get the Corporate Clinical Consultant (nurse consultant) to fill in, but she was on vacation that week.
On 7/11/22, the facility's interim Administrator and Regional Administrator stated that Employee N/Corporate Clinical Consultant is serving as the facilities interim Infection Preventionist.
On 7/12/22 at 10:10 AM, an interview was conducted with Employee N/the Corporate Clinical Consultant/interim Infection Preventionist. Employee N stated, This was not one of my assigned buildings, I just took it over the first of June. [Previous Infection Preventionist name redacted] was here then, she left about 3 weeks ago. The Assistant Director of Clinical Services (also known as the Assistant Director of Nursing) doesn't have a lot of experience in infection control and hasn't done the training yet, but she will become the infection preventionist. Employee N was asked if she works at the facility on a full-time or part-time basis and she said, No, I've just been overseeing it from a distance. I was here two days in June to on-board a new DCS (director of clinical services/director of nursing) but she is gone now. Week before last I was in another facility who was in survey and I was on vacation last week, so yesterday I would have been here anyway.
Review of the facility's job description for the Infection Preventionist revealed the following as Duties and Responsibilities: .2. Oversight of the IPCP to include:
a. Preventing, identifying, controlling, reporting and investigating infections and communicable diseases for all residents, staff and visitors of the centers following local, state and national guidelines as well as recognized best practices.
b. Education, enforcement and reinforcement of the written standards of the program as outlined in the Infection Control Policies and Procedures and as directed by the center Infection Control Program Risk Assessment.
c. Maintain a system of surveillance to identify and prevent spread of infections to other persons within the center.
d. Appropriately report communicable disease to the local, state and federal authorities as directed by regulation and law.
e. Identify, enforce, observe, and reinforce appropriate transmission based and standard precautions within the center.
f. Monitor the appropriate use of isolation within the center to reduce the risk of spread based on the organism and type of infection using the least restrictive measures possible to maintain the resident's highest level of practicable well-being
5. Record, track and trend surveillance and investigation of infections; and actions taken to prevent and control spread of infections and report to center QAPI committee
6. Conduct, record and report on outbreak investigations and the actions taken to mitigate spread of infection.
7. Oversee the center antibiotic stewardship program and monitor resident and physician/extenders use of antibiotics
8. Track and trend organisms within the center based on lab reporting. Report any trending to Medical Director, Director of Nursing and QAPI committee.
The Centers for Disease Control and Prevention (CDC) gives the following recommendations in their document titled, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes: It read, .Infection Prevention and Control Program. Assign One or More Individuals with Training in Infection Prevention and Control to Provide On-Site Management of the IPC Program. This should be a full-time role for at least one person in facilities that have more than 100 residents or that provide on-site ventilator or hemodialysis services. Smaller facilities should consider staffing the IPC program based on the resident population and facility service needs identified in the IPC risk assessment. Accessed online 7/13/22, at web address: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html
During the course of the survey it was determined that the facility's lack of an infection preventionist resulted in the facility not tracking or surveilling for infections, investigating infections, conducting outbreak investigations, or implementing the antibiotic stewardship program. The facility was in an active COVID outbreak and continued to identify new COVID cases during the survey.
On 7/13/22, during a meeting with the facility interim Administrator, Corporate Clinical Consultant and Regional Administrator, they were made aware of the above findings.
No further information was received prior to the end of survey at 5:45 PM, on 7/14/22.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0885
(Tag F0885)
Could have caused harm · This affected most or all residents
Based on staff interview, and facility documentation review, the facility staff failed to notify Residents and families when new cases of COVID-19 were identified in the facility, affecting all 143 Re...
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Based on staff interview, and facility documentation review, the facility staff failed to notify Residents and families when new cases of COVID-19 were identified in the facility, affecting all 143 Residents residing in the facility.
The findings included:
On 7/12/22 at 8:09 A.M., a request for Evidence of Resident and family notifications of COVID cases and the weekly communication for May, June and July was made.
On 7/12/22 at 10:40 AM, the facility provided the survey team with evidence of automated calls being made to Resident's families on 6/10/22, for notification of a COVID case identified on 6/9/22.
On 7/12/22 at approximately 11 AM, during a video call with the Corporate Clinical Consultant/Interim Infection Preventionist (IP). The IP identified that on 5/30, 6/6, 6/13, and 6/20 the facility was in outbreak. She also stated that on 7/4/22, a Resident tested positive for COVID-19, which placed the facility back into an outbreak status.
On 7/13/22, the facility staff provided an infection surveillance log with the last entry being 5/20/22, where a staff member tested positive for COVID-19.
The facility was in an active COVID outbreak and continued to identify new COVID cases during the survey.
On 7/13/22 at 10:44 AM, the facility administration was made aware that evidence of Resident and family notification for the identification of COVID cases in May and July was still outstanding. They stated, That is all I can show, we have no other documentation.
Review of the facility policy titled, COVID-19 - Pandemic Plan with a revision date of 3/11/22, was conducted. This policy read, .35.
Residents and resident representatives will be notified:
* By 5pm the next calendar day following the occurrence of either a single confirmed infection of COVID-19 OR three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other;
* Cumulative update weekly OR by 5pm the next calendar day following the subsequent occurrence of each confirmed infection of COVID-19 or three or more residents or staff with new onset of respiratory symptoms occurring within 72 hours of each other
* Notification must include: mitigating actions implemented to prevent or reduce the risk for transmission, and changes in normal operations at the facility but not include personally identifiable information .
On 7/13/2022, the interim administrator, Corporate Clinical Consultant/Infection Preventionist and Regional Administrator were made aware of the above findings.
No further information was submitted prior to the end of survey at 5:45 PM on 7/14/22.
Apr 2021
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and review of facility documentation, the facility staff failed to ensure mis...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and review of facility documentation, the facility staff failed to ensure misappropriation of resident property to include the diversion of 2 of 40 resident's (#254 and #304) physician ordered controlled substances for staff use or personal gain.
The findings include:
1. Resident #254 was admitted to the nursing facility on 3/16/21 with a primary diagnosis of Human Immunodeficiency Virus (HIV) and secondary diagnoses that included generalized muscle weakness, pressure ulcers, seizures and pain. The resident was discharged to the local hospital on 3/22/21 and did not return to the admitting facility.
The Minimum Data Set (MDS) was an admission dated 3/22/21 and coded Resident #254 on the Brief Interview for Mental Status (BIMS) with a 3 out of a total score of 15 which indicated the resident was severely impaired in the cognitive skills for daily decision making. The resident was assessed to require extensive assistance from two staff for bed mobility, transfer, locomotion on and off the unit, ambulation on and off the unit, dressing, toilet use and personal hygiene. Resident #254 was coded totally dependent on two staff for bathing. The wheelchair was coded as the primary mode of transportation. The resident was assessed frequently incontinent of bowel and bladder. The resident was coded to frequently experience pain in the last 5 days of the assessment period. The numeric pain rating scale from 00-10 (zero being no pain and ten as the worst pain) was left blank. One of the medications coded as received 5 of the last 7 days or since admission was an opioid.
Resident #254's care plan date 3/17/21 indicated the resident needed to be monitored for pain and discomfort, and to give analgesics as ordered. The care plan also indicated to document frequency, severity and location of pain.
Resident #254 had physician's orders for pain management with opioid medications dated 3/18/21 at 12:06 p.m. for *Tramadol HCL tablet 50 milligrams (mg), 1 tablet by mouth three times a day scheduled at 9:00 a.m., 1:00 p.m. and 5:00 p.m., and *Oxycodone HCL 5 mg, 1 tablet 30 minutes before wound care.
*Tramadol HCL is a DEA Schedule IV drug, defined as drugs with a low potential for abuse and low risk of dependence, used to relieve moderate to moderately severe pain. Tramadol is in a class of medications called opiate (narcotic) analgesics (Retrieved on 4/12/21 from reference https://pubchem.ncbi.nlm.nih.gov/compound/63013).
*Oxycodone HCL is a DEA controlled drug opiate (narcotic) and a DEA Schedule II controlled substance. Substances in the DEA Schedule II have a high potential for abuse which may lead to severe psychological or physical dependence. It is widely used for acute or chronic management of moderate or moderately severe pain (Retrieved on 4/12/21 from reference https://pubchem.ncbi.nlm.nih.gov/compound/Oxycodone).
Resident #254's pain management program was reviewed during the course of a complaint investigation. On 4/7/21 at 2:50 p.m., the Director of Nursing (DON) presented a copy of the Controlled Medication Utilization Record (CMUR) for the Tramadol which reflected the pharmacist narcotic was administered 9 times with 21 as the amount remaining on the CMUR. The Medication Administration Record (MAR) indicated 9 Tramadol of the 30 tablets sent from the pharmacy were administered to Resident #254. When asked where she obtained the CMUR, she stated from the locked cabinet in her office and she maintains the keys. This surveyor (D) asked to see the actual remaining Tramadol that matched the CMUR, as well as the remaining Oxycodone HCL that matched its CMUR. According to the MAR, 4 Oxycodone HCL of the 7 tablets sent from the pharmacy were administered to the resident which would stand to reason, 3 would be the remaining amount. In the presence of Assistant Director of Nursing (ADON), Unit I and IV Licensed Practical Nurses (LPN) and the Corporate Registered Nurse (CRN), the DON proceeded to the locked cabinet. Twenty-One Tramadol tablets were visible through the blister card pack that matched the CMUR. After an exhaustive search of all 13 medications in the pad locked cabinet, neither the 3 remaining Oxycodone HCL or its matching CMUR were located for Resident #254.
During the above review, the DON stated, I usually, on Friday's of every week, pick up all resident discharged /discontinued controlled medications from each cart's locked box on every unit and transfer them in a bag to the locked cabinet in my office. Those medications are destroyed once a month (usually last week of the month), depending on the amount of controlled drugs to be destroyed, with another nurse and the pharmacist via Zoom due to the Pandemic, but normally the pharmacist would be present otherwise. We have not destroyed any medications for the month of March. Resident #254 was discharged on 3/22/21 (Monday) which would make his discharged /discontinued controlled medications picked up by the DON and transferred to the locked cabinet in her office on Friday 3/26/21. Neither the DON or the Corporate Registered Nurse could explain the whereabouts of Resident #254's remaining Oxycodone HCL and its matching CMUR.
The Corporate Registered Nurse stated they checked the medical records department since the resident was discharged to determine if the CMUR was filed in Resident #254's closed record documents with no success. She stated they also checked the shred box on Unit II and in the DON's office for the prescription label of the Oxycodone HCL that is torn off when entire medication on the blister pack was used, again with no success.
The Corporate Registered Nurse began immediate inservicing on 4/7/21 at 3:15 p.m. with the ADON and Unit Managers on Controlled Drug Disposal and Storage and Diversion of Drugs. These nurses were tasked to inservice 100% of all nursing staff. Inservicing was continued by them on 4/7/21 at 5:00 p.m.
On 4/7/21 at approximately 5:50 p.m., a debriefing was conducted with the Administrator, DON and [NAME] President of Operations. The Administrator stated the missing narcotics, specifically Oxycodone was serious and said, I am very upset and I contacted the police regarding the theft of these medications. We are drug testing all nursing staff. It was shared that although all nursing staff may test negative, Oxycodone was a popular street drug and could be sold at a high value amount.
On 4/8/21 at 1:15 p.m., an interview was conducted with LPN (L). She stated and wrote the following statement: I counted narcotics for (Resident #254's name) upon discharge (3/22/21). I placed narcotics, Tramadol and Oxycodone, and sheets together in narcotic box (on unit II) to the side. No discrepancies with count .At all times if there are discharge narcotics in the lock box, they are counted every shift with 2 nurses. If any discrepancies with count including discharge medications the DON is alerted. During the conversation, LPN (L) said when the discharge controlled drugs are picked up by the DON, they are counted with the DON, but there is no record of that count. She said, They are taken to the DON's office and placed in a locked drawer until destroyed with two nurses and the pharmacist.
Review of the Controlled Drug Count Sheet with the Corporate Registered Nurse evidenced on 3/19/21 Resident #254's controlled medications were delivered and the count correct at the begining and end of every shift as signed by two nurses through he entire month of March 2021.
On 4/8/21, at the Corporate Registered Nurse forwarded a Facility Reported Incident (FRI) to the physicians, as well as the local, State agencies and law enforcement for misappropriation of resident property. The facility indicated Resident #254 had 7 Oxycodone 5 mg tablets delivered to the facility on 3/19/21. According to the Medication Administration Record (MAR) he was administered 4 tablets, one each day prior to wound care. He was discharged on 3/22/21 and the administration records noted he should have had 3 tablets remaining. The FRI indicated that the nurse implicated in the missing narcotics was LPN (C), but according to the LPN's written statement, she went on vacation 3/19/21 and returned 3/24/21, after the resident was discharged from the nursing facility. In addition, LPN (L) in her aforementioned written statement and during interview stated, she discharged the resident on 3/22/21 and the count at that time revealed no discrepancies for both the Tramadol and the Oxycodone. The facility was unable to locate the Oxycodone or the controlled drug count record/CMUR.
On 4/8/21 at approximately 6:15 p.m., a final debriefing was conducted with the Administrator, the DON and the [NAME] President of Operations. It was shared that although a count takes place between a licensed nurse on that unit at the time of the removal of discharged controlled drugs from the various unit lock boxes, there was no record of that count between the DON or the second nurse. The Administrator stated that was something they needed to implement. No further information was provided prior to survey exit.
2. Resident #304 was admitted to the nursing facility on 3/17/21 with a primary diagnosis of aortic value disorders and physician orders for Intravenous (IV) antibiotic therapy related to infection of the heart valve. The resident signed out Against Medical Advice (AMA) on the same day he was admitted , 3/17/21 at 10:50 p.m.
The resident was not in the facility long enough for initiation of a Minimum Data Set (MDS) assessment or a 48 hour care plan. The nurse's notes dated 3/17/21 indicated the resident arrived to the facility at 5:15 p.m. alert and oriented time 4 (person, place, time and situation).
Based on concerns from a complaint investigation involving another resident, this surveyor (D) requested to filter by the drug Oxycodone 5 mg to determine if any other resident in the month of March 2021 had physician orders for the same narcotic. Resident #304 had admission physician orders dated 3/17/21 at 5:45 p.m. for *Oxycodone HCL 5 mg tablets, 1 tablet by mouth every 6 hours as needed (prn) for pain. According to pharmacy proof of delivery summary, 12 tablets of this medication was delivered to the nursing facility on 3/17/21 at 10:23 p.m., signed as received by Licensed Practical Nurse (LPN) (C). According to the Medication Administration Record (MAR) none of the Oxycodone 5 mg were administered prior to the resident leaving AMA.
On 4/7/21 at approximately 2:50 p.m., the DON stated, I usually, on Friday's of every week, pick up all resident discharged /discontinued controlled medications from each cart's locked box on every unit and transfer them in a bag to the locked cabinet in my office and she maintains the keys. Those medications are destroyed once a month (usually last week of the month), depending on the amount of controlled drugs to be destroyed, with another nurse and the pharmacist via Zoom due to the Pandemic, but normally the pharmacist would be present otherwise. We have not destroyed any narcotics for the month of March. Resident #304's medications would have been secured in the controlled medication's lock box of the medication cart on 3/17/21. This medication would be counted every shift with no reported decrepitates and picked up Friday 3/19/21 and placed in the DON's locked cabinet in her office. In the presence of Assistant Director of Nursing (ADON), Unit I and IV Licensed Practical Nurses (LPN) and the Corporate Registered Nurse (CRN), the DON proceeded to the locked cabinet. During a count of all medications in the DON's locked cabinet, neither Resident #304's Oxycodone HCL tablets blister card pack or its matching Controlled Medication Utilization Record (CMUR) were located, but a second medication *Gabapentin 45 tablets and its CMUR was accounted for in the locked cabinet. Neither the DON or the Corporate Registered Nurse could explain the whereabouts of Resident #304's full script of 12 un-administered Oxycodone HCL and its matching CMUR.
*Gabapentin is approved to treat neuralgia and epilepsy with partial-onset seizures and is a Scheduled V controlled substance and defined as drugs with lower potential for abuse (Retrieved on 4/12/21 from reference https://www.dea.gov/drug-scheduling and https://pubmed.ncbi.nlm.nih.gov/33674205/).
On 4/8/21, at the Corporate Registered Nurse forwarded a Facility Reported Incident (FRI) to the physicians, as well as the local, State agencies and law enforcement for misappropriation of resident property. The facility indicated Resident #304 had 12 Oxycodone 5 mg tablets delivered to the facility on 3/17/21. According to the Medication Administration Record (MAR) none of the 12 tablets of Oxycodone was administered to the resident. According to the nurse's notes, Resident #304 signed out AMA the same day he was admitted [DATE] at 10:50 p.m.
The FRI indicated that the nurse implicated in the missing narcotics was LPN (C), because she had received the medication from the courier, but failed to have two nurses sign the medications into the building per the facility's policy. LPN (C) written statement indicated she had completed the admission for Resident #304 on 3/17/21. She wrote that the resident had a hard script for Oxycodone 5 mg and she called the pharmacy to attempt to cancel all medications due to the resident telling her he may sign himself out AMA, but the medications were processed to come to the nursing facility. The statement indicated she received the medications and per policy signed in his medications and reconciliation sheet, but accepted the controlled medications without a second signature. She documented the count was completed at the end of her shift for Oxycodone and Gabapentin without any discrepancies. She left for vacation on 3/19 and returned to work on 3/24/21. The facility was not able to explain why the 45 Gabapentin tablets and its matching CMUR was in the DON's locked cabinet drawer, but not the 12 Oxycodone or the matching controlled drug count record/CMUR.
On 4/8/21 at approximately 6:15 p.m., a final debriefing was conducted with the Administrator, the DON and the [NAME] President of Operations. It was shared that although a count takes place between a licensed nurse on that unit at the time of the removal of discharged controlled drugs from the various unit lock boxes, there was no record of that count between the DON or the second nurse. The Administrator stated that was something they needed to implement. No further information was provided prior to survey exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected 1 resident
Based on 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-w...
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Based on 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 look back indicated the following:
1.) On 03/14/21, Registered Nurse (RN-A) worked a total of 7.68 hours out of a scheduled 8 hour shift.
2.) On 04/03/21, (RN-B) worked a total of 7.31 hours out of a scheduled 8 hours shift.
A pre-exit conference was conducted with the Administrator, Director of Nursing (DON) and Corporate Nurse on 04/07/21 at 6:30 p.m. During that time, the Administration team were made aware that the facility did not have 8 hours of RN coverage on 03/14/21 and 04/03/21.
A phone interview was conducted with the (DON) on 04/08/2021 at approximately 8:27 a.m. When asked about the facility not having 8 hours of RN coverage on 03/14/21 and 04/03/21, the DON replied, My first time hearing about the nurses not working a full 8 hour shift was yesterday, 04/07/21. The DON stated, I expect for the RN providing coverage to work their full 8 hour shift.
A pre-exit conference was conducted with the Administration team on 04/08/21 at approximately 5:30 p.m. No further information was provided 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
Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide an accurate record of controlled medications and provide safekeep...
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Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide an accurate record of controlled medications and provide safekeeping of hard scripts for controlled drugs, for 3 Residents (Resident #28, #32, and #102) in a survey sample of 40 Residents.
1. For Resident #28, the facility staff failed to maintain an accurate inventory of controlled medications.
2. For Resident #32, the facility staff failed to maintain an accurate inventory of controlled medications.
3. For Resident #102, the facility staff failed to provide safekeeping of hard scripts for controlled drugs, to prevent drug diversion.
The findings included:
1. For Resident #28, the facility staff failed to maintain an accurate inventory of controlled medications.
On 4/7/21 at 1:35 PM, a review of the medication storage of the unit 2 back hall medication cart was performed by Surveyor A, who was accompanied by LPN A, the unit manager. This review revealed the following:
The controlled drug count sheet was compared to the actual medication count and there were a total of 2 discrepancies found as follows:
Resident #28, Tramadol, count per record=15, actual count=14
LPN A confirmed the count was inaccurate according to the Controlled Drug Count Sheet. LPN A stated, it wasn't signed out at 9 AM.
2. For Resident #32, the facility staff failed to maintain an accurate inventory of controlled medications.
On 4/7/21 at 1:35 PM, a review of the medication storage of the unit 2 back hall medication cart was performed by Surveyor A, who was accompanied by LPN A, the unit manager. This review revealed the following:
The controlled drug count sheet was compared to the actual medication count and there were a total of 2 discrepancies found as follows:
Resident #32, Tramadol, count per record=9, actual count=8
LPN A confirmed the count was inaccurate according to the Controlled Drug Count Sheet. LPN A stated, it wasn't signed out at 9 AM.
On 4/7/21 at 1:43 PM, an interview was conducted with LPN H, the nurse assigned to the unit 2 back hall medication cart. LPN H stated, I didn't sign it out this morning when I gave it. When LPN H was asked when she should have signed the Controlled Drug Count Sheet she stated, I should have signed it after they took it, I got distracted and forgot to come back and do it, I am sorry.
On 4/8/21 at 2:09 PM, an interview was conducted with Employee B, the facility Director of Nursing (DON). The DON was asked by Surveyor A, when she expects medications to be signed out, the DON stated, when the meds are given.
Review of the facility pharmacy policy titled General Dose Preparation and Medication Administration read, 5.5 document the administration of controlled substances in accordance with applicable law. 6. After medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: 6.1 document necessary medication administration information (e.g., when medications are opened, when medications are given ) on appropriate forms.
The Facility Administrator (Employee A) was informed of the findings and no further information was provided.
3. For Resident #102, the facility staff failed to provide safekeeping of hard scripts for controlled drugs, to prevent drug diversion.
On 4/7/21, during review of Resident #102's clinical chart an original hard script for Percocet 5 mg-325 mg tablets was noted.
04/07/21 at 09:44 AM, an interview was conducted with LPN A, the unit manager. When LPN A was asked what is the process when admissions come in and have hard scripts for narcotics, LPN A stated, when someone comes back from the hospital we call the doctor immediately, tell them about the resident, give the medication list before we put in anything, once they approve, we take the hard script and fax to the pharmacy and the pharmacy will either send it. We have a baggie that is for prescriptions that get sent to the pharmacy. Surveyor A asked if hard scripts for narcotics are to be in the clinical chart, LPN A stated, no. When asked what is the associated risk of having them in chart usually the pharmacy needs them to verify, they need the hard script. Surveyor A asked what would prevent someone from taking the prescription down to a local pharmacy and having it filled, LPN A stated that is true, nothing really. Hopefully they have better morals than that. LPN A was shown the script for Percocet 5-325 in Resident #102's chart and was asked, should it be in the chart no ma'am whenever we fax it, we have a bag where we put the hard script and send it back with them.
On 4/8/21 at 2:09 PM, an interview was conducted with the facility Director of Nursing (DON). The DON stated, hard scripts should be faxed to the pharmacy, draw a line through it and put it in the bag for the pharmacy. I already know about it. When asked if someone could take the prescription to a retail pharmacy and have it filled if it is left in the chart, the DON stated, yup, we got tagged for that a few years back.
On 4/8/21, during an end of day meeting the Facility Administrator and DON were made aware of the findings.
No further information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
Based on resident interview, staff interviews, clinical record review, and review of facility documents, the facility's staff failed to obtain routine dental services for 1 of 40 residents (Resident #...
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Based on resident interview, staff interviews, clinical record review, and review of facility documents, the facility's staff failed to obtain routine dental services for 1 of 40 residents (Resident #52), in the survey sample.
The findings included:
Resident #52 was originally admitted to the facility 4/20/20 and had never been discharged from the facility. The current diagnoses included; high blood pressure, atrial-fibrillation and a seizure disorder.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/1/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #52's cognitive abilities for daily decision making were intact.
In section L (Dental) the resident was coded as having obvious or likely cavities or broken natural teeth.
On 4/7/21 an interview was conducted with Resident #52. The resident stated he had been seen by the dentist last August and the plan was to have thirteen teeth extracted for they were not repairable and would eventually cause additional pain if not extracted. Resident #52 further stated he was experiencing minor discomfort, not pain but it was his preference to have the dental concerns taken care of before complications like the abscess occurred again. The resident then stated at the time of this conversation the facility's staff had not arranged his follow-up dental appointment.
Review of the clinical record revealed on 8/18/20, Resident #52 was started on an antibiotic for dental caries and an oral abscess.
The dental progress note dated 8/31/20 revealed the resident was seen by the dentist because of pain of the bottom teeth and the treatment would require a dental cleaning procedure, restoration with a resin composite of tooth # 29, 1, 2, 4, 17 and 10, extractions of #18, 19, 20, 21, 22, 26, 27, 23, 24, 25, 2, 7 and 13.
Resident #52 returned to the facility on 8/31/20, after the dental consultation, with a letter of financial approval for the planned services and a document for medical clearance prior to beginning the restoration, use of a local anesthetic and extractions of the unrestorable teeth.
On 9/1/20, the Nurse Practitioner signed the resident was cleared to proceed with the dental treatment plan but the services were not scheduled with the dental office.
On 4/8/21 at approximately 10:30 a.m., an interview was conducted with the Business Development Coordinator for the facility. This team member assisted residents to coordinate outside dental services. The Business Development Coordinator stated because of the pandemic and the procedure was not considered essential by policy, the appointment had not been scheduled. The Business Development Coordinator further stated on 4/8/21 the dental services for Resident #52 had been scheduled for 4/19/21.
On 4/8/21 at approximately 5:00 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultants. The facility's staff presented no additional information.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and facility document review, it was determined that facility staff failed to provide a ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and facility document review, it was determined that facility staff failed to provide a safe environment in 1 bathroom on 1 of the facility's 4 units.
The findings included:
On 4/6/21 at 11:15 a.m., during the orientation tour through 4/8/21 at 3:15 p.m., the ceiling panels in the bathroom of room [ROOM NUMBER] were observed loose, bowed and unstable.
The aforementioned finding was brought to the attention of the Administrator during an end of day debriefing on 4/7/21 at approximately 5:50 p.m. She stated she would have the maintenance inspect all bathrooms and ensure all necessary repairs were made.
On 4/8/21 at approximately 3:15 p.m., Surveyor (D) took the Maintenance Director to room [ROOM NUMBER]. He stated he repaired a ceiling track of a bathroom on the 200 Unit and was never made aware by the Administrator or the maintenance team of the needed repairs in the 301 bathroom. He stated, the housekeeping staff push broom handles up into the ceiling tiles when they are mopping and dislodge them. He made the necessary adjustment and stated he will discuss the matter with the Housekeeping Director.
On 4/8/21 at approximately 6:15 p.m., the Administrator stated she had toured the rooms and saw the bowed ceiling and it was repaired on 4/7/21. It was brought to her attention that the ceiling in room [ROOM NUMBER]'s bathroom was not fixed until 4/8/21 at approximately 3:30 p.m.
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** 3. The facility staff failed to provide housekeeping services to maintain a clean living environment for 2 Resident rooms (room ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The facility staff failed to provide housekeeping services to maintain a clean living environment for 2 Resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) on the 200 unit.
On 4/6/21, during initial tour of the facility at approximately 11:30 AM, the following was observed:
* room [ROOM NUMBER] in the window sill had crumbs of bacon and a yellow substance that appeared to be scrambled eggs.
* room [ROOM NUMBER] had a copious amount of dust and debris under the bed, a used surgical mask in the floor and a q-tip under the bed. Dust and debris build-up was noted around the edges of all furniture and the room walls.
On 4/7/21 at 9:30 AM, observations were made of rooms #206 and #209. The observations revealed the following:
* room [ROOM NUMBER] still had crumbs of bacon and a yellow substance throughout the window sill that appeared to be scrambled eggs. The Resident in room [ROOM NUMBER] stated, they never come in here to clean, sweep or mop, when asked about the frequency of cleaning.
* room [ROOM NUMBER] still had a copious amount of dust build-up throughout the room around furnishings, under the beds, and around the wall edges. A used surgical mask was noted to still be in the floor where observed on 4/6/21, and the q-tip still under the bed.
On 4/8/21 at 11:42 AM, Surveyor A went to room [ROOM NUMBER] and observed the yellow debris/substances still in the window sill.
On 04/07/21 at 09:51 AM, Employee C, a housekeeper was interviewed. When asked about the cleaning of Resident rooms, Employee C stated, we clean all of the rooms every day. We wipe down the bathroom and walls, sweep, mop and sweep under the beds and take out the trash. Employee C was asked if he feels the Resident rooms and facility are clean, he stated, I feel like it is pretty clean. Surveyor A asked Employee C about the frequency of deep cleaning, he said we remove everything twice a week, we take everything out including the dressers wheel chairs, etc. we put them in areas in the hall and clean the entire room.
On 04/07/21 at 11:44 AM, an interview was conducted with Employee D, the regional housekeeping supervisor. When asked how often Resident rooms are cleaned, Employee D stated, every day. When asked what this includes, Employee D said, the floors, bathroom, surfaces, and trash cans. Each room is deep cleaned [all items removed and cleaned from top to bottom], once every 30 days.
On 4/7/21, during an end of day meeting, the facility staff, to include the Administrator and Director of Nursing were made aware of the findings of the rooms on wing 2 to not be clean and sanitary.
On 4/8/21 at approximately 8:30 AM, the facility Administrator advised Surveyor A that wing 2 will look different today, we did a lot of cleaning. When Surveyor A asked the Administrator of her findings of the cleanliness of wing 2, she stated, it needed some work, but it is all taken care of.
On 4/8/21 at 10:23 AM, an interview was conducted with Employee I, the housekeeping supervisor. Employee I stated, Resident rooms are cleaned everyday. When asked to describe what the daily cleaning in Resident rooms entails he stated, high and low dusting, sweeping and mopping floors, cleaning the bathroom toilet, sinks, floors, basin of the commode, wipe down stains on the walls and empty the trash. When asked how he monitors and ensures the Resident rooms are kept clean, Employee I stated, we do QCI [quality control inspections]. When asked what the results of those inspections showed, Employee I stated, last week some were good and some were bad.
Employee I was asked, if he found the conditions of Resident rooms to be acceptable, Employee I stated, no. Surveyor A asked if he saw a build up of dust and debris, Employee I stated, yes. Employee I was asked if it appeared the rooms had been cleaned daily, Employee I said, yes, but the process was skipped. Surveyor A asked Employee I if he was comfortable with Residents living in the conditions he observed, Employee I stated, no. Employee I stated that windows are cleaned 3 times per week, we missed some areas, but what was found has been fixed.
On 4/8/21 at 11:45 AM, Employee I, the housekeeping supervisor, accompanied Surveyor A to room [ROOM NUMBER]. Surveyor A asked Employee I what he observed in the window, Employee I said some type of debris, we didn't lift it [the window blinds] up.
On 4/8/21 at approximately 11:55 AM, Employee D, the regional housekeeping manager was interviewed by Surveyor A on the 200 unit. Employee D was asked about his observations of the Resident rooms on that unit and throughout the facility following the survey team expressing concerns on 4/7/21. Employee D stated, the sticky floor couldn't be resolved with mopping, we had to scrub it with the machine. When asked about the build up of dust and debris throughout the rooms, Employee D acknowledged the facility staff had failed to follow the process.
On 4/8/21, the facility Administrator provided the survey team with a document titled, 5-Step Daily Patient Room Cleaning. This document read, Purpose: To show housekeeping employees the proper cleaning method to sanitize a patient's room or any area in a healthcare facility. 5-step patient room cleaning procedure: 1. Empty Trash .2. Horizontal Surfaces as you enter the room, work clockwise around the room hitting all surfaces. Table tops, head boards, window sills, chairs- should all be done. 3. Spot clean walls .4. Dust mop. The entire floor must be dust mopped- especially behind dressers and beds .move all furniture to dust mop. All corners and along all baseboards must be dust mopped to prevent buildup .
On 4/8/21, during the end of day meeting the facility Administrator and Director of Nursing were made aware of the findings.
No further information was received.
2. The facility's staff failed to maintain a clean, sanitary and homelike environment in room [ROOM NUMBER].
During the initial tour on 4/6/21, at approximately 2:10 p.m., room [ROOM NUMBER] was observed to have an extremely sticky substance in the middle of the floor and in the area where the resident was seated. The stickiness was so severe it adhered your shoes to the floor and resulted in much effort to lift ones feet. Further observation of room [ROOM NUMBER]'s floor revealed food particles, brown stains and other debris. There was also a permeating odor.
On 4/7/21, again in room [ROOM NUMBER], at approximately 10:10 a.m., the middle of the floor and in the area in which the resident sat in the wheel chair revealed a sticky substance, discoloration, crumbs, food and debris as well as a strong odor of uncleanliness.
An interview was conducted with Resident #94 on 4/7/21 at approximately 10:58 a.m. Resident #94 stated no one does anything here for you. The resident wouldn't elaborate on the statement.
On 4/7/21 at approximately 11:08 a.m., the Environmental Services Manager was interviewed about the above conditions observed in room [ROOM NUMBER] over the two days. The Environmental Services Manager stated the specific room was considered a hot room; which indicated it required additional attention/services because of the untidy habits of the resident.
On 4/8/21 at approximately 11:05 a.m., the middle of the floor of room [ROOM NUMBER] was less sticky but continued with stickiness, uncleaned spills and discoloration. No particles of food were present and the smell of uncleanliness was diminished but not eradicated.
Review of Resident Council grievances for 12/29/20, revealed the following concerns: Housekeeping has not cleaned my room for three days, My room is not being cleaned on a regular basis, Resident would like a new trash bag and floor care, Housekeeping does not clean my room on the weekend, and Housekeeping has not come to my room to clean in a couple of days, Housekeeping is not coming in my room, scrubbing/mopping the floors. They are just getting the trash and leaving. The reply to the grievances was, It has been addressed or done.
On 4/8/21 at approximately 5:00 p.m., the above findings were shared with the Administrator, Director of Nursing and two Corporate Consultants. The Administrator stated she was aware of general environmental concerns and had reached out to the corporate office and the Environmental Services Manager regarding her concerns and methods to resolve the concerns.
Based on observations, staff interviews and facility document review, it was determined that facility staff failed to ensure a clean comfortable and homelike environment on 3 of 4 units, unit's 200, 300 and 400.
The findings include:
1. On 4/6/21 at 11:15 a.m. through 4/7/21 at 4:00 p.m., the following rooms represented the facility's failure to maintain a clean and comfortable homelike environment in the following rooms on the 300 and 400 unit:
-In room [ROOM NUMBER] Heavy accumulations of dust, dirt, debris and unidentified food items were identified up against and behind the 5 chest, as well as under both beds. The base of the two over bed tables possessed spillage from liquids and food.
-In room [ROOM NUMBER]-A A urinal with yellow substance inside was wedged against the wall and the wheel of the resident's bed. A prominent urine odor permeated the room. The resident had a urinal on his over bed table that he said he was currently using. This urinal was observed removed on 4/8/21 after brought to the facility's attention on 4/7/21 at approximately 5:00 p.m.
-In room [ROOM NUMBER]-B Heavy accumulations of dust, dirt, debris and unidentified food items were identified up against and behind the chest, as well as under his bed. He stated no one ever addressed making an appointment with him to have him present in order to move his personal items and clean his room. He stated he would have no problem with that arrangement.
-In room [ROOM NUMBER]-B Heavy accumulations of dust, dirt, debris and unidentified food items were identified up against and behind the 5 chest, as well as under his bed. Fruit-loops cereal was most identifiable food item under his bed, along the parenteral of his area, as well as behind and under his chest. He stated no one ever addressed making an appointment with him to have him present in order to move his personal items and clean his room. He stated he would have no problem with that arrangement.
-In room [ROOM NUMBER]-A Heavy accumulations of dust, dirt, debris and unidentified food items were identified up against and behind the chest, as well as under the bed. Although this resident was in his wheelchair, an unidentified black substance was observed on the floor around the front wheels of another wheelchair that was positioned between the A and B bed.
-In room [ROOM NUMBER]-B Heavy accumulations of dust, dirt, debris and unidentified food items were identified up against and behind the 5 chest, as well as under the bed. Heavy accumulations of dust were observed on his window blinds with cobwebs between the blinds and window. He stated no one ever addressed making an appointment with him to have him present in order to move his personal items and clean his room. He stated he would have no problem with that arrangement.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected multiple residents
Based on observation, staff interview and facility documentation review, the facility staff failed to implement their abuse policy with regard to employee screening for 9 Employees (CNA C, CNA D, CNA ...
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Based on observation, staff interview and facility documentation review, the facility staff failed to implement their abuse policy with regard to employee screening for 9 Employees (CNA C, CNA D, CNA E, CNA F, CNA G, LPN D, LPN E, LPN F, LPN G) in a survey sample of 25 employee records.
The findings included:
The facility staff failed to implement their abuse policy to screen employees prior to hire.
On 4/8/21, a review was conducted of a sample of 25 employee records. This review was conducted with Employee J, the human resources coordinator. The review revealed the following:
1. The facility staff failed to check references prior to employment for 8 employees CNA C, CNA E, CNA F, CNA G, LPN D, LPN E, LPN F, LPN G.
2. The facility staff failed to verify employee license prior to hire for 4 employees CNA F, CNA G, LPN D, LPN E.
3. The facility staff failed to obtain a Criminal Background check with the within 30 days of hire for 8 employees CNA C, CNA D, CNA E, CNA F, CNA G, LPN E, LPN F, LPN G.
On 4/8/21 at 8:55 AM, Surveyor A sat with Employee J, the Human Resources Coordinator. The employee file findings for the above noted employees was confirmed by Employee J. Employee J made note of the missing documents and agreed that if she found any of the missing items she would provide them to Surveyor A. No additional information was received prior to the survey team exit at 6:15 PM.
On 4/8/21 at 12:07 PM, Surveyor A met with the Facility Administrator to review the findings. Surveyor A let the Administrator know that if any additional items were found they could be provided to Surveyor A. No additional information was received prior to the survey team exit at 6:15 PM.
On 4/8/21, review of the facility policy titled, Abuse, Neglect, Exploitation & Misappropriation was conducted. Page 5 read, 1. Screening. Persons applying for employment within the center will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. This includes but is not limited to: * employment history, *criminal background check, * abuse check with appropriate licensing board and registries, prior to hire, * licensure or registration verification prior to hire, * documentation of status of any disciplinary actions from licensing or registration boards and other registries, * information from former employers. The center will ensure that all prospective consultants, contractors, volunteers, caregivers, and students are pre-screened as required by law.
The Administrator and Director of Nursing (DON) were made aware of the findings again on 4/8/21 during the end of day meeting.
No further information was received.
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** 3. The facility staff failed to provide proper screening for visitor/vendor entry into the facility.
On 4/6/21 at approximately ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The facility staff failed to provide proper screening for visitor/vendor entry into the facility.
On 4/6/21 at approximately 11:15 AM, Surveyors A, D, F, I, and J arrived at the front door of the facility which was locked. Surveyor A pushed a button located on the outside of the facility near the front door, heard a buzzer that unlocked the door, and entered the facility into the front lobby along with the other 4 Surveyors. The Survey Team was immediately greeted by the Receptionist (Employee M) who was sitting at a desk in the front lobby. Surveyor A identified the members of the Survey Team, stated the purpose for the visit, and asked to meet with the Facility Administrator.
The Survey Team waited approximately 5 minutes in the front lobby without receiving any COVID screening by Employee M. The Facility Administrator and Director of Nursing arrived at the front lobby and escorted the Survey Team to a conference room located on the first floor at the end of the hall on Nursing Unit 1.
On 4/7/21 at 4:27 PM, Surveyor A conducted an interview with Employee L, Administrative Assistant/Receptionist. Employee L stated the facility has been allowing visitors for about 2 weeks and described the process stating, they [visitors] fill out the visitor screening form, I take their [the visitor's] temperature, make sure they have their mask on and sanitize their hands. When asked if this process is the same for anyone that enters, Employee L stated, yes. Surveyor A asked if there was any reason the survey team would not be screened upon entry and Employee L stated, no, I screened everyone [the survey team members] today, I wasn't here when y'all [the survey team] arrived yesterday. Employee L stated that Employee M was working the reception desk at the time the survey team arrived the previous day.
On 4/7/21 at approximately 4:40 PM, Surveyor A conducted an interview with Employee M. Employee M stated she has worked at the facility since May 2020. When asked why the survey team was not screened upon entry on 4/6/21, Employee M stated, This is the first time I've ever worked here when y'all [survey team] come in, I know I was supposed to screen y'all, they had said we didn't have to get your COVID results and I got confused and just froze, I'm sorry.
On 4/7/21 at approximately 5:30 PM, Surveyor A informed the Facility Administrator of the absence of COVID screening when the Survey Team arrived on 4/6/21. The Facility Administrator stated, the Survey Team should have been screened upon entrance into the facility. Facility documents with regard to the visitor/vendor screening process were requested and received.
Review of the facility's policy titled, COVID-19 Pandemic Plan, revised 3/30/2021, Policy, item 4 stated, Receptionist/designee will provide visitor/vendor self-report questionnaire to complete.
The Centers for Disease Control and Prevention (CDC) provided guidance in the document entitled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated February 23, 2021, subheading Screen and Triage Everyone Entering a Healthcare Facility for Signs and Symptoms of COVID-19, item 3 read, Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19, or exposure to others with suspected or confirmed SARS-CoV-2 infection and that they are practicing source control [facemasks, hand hygiene]. This information was accessed online at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-contol-recommendations.html on 4/12/21.
The Facility Administrator and DON were made aware of the findings during the end of day meeting held on 4/7/21. No further information was provided.
Based on observation, staff interview, and facility documentation, the facility staff failed to maintain infection control practices in accordance with the Center for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommendations to prevent the spread of COVID-19 for 2 Residents (Resident #555 and #102) and 2 of 5 areas of the facility.
1. The facility staff failed to implement transmission based precautions (TBP) for Resident #555, who was a new admission to the facility.
2. The facility staff failed to implement transmission based precautions (TBP) for Resident #102, who was a new admission to the facility.
3. The facility staff failed to provide proper screening for visitor/vendor entry into the facility.
4. The facility staff failed to ensure personal protective equipment was properly worn.
The findings included:
1. The facility staff failed to implement transmission based precautions (TBP) for Resident #555, who was a new admission to the facility.
Resident #555 was admitted to the facility on [DATE]. Diagnoses for Resident #555 included, but were not limited to: acute metabolic encephalopathy, seizure disorder, hypertension, hypokalemia, hepatocellular carcinoma and hepatitis-C cirrhosis.
For Resident #555 the facility had not had time to complete a minimum data set (MDS) (an assessment tool). However, nursing staff recorded in the clinical record that Resident #555 required staff assistance with activities of daily living, to include bathing, dressing, toileting and ambulation.
On 4/6/21, upon the survey team entry to the facility, the facility Administrator identified unit 2 is our observational unit for COVID-19.
On 4/6/21 at approximately 11:30 AM, upon Surveyor A's initial tour of unit 2 Resident #555 was observed in her room, in bed. There was no sign on the room door to indicate Resident #555 was on TBP. There was no personal protective equipment (PPE) noted outside of the room of Resident #555.
On 4/6/21 and 4/7/21, facility staff to include nursing staff and housekeeping staff were observed to enter the room of Resident #555, only wearing a surgical mask. None of the staff put on any additional PPE prior to entering the room.
2. The facility staff failed to implement transmission based precautions (TBP) for Resident #102, who was a new admission to the facility.
Resident #102 was admitted to the facility on [DATE]. Diagnoses for Resident #102 included, but were not limited to: type 2 diabetes, metastatic prostate cancer and chronic deconditioning.
Resident #102's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 3/27/21, was coded as an admission assessment. Resident #102 was coded on this assessment as having had a BIMS (brief interview for mental status) score of 8, of a possible 15. This indicated Resident #102 was moderately impaired in cognition. Resident #102 was also coded on this assessment as having required the assistance of at least one staff member for transfers, dressing, personal hygiene and bathing. This same assessment was coded in section O, to indicate Resident #102 had not been on any type of isolation for infectious disease(s).
On 4/6/21, upon the survey team entry to the facility, the facility Administrator identified unit 2 is our observational unit for COVID-19.
On 4/6/21 at approximately 11:45 AM, upon Surveyor A's initial tour of unit 2 Resident #102 was observed sitting in his wheelchair in the hallways outside of his room. There was no sign on Resident #102's room door, to indicate Resident #102 was on TBP. There was no personal protective equipment (PPE) noted outside of the room of Resident #102.
On 4/6/21 and 4/7/21, facility staff to include nursing staff and housekeeping staff were observed to enter the room of Resident #102, only wearing a surgical mask. No additional PPE was donned [put on], prior to entering the room, by any staff. No PPE was available outside of the room for staff.
On 4/7/21, during an end of day meeting the facility Administrator was asked to clarify what the purpose of the observational unit was, because nothing indicated unit 2 was any different from other units within the facility. Surveyor A explained that staff are not wearing any different PPE on unit 2. The Administrator said she would need to check and get back to the survey team.
On 4/8/21 at approximately 8:30 AM, upon Surveyor A's entry to the facility, the Administrator called Surveyor A into her office. The Administrator stated, she and the Director of Nursing were on a conference call a few weeks ago and were confused and had mistaken that admissions needed to be on precautions. The Administrator showed Surveyor A the CDC guidance that she had printed and said, we see we were wrong. The new admissions are now on precautions and staff are wearing PPE, unit 2 will look different today.
On 4/8/21, Employee P, the regional nurse consultant informed Surveyor A that the facility policy is that if a new admissions comes in staff are to wear a surgical mask, gown and gloves. If they [the Resident] is fully vaccinated they can go into a regular room and not on an observation unit. Only one of the new admits has received a COVID vaccine and she only received one, so she would have to be on precautions.
On 4/8/21, during observations on the 200 unit signs were noted outside of the room door for Resident #555 and Resident #102 which stated, STOP. CONTACT PRECAUTIONS EVERYONE MUST: clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. This document had the CDC logo at the bottom. There were PPE bins outside the rooms with isolation gowns and gloves.
Review of the facility policy titled, COVID-19 Pandemic Plan, with a revision date of 3/30/21, read, .17. the center will designate an area and cohort new admissions/re-admissions .Initiate transmission based precautions based on CDC guidance (standard, contact and droplet and eye protection). Including PPE. Respirator, (or facemask if respirators are not available) faceshield or eye protection, gown and gloves. The resident will remain in their room during this time. After 14 days the resident will be moved to a different room/area of the center.
The Centers for Disease Control and Prevention (CDC) guidance for nursing homes dated March 29, 2021, read, New Admissions and Residents who Leave the Facility: Create a Plan for Managing New Admissions and Readmissions . In general, all other new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission. Accessed online at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#new-admissions
The facility Administrator and Director of Nursing were made aware of the findings during an end of day meeting held on 4/7/21 and again on 4/8/21.
No further documentation was provided.
4. The facility staff failed to ensure personal protective equipment was properly worn.
On 04/08/2021 at approximately 12:00 PM, the [NAME] and Dietary Manager were observed standing in the kitchen by the steam table. The [NAME] was observed with her face mask under her nose, exposing her nose. The Dietary Manager was asked if staff were supposed to wear their face mask under their nose and the Dietary Manager replied, No, they are not. The Dietary Manager asked the [NAME] to step away from the steam table and correct the fit of her face mask. The [NAME] walked out of the kitchen and when she returned her face mask was covering her nose and mouth.
On 04/08/2021 at 1:40 PM, an interview was conducted with the Cook. When asked how should you wear your face mask, the [NAME] stated, over my nose and mouth. When asked were you wearing the face mask over your nose when checking the temperature of the food, the [NAME] stated, No. When asked the reason for wearing a face mask over your nose and mouth, the [NAME] stated, Because of the COVID and in case I should sneeze or something.
An interview was conducted with the Dietary Manager on 04/08/2021 at approximately 1:43 PM, when asked what are your expectations of staff when wearing their face mask, Dietary Manager stated, Make sure to cover the nose and mouth and if they need to readjust, they should walk outside and readjust, then wash their hands.
Review of facility document entitled, COVID-19 Pandemic Plan, dated 3/2/2020, Revised 03/30/2021, read, Policy: COVID-19 is a respiratory illness thought to be spread mainly from person to person, between people who come in close contact to one another (about 6 feet). The virus is spread through droplets produced when an infected person coughs or sneezes. Symptoms include fever, cough, shortness of breath, sore throat, vomiting, diarrhea, muscle pain, headache, new loss of taste or smell, chills and repeated shaking with chills and 2. Staff will be re-trained in Hand Hygiene and proper use of PPE (Personal Protective Equipment) including competency
The Administrator, Director of Nursing and Corporate Staff were informed of the finding on 04/08/2021 at approximately 6:45 PM. The facility did not present any further information.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "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
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 2 life-threatening violation(s), 1 harm violation(s), $80,132 in fines. Review inspection reports carefully.
- • 96 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $80,132 in fines. Extremely high, among the most fined facilities in Virginia. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: Trust Score of 0/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Forest Hill Health & Rehabilitation's CMS Rating?
CMS assigns FOREST HILL HEALTH & REHABILITATION 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 Forest Hill Health & Rehabilitation Staffed?
CMS rates FOREST HILL HEALTH & REHABILITATION's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 70%, which is 24 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 71%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Forest Hill Health & Rehabilitation?
State health inspectors documented 96 deficiencies at FOREST HILL HEALTH & REHABILITATION during 2021 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 93 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Forest Hill Health & Rehabilitation?
FOREST HILL HEALTH & REHABILITATION 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 HILL VALLEY HEALTHCARE, a chain that manages multiple nursing homes. With 174 certified beds and approximately 127 residents (about 73% occupancy), it is a mid-sized facility located in RICHMOND, Virginia.
How Does Forest Hill Health & Rehabilitation Compare to Other Virginia Nursing Homes?
Compared to the 100 nursing homes in Virginia, FOREST HILL HEALTH & REHABILITATION's overall rating (1 stars) is below the state average of 3.0, staff turnover (70%) 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 Forest Hill Health & Rehabilitation?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "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?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the facility's high staff turnover rate, and the below-average staffing rating.
Is Forest Hill Health & Rehabilitation Safe?
Based on CMS inspection data, FOREST HILL HEALTH & REHABILITATION has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Virginia. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Forest Hill Health & Rehabilitation Stick Around?
Staff turnover at FOREST HILL HEALTH & REHABILITATION is high. At 70%, the facility is 24 percentage points above the Virginia average of 46%. Registered Nurse turnover is particularly concerning at 71%. 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 Forest Hill Health & Rehabilitation Ever Fined?
FOREST HILL HEALTH & REHABILITATION has been fined $80,132 across 1 penalty action. This is above the Virginia average of $33,880. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Forest Hill Health & Rehabilitation on Any Federal Watch List?
FOREST HILL HEALTH & REHABILITATION 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.