BIRCHWOOD PARK REHABILITATION
For profit - Limited Liability company
150 Beds
EASTERN HEALTHCARE GROUP
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
0/100
#238 of 285 in VA
Photo by Birchwood Park Rehabilitation and Nursing
Photo by Birchwood Park Rehabilitation and Nursing
Photo by Birchwood Park Rehabilitation and Nursing
1 / 5 photos
Last Inspection: December 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Birchwood Park Rehabilitation has received a Trust Grade of F, indicating significant concerns and poor performance compared to other facilities. It ranks #238 out of 285 in Virginia, placing it in the bottom half of all nursing homes in the state, and #9 out of 13 in Virginia Beach City County, meaning there are only a few local options that may be better. Although the facility is on an improving trend, decreasing from 55 issues in 2024 to 6 in 2025, it still has a troubling history, including $127,257 in fines, which is higher than 95% of Virginia facilities and suggests ongoing compliance problems. Staffing is a mixed bag with a rating of 2 out of 5 stars and a turnover rate of 55%, which is about average for the state, while the RN coverage is better than 78% of facilities, indicating some strengths in nursing staff support. Specific incidents have raised concerns, such as staff failing to implement infection control measures, including not wearing masks properly, and a resident being involuntarily sequestered without meeting necessary criteria, which could lead to emotional distress. Families should weigh these strengths and weaknesses carefully when considering Birchwood Park Rehabilitation for their loved ones.
- Trust Score
- F
- In Virginia
- #238/285
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 55% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $127,257 in fines. Lower than most Virginia facilities. Relatively clean record.
- Skilled Nurses ○ Average
- Each resident gets 35 minutes of Registered Nurse (RN) attention daily — about average for Virginia. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 114 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 17%
Review needed
55 → 6 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★☆
4.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 55 issues
2025: 6 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
1-Star Overall Rating
Below Virginia average (3.0)
Significant quality concerns identified by CMS
Staff Turnover: 55%
Near Virginia avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $127,257
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: EASTERN HEALTHCARE GROUP
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (55%)
7 points above Virginia average of 48%
The Ugly 114 deficiencies on record
2 life-threatening 5 actual harm
Apr 2025
6 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
Resident Rights
(Tag F0550)
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 that Residents are tre...
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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 that Residents are treated resident with respect and dignity for 1 Resident (#111) in a survey sample of 29 Residents.
The findings included:
For Resident #111 the facility staff failed to ensure that Resident #111 was treated with respect and dignity during ADL incontinence care.
Resident #111 was admitted to the facility on [DATE]. Diagnoses for Resident #111 included but are not limited to fracture of right femur, aftercare following joint replacement surgery, benign prostatic hyperplasia, major depressive disorder, hx of fall, diabetes type 2, chronic kidney disease, hyperparathyroidism, and dysphagia. Resident #111 ' s Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 3/30/25 coded Resident #111 with a BIMS (Brief Interview of Mental Status) score of 15/15 indicating no cognitive impairment.
On 4/1/25 a review of the clinical record revealed the following progress notes:
3/20/25 11:46 a.m.: More than 2 episodes of Loose BM's. Resident stated he had an upset stomach this morning and is feeling better. [Nurse Practitioner name redacted] CRNP made aware of the above.
3/24/25 10:15 a.m. - Encounter for mental health services for victim of other abuse: Patient reports he was having frequent stools over the weekend. He reports the CNA had an attitude about having to change him frequently. He reports his CNA told him she could not keep coming in here and changing him. Patient denies any physical abuse, denies any injuries. Patient reassured that he is in a safe environment with people that are here to help him. Specifics of allegations reported to the unit manager. Patient unable to tell me specifically which day the event occurred or the name of the CNA.
On the afternoon of 4/3/25 an interview was conducted with the Social Worker, the Administrator and the Unit Manager for Resident #111 ' s unit. The Social Worker stated that when the family member emailed her on 3/23/25, they stated that Resident #111 was pretty upset and told them the One of the cna's / nurses got rough today cleaning up after he had a bowel movement. Slamming stuff down . When asked what she did when she received the email, she stated that she and the Unit Manager for that unit went to interview Resident #111.
The Social Worker stated that when she interviewed the Resident he did not claim to be abused.
When asked about the types of abuse she was able to state the different types of abuse (physical, sexual, financial, verbal, emotional / psychological).
A review of the Grievance Form filled out by the Unit Manager dated 3-24-25 read as follows:
[Resident #111 name redacted] Date: 3-24-25 Grievance / Concern Received by: Daughter & Resident. Reported To: [Unit Manager name redacted]
Summary of Grievance: CNA rude and spraying .
Resolution: CNA counseled.
On the afternoon of 4/3/25 an interview with CNA #1 was conducted and she was asked if she had taken care of Resident #111, and she stated that she had. When asked about the interaction she had with Resident #111, and she stated that he had to be changed, and she admitted to spraying air freshener in the room when she was changing him. She also stated that she was singing while she was changing him. She denied slamming things, she denied being rude or disrespectful. When asked if it could be perceived as rude to be spraying air freshener while cleaning up a resident, she stated that she did not feel it was rude. When asked if she thought it was unprofessional to be singing while caring for a resident, she stated that she Always Sings.
A review of the personnel file for CNA #1 revealed the following excerpts from the Counseling Form related to this incident:
Reason for action: Report of [CNA name redacted] spraying air freshener and mumbling under her breath after providing care to a resident that had a BM [bowel movement], causing the resident to feel embarrassed and uncomfortable
Goals specifically related to employee's recent job performance:
1. Maintain professionalism
2. Remain sensitive to resident's perception
3. Maintain dignity.
A review of the facility policy entitled Abuse Neglect and Exploitation Policy # 10171 revealed the following excerpts:
Definitions:
Verbal Abuse: Means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing
distance regardless of their age, ability to comprehend, or disability.
Mental Abuse: includes but is not limited to, humiliation, harassment, threats of punishment or deprivation .
On 4/3/25, 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
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 interview, clinical record review and facility documentation the facility staff failed to implement the abuse policy fo...
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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 implement the abuse policy for reporting allegations of abuse for 1 Resident (#111) in a survey sample of 29 Residents.
The findings included:
For Resident #111 the facility staff failed to follow abuse reporting guidelines set forth in the State Operations Manual and the facility abuse policy.
Resident #111 was admitted to the facility on [DATE]. Diagnoses for Resident #111 included but are not limited to fracture of right femur, aftercare following joint replacement surgery, benign prostatic hyperplasia, major depressive disorder, hx of fall, diabetes type 2, chronic kidney disease, hyperparathyroidism, and dysphagia. Resident #111 ' s Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 3/30/25 coded Resident #111 with a BIMS (Brief Interview of Mental Status) score of 15/15 indicating no cognitive impairment.
On 4/1/25 a review of the clinical record revealed the following progress notes:
3/20/25 11:46 a.m.: More than 2 episodes of Loose BM's. Resident stated he had an upset stomach this morning and is feeling better. [Nurse Practitioner name redacted] CRNP made aware of the above.
3/24/25 10:15 a.m. - Encounter for mental health services for victim of other abuse: Patient reports he was having frequent stools over the weekend. He reports the CNA had an attitude about having to change him frequently. He reports his CNA told him she could not keep coming in here and changing him. Patient denies any physical abuse, denies any injuries. Patient reassured that he is in a safe environment with people that are here to help him. Specifics of allegations reported to the unit manager. Patient unable to tell me specifically which day the event occurred or the name of the CNA.
On the afternoon of 4/3/25 an interview was conducted with the Social Worker, the Administrator and the Unit Manager for Resident #111's unit. The Social Worker stated that when the family member emailed her on 3/23/25, they stated that Resident #111 was pretty upset and told them the One of the cna's / nurses got rough today cleaning up after he had a bowel movement. Slamming stuff down . When asked what she did when she received the email, she stated that she and the Unit Manager for that unit went to interview Resident #111.The Social Worker stated that when she interviewed the Resident he did not claim to be abused. When asked about the types of abuse she was able to state the different types of abuse (physical, sexual, financial, verbal, emotional / psychological). When asked if other Residents cared for by this CNA were interviewed for possible abuse the Social Worker stated that they were not.
The Administrator was asked what are the steps that should be taken with an abuse allegation, and he stated that first ensure Resident safety, then report to the APS, OLC and Ombudsman and local law, if need be, then investigate the allegations. When asked if this allegation was reported he indicated that it had not been reported because the staff felt abuse had not taken place. When asked if that is the correct order in which to proceed after an abuse allegation, according to the SOM and facility policy, and he stated that the SOM and facility policy indicate reporting should be done immediately but no later than 2 hours after an allegation of abuse is made. When asked was this done in this case, he stated that it was not.
A review of the facility policy entitled Abuse Neglect and Exploitation Policy # 10171 revealed the following excerpts:
Page 1
Definitions:
Verbal Abuse: Means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing
distance regardless of their age, ability to comprehend, or disability.
Mental Abuse: includes but is not limited to, humiliation, harassment, threats of punishment or deprivation .
Page 5 Paragraph 2
VII. Reporting / Response
The company will have written procedures that include:
1.
Reporting of all alleged violations to the Administrator, state agency, adult protective services, and all other required agencies (e.g. law enforcement when applicable) within specified timeframes:
a.
Immediately but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury
On 4/3/25 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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review and facility policy the facility staff failed to report allegations of abuse in a tim...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review and facility policy the facility staff failed to report allegations of abuse in a timely manner for 1 Resident (#111) in a survey sample of 29 Residents.
The findings included:
For Resident #111 the facility did not report allegations of abuse in the required timeframe of no later than 2 hours after the allegation is made.
Resident #111 was admitted to the facility on [DATE]. Diagnoses for Resident #111 included but are not limited to fracture of right femur, aftercare following joint replacement surgery, benign prostatic hyperplasia, major depressive disorder, hx of fall, diabetes type 2, chronic kidney disease, hyperparathyroidism, and dysphagia. Resident #111 ' s Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 3/30/25 coded Resident #111 with a BIMS (Brief Interview of Mental Status) score of 15/15 indicating no cognitive impairment.
On 4/1/25 a review of the clinical record revealed the following progress notes:
3/20/25 11:46 a.m.: More than 2 episodes of Loose BM's. Resident stated he had an upset stomach this morning and is feeling better. [Nurse Practitioner name redacted] CRNP made aware of the above.
3/24/25 10:15 a.m. - Encounter for mental health services for victim of other abuse: Patient reports he was having frequent stools over the weekend. He reports the CNA had an attitude about having to change him frequently. He reports his CNA told him she could not keep coming in here and changing him. Patient denies any physical abuse, denies any injuries. Patient reassured that he is in a safe environment with people that are here to help him. Specifics of allegations reported to the unit manager. Patient unable to tell me specifically which day the event occurred or the name of the CNA.
On the afternoon of 4/3/25 an interview was conducted with the Social Worker, the Administrator and the Unit Manager for Resident #111 ' s unit. The Social Worker stated that when the family member emailed her on 3/23/25, they stated that Resident #111 was pretty upset and told them the One of the cna's / nurses got rough today cleaning up after he had a bowel movement. Slamming stuff down . When asked what she did when she received the email, she stated that she and the Unit Manager for that unit went to interview Resident #111.
The Social Worker stated that when she interviewed the Resident he did not claim to be abused.
When asked about the types of abuse she was able to state the different types of abuse (physical, sexual, financial, verbal, emotional / psychological). When asked if other Residents cared for by this CNA were interviewed for possible abuse the Social Worker stated that they were not.
The Administrator was asked what are the steps that should be taken with an abuse allegation, and he stated that first ensure Resident safety, then report to the APS, OLC and Ombudsman and local law, if need be, then investigate the allegations. When asked if this allegation was reported he indicated that it had not been reported because the staff felt abuse had not taken place. When asked if that is the correct order in which to proceed after an abuse allegation, according to the SOM and facility policy, and he stated that the SOM and facility policy indicate reporting should be done immediately but no later than 2 hours after an allegation of abuse is made. When asked was this done in this case, he stated that it was not.
A review of the facility policy entitled Abuse Neglect and Exploitation Policy # 10171 revealed the following excerpts:
Definitions:
Verbal Abuse: Means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing
distance regardless of their age, ability to comprehend, or disability.
Mental Abuse: includes but is not limited to, humiliation, harassment, threats of punishment or deprivation .
Page 5 Paragraph 2
VII. Reporting / Response
The company will have written procedures that include:
1.
Reporting of all alleged violations to the Administrator, state agency, adult protective services, and all other required agencies (e.g. law enforcement when applicable) within specified timeframes:
a.
Immediately but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury
On 4/3/25 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
Investigate Abuse
(Tag F0610)
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 allegations of abuse a...
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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 allegations of abuse and neglect are thoroughly investigated for 1 Resident (#111) in a survey sample of 29 Residents.
The findings included:
For Resident #111 the facility failed to thoroughly investigate allegations of abuse.
Resident #111 was admitted to the facility on [DATE]. Diagnoses for Resident #111 included but are not limited to fracture of right femur, aftercare following joint replacement surgery, benign prostatic hyperplasia, major depressive disorder, hx of fall, diabetes type 2, chronic kidney disease, hyperparathyroidism, and dysphagia. Resident #111 ' s Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 3/30/25 coded Resident #111 with a BIMS (Brief Interview of Mental Status) score of 15/15 indicating no cognitive impairment.
On 4/1/25 a review of the clinical record revealed the following progress notes:
3/20/25 11:46 a.m.: More than 2 episodes of Loose BM's. Resident stated he had an upset stomach this morning and is feeling better. [Nurse Practitioner name redacted] CRNP made aware of the above.
3/24/25 10:15 a.m. - Encounter for mental health services for victim of other abuse: Patient reports he was having frequent stools over the weekend. He reports the CNA had an attitude about having to change him frequently. He reports his CNA told him she could not keep coming in here and changing him. Patient denies any physical abuse, denies any injuries. Patient reassured that he is in a safe environment with people that are here to help him. Specifics of allegations reported to the unit manager. Patient unable to tell me specifically which day the event occurred or the name of the CNA.
On the afternoon of 4/3/25 an interview was conducted with the Social Worker, the Administrator and the Unit Manager for Resident #111 ' s unit. The Social Worker stated that when the family member emailed her on 3/23/25, they stated that Resident #111 was pretty upset and told them the One of the cna's / nurses got rough today cleaning up after he had a bowel movement. Slamming stuff down . When asked what she did when she received the email, she stated that she and the Unit Manager for that unit went to interview Resident #111.
The Social Worker stated that when she interviewed the Resident he did not claim to be abused. When asked about the types of abuse she was able to state the different types of abuse (physical, sexual, financial, verbal, emotional / psychological). When asked if other Residents cared for by this CNA were interviewed, she stated that they were not. When asked about the interview with the Resident she stated that the Resident complained of the CNA spraying air freshener and mumbling under the breath.
The Administrator was asked what are the steps that should be taken with an abuse allegation, and he stated that first ensure Resident safety, then report to the APS, OLC and Ombudsman and local law, if need be, then investigate the allegations. When asked if this allegation was reported he indicated that it had not been reported because the staff felt abuse had not taken place. When asked what steps were taken to protect Residents while the investigation was ongoing, and the Administrator stated that they filled out a grievance form and, interviewed CNA #1 and wrote up a counseling statement for her as they did not feel this was abuse.
A review of the Grievance Form filled out by the Unit Manager dated 3-24-25 read as follows:
[Resident #111 name redacted] Date: 3-24-25 Grievance / Concern Received by: Daughter & Resident. Reported To: [Unit Manager name redacted]
Summary of Grievance: CNA rude and spraying .
Resolution: CNA counseled.
On the afternoon of 4/3/25 an interview with CNA #1 was conducted and she was asked if she had taken care of Resident #111, and she stated that she had. When asked about the interaction she had with Resident #111, and she stated that he had to be changed, and she admitted to spraying air freshener in the room when she was changing him. She also stated that she was singing while she was changing him. She denied slamming things, she denied being rude or disrespectful. When asked if it could be perceived as rude to be spraying air freshener while cleaning up a resident, she stated that she did not feel it was rude. When asked if she thought it was unprofessional to be singing while caring for a resident, she stated that she Always Sings.
A review of the personnel file for CNA #1 revealed the following excerpts from the Counseling Form related to this incident:
Reason for action: Report of [CNA name redacted] spraying air freshener and mumbling under her breath after providing care to a resident that had a BM [bowel movement], causing the resident to feel embarrassed and uncomfortable
Goals specifically related to employee's recent job performance:
1. Maintain professionalism
2. Remain sensitive to resident's perception
3. Maintain dignity.
A review of the facility policy entitled Abuse Neglect and Exploitation Policy # 10171 revealed the following excerpts:
Definitions:
Verbal Abuse: Means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing
distance regardless of their age, ability to comprehend, or disability.
Mental Abuse: includes but is not limited to, humiliation, harassment, threats of punishment or deprivation .
On 4/3/25, 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 observations, resident interviews, staff interview, and clinical record review the facility staff failed to provide nee...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interviews, staff interview, and clinical record review the facility staff failed to provide needed oral care to a dependent resident receiving enteral feedings for 1 of 29 residents (Resident #123), in the survey sample.
The findings included:
The facility staff failed to provide needed oral care to a dependent resident receiving enteral feedings, Resident #123.
Resident #123 was originally admitted to the facility 6/10/2022 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included a stroke with hemiparesis, dysphagia causing pulmonary aspiration, enteral feedings are required.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/28/2025 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #14's cognitive abilities for daily decision making were intact.
Resident # 128's care plan with a revision dated of 3/20/25 stated (name of resident) has an ADL self-care performance deficit related to a CVA with hemiparesis. The goal stated (name of resident) will improve current level of function in ADLs through the review date, 6/29/25. The intervention dated 7/20/22 stated, oral care routine (AM, PC, HS) brush (name of resident) teeth, rinse dentures, clean gums with toothette, and rinse mouth with wash.
An observation was made of Resident #123 on 4/1/25 at approximately 1:31 PM. The resident was in bed at a 60-degree position. The resident was attempting to make a need known but experienced much difficulty because his difficulty with speech and the hygiene of his oral cavity. The resident's lips were covered with very dry and stringy mucus, while the inside of his mouth and his tongue was with a large amount of dry and whitish mucus.
On 4/3/25 at approximately 4:05 PM another observation was made of Resident #123 while he was in bed. The resident inner mouth and his lips were with a large amount of dried which made it difficult for him to open and close his mouth. The resident cleared his throat and moved his head to stated that his lips and mouth were dry and uncomfortable.
On 4/3/25 at approximately 5:25 PM, a final interview was conducted with the Administrator, Director of Nursing, the Assistant Director of Nursing and four Corporate Consultants. The above information was reviewed, and the Director of Nursing stated the resident had received oral care and going forward they would stay on top of his oral care needs.
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 resident interview, staff interview, and clinical record review, the facility staff failed to maintain ongoing records ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and clinical record review, the facility staff failed to maintain ongoing records of communication between the facility and the dialysis center for 2 of 29 residents (Resident 126 and Resident #128), in the survey sample.
The findings included:
1.Resident #126 was originally admitted to the facility 6/25/24. The current diagnoses included end stage renal disease requiring dialysis. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/2/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #126's cognitive abilities for daily decision making were intact
A review of the Resident #126's dialysis communication book revealed no communications notes from the dialysis center on 3/24/25 and 3/26/25. An interview was conducted with the Resident #126 on 4/3/25 at 4:35 PM. The resident stated she received dialysis services on Mondays, Wednesdays and Fridays, and she attended dialysis on 3/24/25. The resident further stated that she missed dialysis on 3/26/25 because she had a dermatology appointment, regarding the underarm irritation.
The person-centered care plan dated 6/27/24 had a problem which stated (name of the resident) needs hemodialysis related to renal failure. The goal read (name of the resident) will have no signs or symptoms of complications from dialysis through the review date, 7/6/25. The interventions included Coordinate plan of care with dialysis as needed but it failed to include ongoing communication, coordination and collaboration between the nursing home and the dialysis center.
An interview was conducted with the Licensed Practical Nurse (LPN) #3 at approximately 4:30 PM. LPN #3 stated there were no dialysis communication notes in the book for 3/24/25 or 3/26/25, but she had spoken with the Unit Manager to determine if they had been removed to be uploaded to the electronic record by medical records. On 4/3/25 at approximately 5:05 PM the Unit Manager stated they were unable to locate dialysis communications which were not in the communication's book.
On 4/3/25 at approximately 5:25 PM, a final interview was conducted with the Administrator, Director of Nursing, the Assistant Director of Nursing and four Corporate Consultants. The above information was reviewed, and the facility's Team offered no comments and voiced no concerns.2. Resident #128 was originally admitted to the facility 01/02/24 and readmitted on [DATE]. The facility staff failed to maintain ongoing records of communication between the facility and the dialysis center. The current diagnoses included end stage renal disease requiring dialysis. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 01/09/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #128's cognitive abilities for daily decision making were intact
A review of the Resident #128's dialysis communication book revealed no communications notes from the dialysis center for last week of February. An interview was conducted with the Resident #128 on 4/03/25 at 1:30 PM. The resident stated that he received dialysis services Monday through Friday and carries the communication book from the his unit to the dialysis Monday through Friday.
The person-centered care plan dated 2/16/24 reads Resident #128 has End Stage Renal Disease (ESRD) and does require Dialysis interventions at this time - conducted inhouse with Dialyze Direct Mon - Fri. The goal read the resident will have immediate intervention should any s/sx of complications from dialysis occur through the review date. The interventions included Dialysis Communication Record is sent to the dialysis center with each appointment, and return of form is ensured after appointment is completed and to Dialyze Direct in-house dialysis m-f.
An interview was conducted with the Licensed Practical Nurse (LPN) #3 at approximately 3:45 PM. LPN #3 stated there were no dialysis communication notes in the book for the last 2 weeks of February 2025 (excluding Saturday and Sunday) because the medical records staff need to upload them in electronic medical records (EMR).
On 4/3/25 at approximately 5:25 PM, a final interview was conducted with the Administrator, Director of Nursing, the Assistant Director of Nursing and Corporate Consultants. The above information was reviewed. No further information was given.
Dec 2024
53 deficiencies
5 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0603
(Tag F0603)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, Resident interview, facility staff interviews, clinical record review, and facility documentation review,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility staff involuntarily secluded one (1) Resident (Resident #226) in a survey sample of 74 Residents, resulting in psychosocial harm.
The findings included:
For Resident #226, who refused a transfer to the locked memory care unit (for residents with dementia and behaviors), the facility staff failed to honor the resident's request. The staff moved him against his will, into the secured unit with no access codes to afford him independent egress. The resident did not meet the criteria for the move as no criteria was ever derived in the facility by way of policy or procedure, which resulted in a move for staff convenience.
Resident #226 was admitted to the facility on [DATE] with diagnoses including: End stage renal disease with hemodialysis, history of stroke, anemia, chronic congestive heart failure, hypertension, and diabetes type 2. The Resident did not have a diagnosis of dementia and was his own responsible party and by facility agreement cognitively intact and able to make his own decisions.
Three MDS (minimum data set) federal assessments were reviewed since the resident's admission through the time of survey on 12-10-24. Those follow below:
1. The first MDS admission assessment was dated 6-10-24 and indicated the resident had a Brief Interview for Mental Status BIMs score of 8 of a possible 15 points upon admission after Acute hospitalization for encephalopathy from a fall and missing hemodialysis. He was coded in the document as able to understand and be understood, no aberrant behaviors, needed only limited assistance with most (activities of daily living) ADLs such as toileting, ambulating, hygiene, transferring, and bed mobility, and was dependant on staff only for bathing, however needed only tray set up and clean up for meals.
2. The second MDS was a quarterly assessment dated [DATE] which indicated the Resident had a Brief Interview for Mental Status BIMs score of 11 of a possible 15 points after a rehospitalization for septic shock due to hypovolemia, as no infection was found to support septic shock, nor sedation as narcan had no effect. He was coded in the document as able to understand and be understood, no aberrant behaviors, and functional abilities were not coded.
3. The third MDS was a quarterly assessment dated [DATE] indicated the Resident had a Brief Interview for Mental Status BIMs score of 10 of a possible 15 points. He was coded in the document as able to understand and be understood, no aberrant behaviors, needed only set up and clean up for bathing, otherwise, was completely independent for all (activities of daily living) ADLs such as toileting, ambulating, hygiene, transferring, and bed mobility, and eating.
On 9-26-24 at 4:42 PM the Resident was moved to the memory care locked unit and the Resident's son was notified according to the room change notification document in the clinical record, however, the document stated that the Resident's brother agreed to the room change even though these individuals were only emergency contacts and the Resident refused and was his own responsible party. The reason given for the move, was elopement risk. The Resident had never eloped and on the one occasion that he went outside to sit in the sun after dialysis he did not leave, even though he could have walked away, he simply sat there until staff came to take him back to his room. When asked about this incident the Resident stated there is no reason that I can't sit outside for awhile and get some fresh air. I am not a prisoner.
During an initial interview on 12-10-24, at 11:40 AM, Resident #226 was found to be alert and oriented to person, place, time, and situation. He stated that he had requested to stay in his current room after learning that the facility planned to move him rather than discharge him home. Resident #226 stated he was told his son and grandson were not able or willing to care for him in the home that the three of them had formerly shared. The Resident insisted on planning a discharge back to the community, or an assisted Living Facility as soon as possible, however, he stated no one listened, no one came to talk to me about it, and nothing ever happened even though I kept telling them. During this interview, Resident #226 verbalized that he is a dialysis patient and that he received dialysis there in the facility. He further stated he hates the memory care unit because everyone is crazy in here, they wander into my room and take things, my room mate yells and cries all night for something to drink, I don't even get food every meal, the room is nasty and falling apart, and I can't even get a shower in here because the showers are so nasty dirty. He went on to say I like to walk around, it makes the time go faster, if I don't walk now I won't be able to leave, but locked in here I have no where to walk, I don't even have a TV to watch and I love TV, being in here will make you crazy with nothing to do.
The surveyor and Resident then immediately walked to the shower room for an initial observation and found it to be dirty, mildewed/moldy, foul smelling, had a strong odor of urine and feces, trash and debris littered the floor, used brown stained wet linens were on the floor, a white crusted substance was on the floor and walls, used soap and shampoo bottles were crusted on the shelves and hand rails in the shower, and the room was being used as a storage area as well for boxes of supplies and durable medical equipment. The Resident asked would you want to take a shower in here?
Immediately following the shower room observation the Resident's room was examined. The Resident's room was shared with a second Resident. Resident #226's room tour included but was not limited to the following environmental observations:
Broken vinyl window blinds, no curtains, a urine soaked bathroom, a pervasive smell of urine and feces in the room and on the entire unit.
The free standing broken armoire closets in the rooms were swollen and splitting, with rotten splinters and chunks of disintegrating wood and wood particles all over the Residents few items in the closet, and in the rooms.
The sink vinyl laminate countertop area was water damaged and swollen and separated revealing particle board disintegration with the sink partially separated from the wall in a downward unstable dropped position, and wood dust everywhere.
Under the sink a cabinet door was ajar as it would not close because of the downward sloping sink, and the inside compartment was an open hole with what appeared to be a black concrete floor. Inside was found mildew, mold, trash, a pair of urine stained white tennis shoes, and 2 shirts that were stuck together with an unknown substance, all thrown in onto the floor.
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 bed divider curtain had brown stains and smeared feces on it.
The PTAC (air conditioning wall unit) was not secured and had fallen forward into the room approximately 12 inches revealing light around it and cold air coming into the room from the outside of the building. The front cover of the unit was also missing and the sharp metal grill was exposed. The Resident's room mate's bed was pushed against the PTAC holding it in place so it would not completely fall out of the hole in the outside facing wall.
The Residents had no television, no clock, no telephone, no radio and the room had no personal items in it nor on the walls.
Resident #226 had no shoes, no coat, 2 pairs of pants, and 2 shirts (the Resident was wearing one of each). When asked about his clothing he stated I had more, but they have been stolen.
Each room on the unit was then inspected by all surveyors and found to be in the same condition as Resident #226's room. There were no televisions in any room, and no water to drink in any room.
There was also noted in the hallway the air conditioning main vent in the ceiling and air return on the wall were so dusty that they had the appearance of brown fur coating them. The walls were marked and smeared and had paint scraped off in places
It is notable to mention that no activities were noted to be conducted in the secured unit from 12-10-24 until 12-18-24. The staff were asked why no activities were being conducted for the residents and they replied that we only have one activity person for the whole 150 bed facility.
Facility CNA (Certified nursing Assistant) and LPN (Licensed Practical Nurse) staff on the memory care unit and other units were interviewed, and stated the reason that Resident #226 had been placed on the memory unit was wandering and behaviors When asked what his behaviors were, they were only able to say he went outside and sat in his wheel chair one time after dialysis, and further stated he would wander up and down the halls and that will get you put in here for sure. The surveyor asked why he walked, and there was no response.
The Social worker was interviewed on 12-10-24 and revealed that she had just been hired on 11-19-24. The former Social worker resigned on 6-28-24, and there had been no social worker in the facility from 6-28-24 until 11-19-24. She stated she would be putting in a progress note for Resident #226 on this same day, and she stated that she didn't really know much about him.
On 12-11-24 the social work note was reviewed and revealed a progress note that documented the Resident as long term care during a care planning meeting, and nothing about discharge planning or his desire to be discharged .
On 12-12-24 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 not sufficient for the role.
The Director of Nursing and Administrator were asked for a policy or procedural guidance for moving a Resident onto the memory care locked unit. Both stated that they did not have one, and could not describe a pathway to the decision for moving a resident into the secure unit.
On 12-11-24, through 12-19-24 a clinical record review was conducted. There was no evidence in the clinical record that the physician had been called and notified of the Resident's move, nor was a request made for assessment and told that the Resident wished to discharge.
On 12-5-24 a PHQ-9 (the only one during his stay) evaluation for depression was conducted and gave a score of 3 which equaled minimal or not at all suffering from depression. The Resident was not ordered to have any psychoactive medications, nor did he have any diagnoses to support the use of them.
Resident #226 refused the move to the secured unit and was moved against his will. Resident #226 was unable to bathe in a safe, clean environment, and his room was not a safe, clean environment. The room was cold with the heating unit out of the wall. The Residents personal items and clothing were missing and not available to him. Confused Residents wandered in and out of his room affording him no private space. The Resident was unable to sleep as his roommate called out all night for water to drink, and food was found to be insufficient. The Resident kept a jar of peanut butter by his bed and a loaf of bread so that I can eat something when they forget my tray like they do my roommate's tray. The Resident repeatedly told staff he wanted to be let out of the unit and wanted to be discharged . There were no activities being held on the unit, and there was no television for any of the Residents. Resident #226 received no care planning by an interdisciplinary team, no social work for room moves or discharge assistance, and he received no psychosocial support. The Resident stated no one listened to him, he felt locked in, unable to walk or go outside, and he felt like a prisoner that was going crazy with nothing to do but stare at the walls.
On 12-12-24, during the end of day debriefing meeting with the Administrator, Director of Nursing, and Corporate clinical support consultant, the facility staff were made aware of the above concerns and that the Resident had requested to stay in his room, and to be planned for discharge, which was denied and there was no evidence that the physician was notified of this request. Further they were notified that no Social Worker was providing care during the Resident's stay which compounded the incident further, and culminated in the withholding of a resident's rights, and involuntary seclusion resulting in psychosocial harm.
On 12-19-24, prior to the survey exit the Director of Nursing informed surveyors that Resident #226 and his roommate had been moved back onto regular units last night (12-18-24). This indicated that the involuntary seclusion was borne out by the fact that the day before survey exit the Resident was moved back to a regular unit.
At the time of survey exit on 12-19-24 the facility Administrator, and Director of Nursing stated they had nothing further to provide.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · 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 residents receive treat...
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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 residents receive treatment and care in accordance with professional standards of practice for one (1) Resident (#376) in a survey sample of 74 Residents, which resulted in harm.
The findings included:
For Resident # 376 the facility staff failed to ensure follow up on lab work which led to the resident having to be hospitalized for a blood glucose of over 900, this is harm.
On 12/13/24 a review of the clinical record revealed that Resident #376 was admitted to the facility on [DATE] with diagnoses that included but were not limited to dialysis dependent end stage renal disease, myocardial infarction, hemiplegia / hemiparesis following CVA (Cerebral Vascular Accident), hypertension and generalized muscle weakness. Resident #376's most admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/11/22 coded Resident #376 as having a BIMS (Brief Interview of Mental Status) score of 13 / 15 indicating mild cognitive impairment.
A review of the clinical record revealed that there were discrepancies in the discharge orders from the hospital. The following excerpts are from the physician progress notes:
10/6/22 1:00 p.m. - Clarification with nurse: d/c [discharge] med list has pt on Lokelma weekly, [Electronic Health Record name redacted] med list does not have pt on Lokelma weekly also calcium acetate missing from PCC orders, also metoprolol is 50 mg on d/c med list but 25 mg in [EHR name redacted] (d/w nursing so corrections can be made).
10/10/22 1:00 p.m. - Chief Complaint / Nature of Presenting Problem: Patient reports a diabetic patient reports receiving insulin and blood sugar checks throughout the day.
History Of Present Illness:
[AGE] year-old male seen per staff request indicated he is a diabetic blood sugars throughout the day as well as insulin. On arrival patient was sitting. Discussed with patient regarding his concerns. Reviewed hospital charts information indicating patient was a diabetic. Patient indicated he was insulin dependent.
10/16/22 7:30 p.m. - patient has some cognitive impairment however indicated he received insulin in the past will obtain hemoglobin A1c Plan: Patient indicated that the mail he received was in correct concerns for other following underlying conditions will obtain lab overview patient indicated he was a diabetic was taken other medication 1 he was homeless. Patient indicated he was on insulin however he was homeless and indicated that he moved from New York. Patient does have some cognitive impairment for further overview will obtain labs to establish baseline
10/17/22 1:00 p.m. - Patient reported that he was a diabetic however unable to identify hemoglobin A1c any labs indicating that patient is diabetic. Labs were ordered multiplications however patient refused because he receives dialysis receives labs at the dialysis unit. Discussed with patient additional labs are needed to determine his overall health and chronic disease. He verbalized understanding and agreed to receive lab work. Discussed with dialysis unit regarding patient's labs and asked him to add additional labs to help reduce with invasive treatment for patient she verbalized understanding nursing staff printed out labs and provided to staff. Patient denies any further complaints or concerns at this time we will continue to monitor patient closely he continues to progress with physical and Occupational Therapy further evaluation conducted he has not required any rehospitalization or any antibiotic course since his rehabilitation stay, he has a good nutritional intake we will continue to monitor.
10/25/22 1:00 p.m. Patient has some concerns regarding diabetes his hemoglobin A1c was obtained waiting for results from dialysis. The blood sugars remained stable 100 he denies any further complaints or concerns at this time no increased pain or discomfort. Tolerating dialysis. Further evaluation conducted.
1/8/23 3:15.m.- Note Text: @ 1445 can noted resident's speech unclear,& trying to eat but is drooling from right side of mouth, full body check completed resident lungs clear, BS hyperactive, resident noted w/ loose stools, eyes dilated, BP 180/88, 92,20, 98.8, O2 sat 94%, resident continue to try to communicate verbally, but speech unclear, Rt side face droop, On- call NP notified gave N/O to send resident to ER 911 for eval. Transfer summary, care plan, bed hold, med list sent w/ emt's, resident skin dry & intact, but confused upon exiting this facility, emergency contact (friend) notified no answer.
On 12/11/24 a review of the clinical record revealed that on admission to the facility the Resident discharge paperwork from the hospital did not list diabetes as a diagnosis. The progress notes, however, did reflect the Resident telling the nurse and the Nurse Practitioner on several occasions that he was diabetic and took Lantus and Metformin daily. The Nurse Practitioner ordered labs including an HgbA1C on 10/11/22. A review of the clinical record revealed that there were no A1C lab results scanned into the record. A request was made to obtain the lab results from the on-site dialysis center. The results were obtained on 12/15/24 and revealed an A1C abnormal.
On 12/15/24 at approximately 2:00 p.m. an interview was conducted with the DON who was asked if the nurses follow up on the labs and she stated that when the labs come in the doctor or NP usually sees them and signs off on them. She further said that if the nurses are made aware of a lab that is abnormal or critical value, they will notify the physician or NP. When asked why this abnormal A1C lab was not followed up on, she stated that the results were not received from the dialysis center.
The surveyor requested medical records from the hospital and on 12/17 /24 the records received from the hospital revealed that Resident #378 did indeed have a diagnosis of diabetes since 2008. The Resident was sent out from the facility unresponsive via rescue squad on 1/8/24 and when arrived at the ER the Resident's blood sugar was over 900.
On the afternoon of 12/18/24 an interview was held with the Nurse Practitioner currently at the facility who stated that all the NP and physicians have access to the local Hospital's electronic health record. When asked if they could view a Resident record from an inpatient stay, she indicated that they could. When asked if the Resident's A1C lab was showing up in the system and she stated that she could not find it. She then stated she would get in touch with the onsite dialysis center to obtain the lab. She looked in the record and found that Resident #376 did have a diagnosis of diabetes and was admitted to the hospital from the facility on 1/8/23 through 1/18/23 with admitting diagnoses of hyperosmolar hyperglycemic state. The Resident did not return to the facility after his stay in the hospital.
On 12/19/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #379 the facility staff failed to ensure Resident had weekly skin assessments and interventions in place to prev...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #379 the facility staff failed to ensure Resident had weekly skin assessments and interventions in place to prevent the development of pressure injury, resulting in the development of four (4) pressure ulcers.
On 12/11/24 a review of the clinical record revealed that Resident #379 was admitted to the facility on [DATE] with diagnoses that included but was not limited to sepsis, metabolic encephalopathy, protein-calorie malnutrition, acute kidney failure, atherosclerotic heart disease, hypothyroidism, Alzheimer's disease, dementia, anxiety disorder hypertension, dysphagia, g-tube dependence, instability of gait and mobility and insomnia.
Upon admission the admission Screening form was completed. The admission screening form dated 1/12/24 section C states that the skin turgor is normal, skin temp is warm and there are no wounds or open areas documented on the form.
A review of the clinical record revealed that the care plan for Resident #379 read as follows:
FOCUS: [Resident name redacted] has DTI [Deep Tissue Injury] pressure ulcer to left hell [sic], left lateral ankle, right later ankle pressure or potential for pressure ulcer and potential for skin breakdown development r/t Dehydration, disease process, incontinence, Hx of ulcers, Immobility. Date Initiated: 01/24/2024 Created on: 01/24/2024.
GOAL: Pressure ulcer will show signs of healing and remain free from infection by/through review date. Date Initiated: 01/24/2024 Target Date: 04/11/2024.
INTERVENTIONS: Administer medications as ordered. Observe/document for side effects and effectiveness.
Date Initiated: 01/24/2024 Created on: 01/24/2024.
Administer treatments as ordered and observe for effectiveness. [duplicate] Date Initiated: 01/24/2024 Created on: 01/24/2024
Follow facility policies/protocols for the prevention/treatment of skin breakdown. Date Initiated: 01/24/2024 Created on: 01/24/2024
If the resident refuses treatment, confer with the resident, IDT and family to determine why and try alternative methods to gain compliance. Document alternative methods. Date Initiated: 01/24/2024 Created on: 01/24/2024
Inform the resident/family/caregivers of any new area of skin breakdown Date Initiated: 01/24/2024 Created on: 01/24/2024.
On 12/12/24 a review of Policy entitled Pressure Injury Prevention and Management revealed the following excerpt:
3. Assessment of Pressure Injury Risk
a. Licensed nurses will conduct a pressure injury risk assessment using the Braden Scale, on admission/readmission, weekly x four weeks, then quarterly or whenever the residents condition changes significantly.
c. Licensed nurses will conduct a full body skin assessment weekly and after any newly identified pressure injury
Findings will be documented in the medical record.
4. Interventions for Prevention and to Promote Healing
c. Evidence based interventions for prevention will be implemented for all resident who are assessed at risk or who have a pressure injury present. Basic or routine care could include but are not limited to:
i. Redistribute pressure (such as repositioning, protecting and or offloading heels, etc.)
ii. Minimize exposure to moisture and keep skin clean, especially of fecal contamination.
iii. Provide appropriate pressure-redistributing support surfaces
iv Maintain or improve nutrition and hydration status where feasible.
A review of the clinical record revealed the following:
1/17/24 - Weekly Skin assessment not filled out entire document left blank.
1/23/24 - Weekly skin assessment all questions left unanswered, and one comment was placed in the wound section
Right heel - sdti [suspected deep tissue injury] right lateral ankle - sdti left heel - sdti left lateral ankle - sdti
1/31/24 - Weekly Skin Assessment all questions left unanswered and one comment in the wound section read:
Left big toenail bleeding during morning hygiene.
Weekly Wound Assessments:
1/17/24 - Wound #1
Location - Left heel SDTI (Suspected Deep Tissue Injury)
3a. SDTI
5a. Overall Impression -First observed
8a. Wound Measurements
Length 7 cm
Width 5.5 cm
Depth 0.1 cm
1/17/24 Wound #2
1.Location - Left Lateral Ankle
3a. SDTI
5a. Overall Impression - First observed
8a. Length 2.0 cm
Width 2.0 cm
Depth 0.1 cm
1/17/24 - Wound #3
Right Lateral Ankle
3a. SDTI
5a. Overall Impression - First observed
8a. Length 3.0 cm
Width 2.5 cm
Depth 0.1 cm
1/17/24 - Wound #4
Right Lateral Foot
3a. SDTI
5a. Overall Impression - First observed
8a. Length 3.5 cm
Width 1.5 cm
Depth 0.1 cm
On 12/17/24 at approximately 1:00 p.m. an interview was conducted with the DON who was asked when interventions should be put in place for prevention of pressure ulcers, she stated that they should be done on admission. When asked if this was done in Resident #379's case she stated that it was not. When asked when the care plan should be updated after the development of a new pressure area, and she stated that the care plan should be updated immediately following a change in the condition of the Resident to include development of pressure areas treatment and any new interventions. When asked if that was done in this case, she stated it was not updated when the pressure areas were discovered on 1/17/24, and the care plan was not updated until a week later. When asked if the Resident received repositioning devices, booties, an air mattress or any specific turning and repositioning schedule to prevent or aid in healing of the pressure wounds, she stated, There is no evidence of these interventions in the chart.
On 12/19/24 the during the end of day debreifing meeting, the Administrator was made aware of the findings and no further information was provided.
Based on observation, staff interview, facility documentation review, and clinical record review the facility staff failed to prevent, assess, identify timely, and treat avoidable pressure ulcers resulting in harm for two Residents, (Resident #117, and Resident #379) in a survey sample of 74 Residents.
The findings included:
1. For Resident #117, the facility staff did not assess, nor identify an avoidable sacral pressure ulcer prior to it becoming a stage 3 full thickness ulcer with 80 % slough (dead stringy yellow tissue) in the wound bed, first identified during survey on 12-11-24. The Resident was also suffering from significant weight loss, malnutrition, and meals were not provided, which would impact his skin and ability to heal. The Resident did not receive timely ADL care, did not receive preventative skin care and pressure reduction devices, and was not gotten out of bed during the entire 2 week survey.
Resident #117 was originally admitted to the facility on [DATE], and was hospitalized 10 days later on 9-15-24 for a colonic hemorrhage caused by a Stercoral ulcer (impacted hard stool at the anus and distal rectum) which pierced the bowel wall, after having had no bowel movements. The ulcer/perforation of the bowel wall resulted in blood loss requiring 2 blood transfusions according to hospital records.
The Resident was again sent out to the hospital on [DATE] through 10-15-24 for a severe urinary tract infection causing sepsis and septic shock, and acute kidney injury which was reversed successfully in the hospital with IV (intravenous) fluids for dehydration and IV antibiotics.
Resident #117 had a medical diagnosis history including; Congestive heart failure with diuretic use, unspecified dementia without behaviors, hypertension, depression, anxiety, dysphagia, gastro-esophageal reflux disease, and cardiac disease.
Resident #117's most recent Minimum Data Set (MDS) assessment was a Significant change assessment with an assessment reference date of 11-28-24. Resident #117 had a Brief Interview of Mental Status score of 99 indicating severe cognitive impairment. He was dependant on staff for eating, bathing and personal hygiene. He was coded to have no skin impairment, and at risk for skin impairment. He was coded with no weight loss (which was incorrect), a weight of 123 pounds, no swallowing difficulty, and having a mechanically altered diet.
The only previous MDS assessment to the 11-28-24 MDS was dated 9-23-24, and was the Resident's admission assessment. This MDS had not been signed as completed until 11-23-24, and submitted late. The document revealed the Resident's weight at that time to be 139 pounds. This indicated a greater than 10% weight loss in the previous 2 months. It is notable to mention that the Resident was admitted with a weight of 145.3 pounds on 9-6-24. This revealed a significant weight loss of 22.3 pounds since admission, equaling a greater weight loss than 15% in the 3 month period from admission to the current survey which was well documented in the clinical record.
Before hospitalization and after hospitalization the Resident's diet remained the same. Regular diet, Dysphagia pureed texture, thin consistency. On 10-16-24 mighty shakes 4 ounces was ordered at bedtime for a supplement. No other diet changes nor supplements were ever ordered during the Resident's stay.
The Resident was observed during initial tour of the facility on 12-10-24 immediately following a shower room observation with Resident #117's room mate. The room tour revealed a dirty and unsafe room environment which included but was not limited to the following being observed;
broken vinyl window blinds, no curtains, a urine soaked bathroom, a pervasive smell of urine and feces in the room and on the entire unit.
Under the sink a cabinet door was ajar as it would not close because of the downward sloping sink, and the inside compartment was an open hole with what appeared to be a black concrete floor. Inside was found mildew, mold, trash, a pair of urine stained white tennis shoes, and 2 shirts that were stuck together with an unknown substance, all thrown in onto the floor.
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 bed divider curtain had brown stains and smeared feces on it.
The PTAC (air conditioning wall unit) was not secured and had fallen forward into the room approximately 12 inches revealing light around it and cold air coming into the room from the outside of the building. The front cover of the unit was also missing and the sharp metal grill was exposed. Resident #117's bed was pushed against the PTAC unit holding it in place so it would not completely fall out of the hole in the outside facing wall.
Resident #117 was in bed covered with only a bed sheet with no blanket and wore no clothing nor gown, and only an incontinence brief under the bed sheet. The fitted bed sheet under the Resident had a yellow halo around the Resident which appeared to be dried urine with a strong odor. The Residents incontinence brief was obviously soaked with urine and wrinkled down at the waist with the heaviness of the liquid it contained. The Residents hair was matted to his head, greasy, dandruff lay in his bed and on his pillow, and body odor/sweat could be clearly smelled.
During the entire survey Resident #117 was never observed during the day shift out of bed, and asked the surveyors often for something to drink stating Please, Please bring me some water I'm so thirsty. The Residents lips were noted to be cracked and dry, and his eyes were sunken. His skin was flaking and dry and when the skin on his hand was examined it tented when pulled gently in an upward fashion and stayed that way. His mucus membranes were sticky and when he spoke his lips would stick together with thick saliva briefly. He constantly complained my butt hurts, my butt hurts. Staff were made aware that the Resident was thirsty, and complaining of butt pain. Staff stated they would have the NP look at him.
On 12-11-24 the Resident was assessed by the Registered Nurse Practitioner (NP) and found to have a stage 3 sacral pressure sore. Each day of survey the Resident was visited and observed to be in bed lying on his back or right side facing the window. No pressure reduction support devices and repositioning was ever observed.
Each room on the unit was then inspected by all surveyors and found to be in the same condition as Resident #117's room. There were no televisions in any room, no personal items, and no water to drink in any room. There was no soap nor paper towels in the Resident rooms for hand washing of staff or Residents.
Staff on the memory care unit were interviewed and asked why Resident #117 was not clean, they stated well, he refuses a lot, and (name) Resident #117 is hospice now and doesn't like to be moved much. Staff were taken to the Residents' room and #117 was asked if he would like a shower or bath, and he simply shook his head yes.
ADL (activities of daily living) care records were reviewed for Resident #117 and revealed that the Resident was totally dependant on one staff member. The document indicated that a bath was given every morning, however, the Resident was observed every day during survey and found to be dirty and unkempt with flaking skin, dandruff, greasy hair, and in a soiled bed with soiled linens. At times the Resident was found wearing only an incontinence brief, and at other times wearing a white stained T-shirt and also an incontinence brief. The Resident was never seen out of bed during daytime hours for the entire survey.
On 12-10-24 A Certified Nursing Assistant (CNA) was found in the hallway after Resident #117 was found begging for water. The CNA brought in 120 milliliters of tea for the Resident, and was again told he asked for water. She stated oh he just wants to drink, not eat. The CNA was asked if she was aware that the caffeine in tea was a diuretic and could further dehydrate the Resident. She did not respond.
On 12-10-24 the Kitchen manager was interviewed and stated that they did not keep track of percentages of meals and fluids consumed, and stated that the nursing staff were responsible for that. She was asked if she had decaffeinated tea on hand, and she stated she had decaf coffee but not tea.
On 12-12-24 A CNA was interviewed and stated, he (Resident #117) went out to the hospital with altered mental status, low blood pressure, dehydration and a UTI (urinary tract infection), and when he came back he went on hospice. He's been in bed now since then. The Resident had actually returned on 10-15-24, and was not placed on hospice until 11-19-24 (one month later). The CNA was asked for his hospice notes, and she went to the LPN (Licensed Practical Nurse) unit manager with the surveyor accompanying her and asked for the notes. The LPN stated I will look for them, and later stated I don't have any. The entire clinical record was reviewed and no hospice notes were in the clinical record.
Staff were then asked if hard copy notes could be located in a binder, and they stated they had no such binder. There was an observed notice taped to the Resident's closet door from the new social worker addressed to the hospice staff. The document instructed that the Resident's hospice supplies had been found in the general supply closet in the facility with normal inventory. The document instructed hospice staff to inform the nurses on the unit when hospice supplies were brought in for the Resident. It appeared that the facility staff and hospice staff were not communicating.
On 12-13-24 from 11:30 AM until 1:00 PM a second surveyor was observing lunch service on the memory care secured unit until the meal was finished. Resident #117 was never fed, and his tray was removed from his room. The tray was placed back on the tray cart to return to the kitchen for disposal, untouched. The CNA was asked why he was not fed, and she replied oh he's hospice he don't want it. The Resident received no food, and no fluids from 9:00 AM breakfast to 5:00 PM dinner (8 hours). No water was in any Resident room on the secured unit during the entire survey.
Resident #117's clinical record was reviewed. Weight documents all completed by chair scale revealed the following;
9-06-24 - 145.3 pounds on admission.
9-10-24 - 143.0 pounds out to hospital on 9-15-24 with bleeding, returned 9-20-24.
9-21-24 - 139.0 pounds
9-24-24 - 139.0 pounds
10-29-24 - 123.0 pounds
11-05-24 - 122.6 pounds
No further weights were being recorded as staff stated well, he's hospice now, so no need really. The Resident was not placed on hospice until 11-19-24, (2 weeks later with no weights completed) and remained a Full Code CPR status.
The Registered Dietician (RD) was called via cellular phone for interview and was unable to be contacted. A message was left on voicemail, however, surveyors received no call back. No RD notes were found in the clinical record, however, on 12-17-24 at 12:11 PM, the Administrator and Director of Nursing (DON) supplied one note they had received from the RD dated 10-23-24. The RD note was reviewed and revealed continued weight loss and the following 4 recommendations, none of which were followed:
1. Consider benefit of appetite stimulant medication due to poor oral intake.
2. when poor oral intake less than 50% offer alternate meal options.
3. weekly weights for one month due to readmit.
4. RD to monitor for significant changes in weight poor oral intake or skin integrity and follow up as needed.
Weekly Skin Review assessments were reviewed and were only completed on (5) weekly occasions during the Resident's 3.25 month stay equaling (13) weekly opportunities, and (8) missed weekly opportunities.
The weekly skin checks were only completed on 10-4-24, 10-21-24, 11-5-24, 11-11-24, and 12-9-24. No wounds were identified in any of the documents.
All Nursing and physician progress notes, and a care plan meeting note from 12-10-24 were reviewed and revealed no identification of a wound on the Resident until 12-11-24, when the Registered Nurse Practitioner (NP) assessed the Resident.
On 12-11-24 the NP documented on a Wound Assessment Report location sacrum, 14 centimeter (cm) length x width total measurement of the wound, 0.1 cm deep date acquired 12-11-24 in house, wound status new, stage/severity Full Thickness, 20% granulation, 80% slough, Erythema peri wound (red and inflamed), exposed tissue Epithelium, Dermis. Treatment daily and as needed cleanse with wound cleanser, hydrogel primary treatment, dressing bordered gauze.
The report documented as an etiology skin failure at end of life. While this is a chronologically correct description, it is not a diagnosis of the causation of the skin failure, which was a pressure ulcer/skin failure. The Resident was experiencing no other skin failure/breakdown anywhere else on his body. This included his face and nose having undergone treatment for cancer, and no tissue there was failing nor open.
The only skin failure for this Resident with a known high risk for skin breakdown, who suffered from incontinence of bowel and bladder was the pressure ulcer wound over a bony prominence. The Resident wore incontinence briefs and was found to be lacking adequate ADL care timely. Resident #117 was also not fed meals culminating in significant weight loss, nor given fluids adequately, culminating in dehydration and urinary tract infection with sepsis and hospitalization. He was afforded no preventive measures in place to relieve pressure while being bed ridden for 2 months per staff interview since his return from the hospital on [DATE].
Staff were interviewed on 12-11-24 and asked what interventions could be offered to a Resident to prevent pressure sores. The Director of Nursing (DON) provided a policy on Pressure Injury Prevention and Management that documented basic or routine care interventions which could include but were not limited to the following 4 items for prevention in one who was at risk for developing pressure sores. No other items were named specifically in the policy for prevention of pressure sores, and none of the 4 on the policy were followed;
1. Redistribute pressure (such as repositioning/protecting offloading)
2. Minimize exposure to moisture, and keep skin clean, especially of fecal contamination.
3. Provide appropriate pressure redistributing, support surfaces.
4. Maintain or improve nutrition and hydration status, where feasible.
The DON was asked if Foley catheters were available to those who were bed ridden with incontinence to prevent pressure sores, and she stated yes. She was asked if supplements, fluids, diet changes, and moisture barrier creams, and positioning devices were available, and she stated yes. She was asked if she was aware that the mattress for Resident #117 was the same as the ones used for the ambulatory residents on the memory care unit, and she stated she was not aware of that. None of the above prevention strategies were afforded Resident #117 for prevention of the pressure sore indicating this ulcer was potentially avoidable. On 12-11-24 a redistribution air mattress was ordered for the Resident, however did not arrive until after his move to another unit on 12-18-24 (7 days after identification of the stage 3 pressure sore.
The professional nationally recognized experts in pressure ulcer staging, identification, and care are NUPAP. The National Pressure Injury Advisory Panel. In their reference guidance literature, it documents that this wound to be a stage 3 full thickness tissue loss at identification.
On 12-11-24 a Weekly Non-pressure Wound Observation Tool document was completed by the LPN during wound rounds with the NP for the Resident and documented that the wound was first observed on 12-6-24, (even though there is no information nor documentation to support this) and the LPN documented that on 12-11-24 no inflammation was noted (in error) even though the NP documented there was Erythema (red and inflamed) by definition.
The Wound Observation Tool note completed by the LPN went on to document that the Interdisciplinary Care Planning Team (IDT) and Responsible Party (RP) were notified at that time (on 12-11-24). The IDT that was mentioned in the document was also documented in nursing progress notes and described the team as consisting only of the unit manager LPN and the new social worker which does not constitute an interdisciplinary team.
The new Social worker was also found during survey not to be qualified for the position. The Wound Observation Tool document describes that the LPN writing the note was with the NP during the observation.
The Care plan was reviewed and included focuses, goals and interventions for potential for pressure ulcer development created on 10-1-24 related to Dementia and bowel and bladder incontinence. A new care plan entry was created on 12-11-24 which identified the first actual impairment to skin integrity with interventions for the 3 following items;
1. Follow facility protocols for treatment of injury.
2. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands to avoid striking any sharp or hard surface.
3. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate, and any other notable changes or observations.
The care plan was not Resident specific and did not specify treatments, moisture barrier creams, nor devices, supplements, diet changes, nor any measures/interventions to be instituted to prevent new pressure sores, and to prevent this new pressure sore from worsening, as an interdisciplinary care plan team would be expected to produce.
On 12-12-24 Review and copy of Physician's orders was conducted, and on 12-16-24 The Medication Administration Record (MAR) was copied, which is an exact copy of the physician orders. The MAR is used to document nursing signatures to show the orders are recorded as completed. Both revealed the 2 current orders for wounds;
1. Cleanse sacrum with wound cleanser, apply hydrogel and cover with dry dressing every day start date 12-6-24. 2. Cleanse right buttock (MASD) moisture associated skin damage with wound cleanser and apply triad paste every day and evening shift start date 12-5-24, which was not identified in the NP assessment.
It is unknown why the 12-5-24 orders were derived as skin assessment documents clearly denote no wounds for this Resident until 12-11-24, and the right buttock was never mentioned in any assessments, even by the NP on 12-11-24.
No documentation of wounds existed prior to 12-11-24, and the Resident's skin was documented as intact with no wounds up to 12-11-24. No formal assessment was never completed and documented of wounds until 12-11-24. This information indicates that there may have been further wounds that existed and were not documented prior to the identification of the full thickness sacral wound found on 12-11-24.
Only one supplement was ordered for the Resident, and it follows below;
1. Mighty shake 4 ounces at bedtime ordered 10-16-24. The Might Shake was not given on the following nights, with no reason documented as to why it was withheld;
October - 10-20-24, 10-26-24.
November - 11-8-24, 11-19-24, 11-16-24, 11-29-24.
December - 12-3-24, 12-12-24, 12-14-24.
Resident #117 experienced a potentially avoidable pressure ulcer injury which was not assessed nor identified until it became a full thickness wound with dead yellow slough tissue obscuring the base of the wound by 80%. The Resident was at risk for skin breakdown after being continuously bed ridden for months, was experiencing continued significant weight loss, and was hospitalized for fecal impaction with hemorrhage, and hospitalized for a urinary tract infection, dehydration, and severe sepsis while in the facility.
No interventions were in place for a moisture barrier cream after incontinence, which was recommended in the NP note yet never ordered. The NP also recommended an air mattress which was ordered on 12-11-24, however, did not arrive until the Resident was moved a week after the identification of a stage 3 pressure sore. The pressure sore injury should have been identified during ADL care of the Resident, and no preventive interventions were ever care planned for this Resident until he exhibited a stage 3 pressure sore.
On 12-12-24 at 11:15 a.m., 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. They stated they had no further information to provide.
On 12-13-24, and 12-18-24 during a meeting with the Administrator, Director of Nursing, and Corporate clinical support consultant, the facility staff were made aware of the above concerns which could constitute harm for this Resident. Furthermore they were made aware that Residents were not being bathed and given hygiene timely, nor as often as needed, as this was the observation on days during the survey with multiple Residents being soiled and unkempt, in a dirty room with dirty linens and clothing. They were made aware that Resident #117 was not afforded preventive measures that were available such as; moisture barrier creams, Foley catheters, oral fluid increases, air mattress, protein and vitamin supplements, and alternate meal offerings.
On 12-19-24, prior to the survey exit the Director of Nursing informed surveyors that Resident #117 and his room mate had been moved back onto regular units last night (12-18-24).
At the time of survey exit on 12-19-24 the facility Administrator, and Director of Nursing stated they had nothing further to provide.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility's staff failed to provide supervision and implement interventions to reduce environmental hazards for a resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility's staff failed to provide supervision and implement interventions to reduce environmental hazards for a resident who was burned after heating up her coffee in a microwave located in a communal dining room on Unit 2, resulting in harm.
Resident #56 was originally admitted to the facility 08/22/19 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Unsteadiness on feet and Impulsiveness, Burn of first degree of left forearm, initial encounter. Burn of unspecified degree of single right finger (nail) except thumb, initial encounter. Unspecified dementia without behavioral disturbance. Unsteadiness on feet. Impulsiveness.
The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/01/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #56 cognitive abilities for daily decision making were intact.
In sectionGG(Functional Abilities and Goals) the resident was coded as independent with eating, oral care, toileting hygiene, personal hygiene, bathing/showering self. Sub section: GG0120 coded resident as using a walker as a Mobility Device.
The care plan focus dated 10/14/24 read that Resident #56 has actual impairment to skin integrity of the left third finger and right forearm burn r/t impaired safety awareness. The Goal was that resident will have no complications r/t burn of the right forearm and left third finger through the review date. The interventions: Encourage good nutrition and hydration in order to promote healthier skin, follow facility protocols for treatment of injury, identify/document potential causative factors and eliminate/resolve where possible and Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations.
During the initial rounds on 12/11/24 at approximately 10:27 AM., an interview was conducted with another resident, Resident #5 concerning warming her foods. Resident #5 mentioned We had a communal microwave in the break room. They took it away after a lady burned herself. Resident #5 also said that she didn't know the resident but after she was burned the microwave was removed and they could no longer warm their foods.
A review of the Synopsis of the event: Date of incident: 6/03/24. Time: 6:00 PM. Location: Dining Area., Type of Injury: Burn to include redness, swelling and pain. Assessment: Redness, blistering, and swelling noted to left forearm, and right middle finger. Description of event: Resident was heating up coffee in a microwave in the unit 2 dining area. When attempting to pick coffee up, resident spilled hot coffee on her hand. According to the investigative document, Resident #56 was interviewed by staff at 10:00 AM., by then Unit 2 manager, now currently, the Infection Preventionist (IP) OSM #5. The resident stated the above mentioned had occurred. According to the staff interview, the resident was heard yelling out from the dining room.
The June Treatment Administration Record (TAR).
Right 3rd finger treatment. Clean area with durable wound cleanser (dwc), apply xeroform and cover with band aide everyday shift for wound care -Start Date- 06/06/2024. Discontinued Date-06/07/2024.
Right Hand 3rd Digit. Cleanse with wound cleanser, apply bacitracin and cover with dry bandage every day shift for wound care -Start Date- 06/08/2024 0700 -Discontinued Date- 06/19/2024.
Left Forearm. Apply Skin Prep and LOA every day and evening shift for Blister -Start Date- 06/07/2024 1500 -Discontinued Date- 06/12/2024.
A review of the June 2024 TAR revealed daily wound care of the Right-Hand 3rd Digit. Cleanse with wound cleanser, apply bacitracin and cover with dry bandage every day shift for wound care -Start Date= 06/08/2024 0700. Discontinue Date =06/19/2024.
Apply Skin Prep and LOA to Left Forearm every day and evening shift for Blister. Start Date= 06/07/2024 3:00 PM. discharge date =06/12/2024.
A review of the Nurse Practitioner's Skin and Wound note on 06/05/2024 at 12:46 PM., read: Patient being evaluated for new left dorsal forearm burn and right middle finger burn secondary to coffee spill by the patient. Right middle finger with pink epithelial tissue and left dorsal forearm with intact blister. Recommend skin prep to forearm and bacitracin to right middle finger.
WOUND ASSESSMENTS: Date wounds were acquired: 6/03/24
6/05/24- Wound #1 Location: right middle finger, Primary Etiology: Burn, Stage/Severity: Partial Thickness, Wound Status: New, Odor Post Cleansing: None, Size: 2.2 cm x 0.9 cm x 0.1 cm. Calculated area is 1.98 sq cm. Wound Base: 100% epithelial, Wound Edges: Attached, Peri wound: Intact, Exposed Tissues: Epithelium, Exudate: Scant amount of Serosanguineous, Wound Pain at Rest: 6.
Wound: 2=6/04/24 Location: left forearm, Primary Etiology: Burn, Stage/Severity: Partial Thickness, Wound Status: New, Odor Post Cleansing: None, Size: 1.2 cm x 1.1 cm x 0.1 cm. Calculated area is 1.32 sq cm., Wound Base: 100% epithelial, Wound Edges: Attached, Peri wound: Intact, Exposed Tissues: Epithelium, Exudate: None amount of None, Wound Pain at Rest: 5.
PLAN: Wound #1 right middle finger Burn Treatment Recommendations: 1. Cleanse with wound cleanser. 2. apply Bacitracin ointment to base of the wound. 3. secure with Bordered gauze. 4. change BID, and PRN.
PLAN: Wound #2 left forearm Burn. Treatment Recommendations: 1. Cleanse with wound cleanser. 2. apply Skin Prep to base of the wound. 3. secure with Leave open to air. 4. change BID.
PLAN: Wound #1=6/12/24 Location: right middle finger Burn, Partial Thickness, Improving without complications. Size: 1.0 cm x 0.20 cm x 0.10. 100% epithelial, wound edges attached, peri wound intact, scant exudate, serosanguinous, no odor. Treatment Recommendations: 1. Cleanse with wound cleanser. 2. apply Bacitracin ointment to base of the wound. 3. secure with Bordered gauze. 4. change Daily and PRN.
PLAN: Wound #2=6/12/24-24 Location: left forearm, Primary Etiology: Burn, Stage/Severity: Partial Thickness, Wound Status: Improving without complications: None, Size: 1.2 cm x 0.60 cm x 0.10 cm. Wound Base: 100% epithelial, Wound Edges: Attached, Peri wound: Intact, Exposed Tissues: Epithelium, Exudate: scant, serosanguineous, no odor. Treatment recommendations: Change dressing daily, Cleanse with wound Cleanser, apply bacitracin ointment use bordered gauze.
PLAN: Wound #1=6/19/24 Location: right middle finger Burn. Wound Resolved.
PLAN: Wound #2=6/19/24-24 Location: left forearm. Wound Resolved.
On 12/12/24 at approximately 5:00 PM., during the end of day meeting. The Director of Nursing (DON), the Administrator and Corporate Staff #2., were asked if they had a Communal Microwave on Unit 2 and requested accident hazard reports on residents receiving burns. The DON said that she remembered an accident that took place months ago. The DON was asked if the microwave was still in the communal dining room. The DON said that the microwave had been removed, but she doesn't remember when the microwave was removed.
On 12/13/24 at approximately 10:10 AM., the DON and Corporate Staff #1 informed surveyor of resident #56 receiving a coffee burn months ago. Documents of the incident were given to the survey staff.
On 12/13/24 at approximately 3:55 PM., Resident not available to interview. Staff states resident was on Leave of Absence with activities.
On 12/17/24 at approximately 11:15 AM., Resident not available to interview. Staff states resident was at an appointment.
On 12/17/24 at approximately, 11:15 AM., an interview was conducted with Other Staff Member (OSM) #5. OSM #5 said that the room was for staff to heat up food, but the residents would use the microwave also. OSM #2 said that she took the microwave off the unit to keep everyone safe after the resident was burned. OSM #2 said they provided First aide to Resident #56. The forearm looked red and was swollen. Nurse didn't physically see the resident as she was warming up her coffee who used a walker for mobility on and off the unit.
On 12/17/24 at approximately 3:25 PM., an interview was conducted with Certified Nursing Assistant (CNA) #11. CNA #11 said that she heard about the incident but didn't witness it. CNA #11 also mentioned that the incident occurred in the dining room on Unit 2. CNA #11 also said that initially a resident had the microwave in his room, but it was removed and put in the dining room. Licensed Practical Nurse (LPN) #7 wrapped her hand.
On 12/17/24 at approximately 4:25 PM., an interview was conducted with Resident #56 concerning her incident. Resident #56 said that after she heated and removed her cup of coffee from the microwave, she spilled it on her hand and arm as she was using her walker.
On 12/19/24 at approximately 5:55 p.m., 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 prior to survey exit.
Based on interview, clinical record review and facility documentation the facility staff failed to ensure Residents were free from accidents, hazards receive adequate supervision and assistance devices to prevent accidents, resulting in harm for two (2) Residents (#78 & 56) in a survey sample of 74 Residents.
1. For Resident #78 the facility staff failed to implement fall precautions for a Resident known to be a high fall risk resulting in Resident #78 sustaining a fractured hip after a fall from her wheelchair, this is harm.
On 12/11/24 a review of the clinical record revealed that Resident #78 was admitted to the facility on [DATE] with diagnoses that included but were not limited to cognitive communication deficit, dysphagia, muscle weakness, dementia, severe without behavioral disturbance, psychotic mood disturbance and anxiety, abnormalities of gait and mobility, hypertension, hx (history) of renal cancer, and hx of repeated falls. Resident #78 had a BIMS (Brief Interview of Mental Status) score of 13/15 on admission indicating mild cognitive impairment. On 2/13/24 (one month prior to falls) Resident #78 BIMS was assessed at 5/15 indicating severe cognitive impairment.
A review of the clinical record revealed that Resident #78 had 6 falls from 3/23/24 through 11/24/24 (3/23/24, 3/30/24, 7/1/24, 8/2/24, 11/23/24 and 11/24/24). Each of those aforementioned falls had a Post Fall Review Sheet attached in the clinical record with the exception of the 3/23/24 fall. The progress notes for the fall on 3/23/24 read:
3/23/2024 4:53 p.m. - Note Text: Entered resident room at 4:12 pm noted resident laying on right-side head-on flood large amount of blood on floor surrounding head area. when spoke to resident she responded by saying help me, did not move resident due to large amount of blood, 911 called at 4:13pm and reported incident EMT response team arrived at 4:20pm, Place call to MD on call message left to return. received return call and they were made aware of the injury and okay to send to ER. Resident was assess [sic] by EMT and they transported resident to [Hospital name redacted] with Head Laceration. Call place to family member and spoke with family member. Call place to [Hospital name redacted] report given RN [Nurse name redacted]. Bed hole [sic] sent with paperwork.
The clinical record revealed that Resident #78 returned to the facility on 3/25/24 the progress note read as follows:
3/25/24 4:16 p.m. - Note Text: At 2:58pm resident arrived from [Hospital name redacted] via stretcher. family member in room with resident. Resident back with diagnosis of hip fracture 1. Left valgus impacted femoral neck fracture. Alert and verbally responsive, skin warm and dry [sic], respiration even no distress noted. No complain [sic] or facial expression of pain or discomfort. Old dry wound to forehead no drainage or s/s of infection observed. Peripheral IV assess to right arm antecubital. Meds verified by NP. [Nurse Practitioner name redacted]. V/S 96.9, 99%,18,96/56,77. Fall precautions in place, bed in the lowest position, call light within reach. Will continue to monitor.
A review of Resident #78's complete care plan revealed that on admission the Resident was identified as being a high fall risk as evidenced by the following entry on admission, dated 4/30/23:
FOCUS:
[Resident #78 name redacted] is High, risk for falls r/t Confusion, Gait/balance problems, Incontinence, Unaware of safety needs Date Initiated: 04/30/2023 Created on: 04/30/2023
GOAL:
[Resident #78 name redacted] will be free of falls through the review date. Date Initiated: 03/05/2024 Revision on: 04/18/2024 Target Date: 10/09/2024
INTERVENTION:
Anticipate and meet her needs. Date Initiated: 04/30/2023 Created on: 04/30/2023
Be sure call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Date Initiated: 04/30/2023 Created on: 04/30/2023
Follow facility fall protocol. Date Initiated: 04/30/2023 Created on: 04/30/2023
Pt evaluate and treat as ordered or PRN. Date Initiated: 04/30/2023 Created on: 04/30/2023.
The care plan update was not updated reviewed and revised after the fall with major injury on 3/23/24. The following revision to the care plan was made after the fall on 8/5/24.
FOCUS:
[Resident #78 name redacted] has had an actual fall with no injury, R/T Poor communication/comprehension Date Initiated: 08/05/2024 Created on: 08/05/2024
GOAL:
[Resident #78 name redacted] will resume usual activities without further incident through the review date. Date Initiated: 08/05/2024 Revision on: 08/05/2024
INTERVENTIONS:
Continue interventions on the at-risk plan. Low bed, Rt & Lt fall mats, repositioning every shift Date Initiated: 08/05/2024 Created on: 08/05/2024
Observe and report PRN to MD for s/sx: Pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. Date Initiated: 08/05/2024 Created on: 08/05/2024
Neuro checks per protocol. Date Initiated: 08/05/2024 Created on: 08/05/2024.
On 12/18/24 an interview with LPN 1 (Unit Manager), who was asked what the expectation is for nursing staff after a fall occurs and she stated that Nurses are expected to assess the Resident for injuries, notify physician and family, follow any new orders from physician pertaining to the incident, and document the fall as well as the post fall follow up, and the care plan should be updated to add new interventions after a fall. When asked if this was done after each fall, she stated that it was not.
On 12/18/24 a review of the facility FALL POLICY revealed the following excerpts:
9. When any resident experiences a fall, the facility will:
a. Assess the resident.
b. Complete a Post fall review and a Post fall follow up note in PCC [the electronic health record]
c. Complete an incident report in PCC
d. Notify physician and family.
e. Review the resident's care plan and update as indicated
f. Document all assessments and actions
g. Obtain witness statements in the case of injury
h. If there are signs of serious injury or there are concerns about the circumstances of the fall notify the Director of Nursing and or the Administrator.
i. Begin neurologic assessment using Neurological Record assessment tool in PCC
On 12/18/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0697
(Tag F0697)
A resident was harmed · This affected 1 resident
Based on a resident interview, staff interviews, and clinical record review, the facility staff failed to manage pain for one (1) of 74 residents (Resident #280), in the survey sample which resulted i...
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Based on a resident interview, staff interviews, and clinical record review, the facility staff failed to manage pain for one (1) of 74 residents (Resident #280), in the survey sample which resulted in harm.
The findings included:
Resident #280 was originally admitted to the facility 12/3/24 after an acute care hospital stay. The resident's current diagnoses included a TIA, migraines, chronic pain of the back and neck, fibromyalgia, and Raynaud's phenomena.
The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) 12/10/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #280's cognitive abilities for daily decision making were moderately impaired.
On 12/13/24 at approximately 12:55 PM an interview was conducted with Resident #280. The resident stated she arrived at the facility on 12/3/24 after 5:00 PM and she was experiencing significant neck and back pain at the time of her arrival. The resident stated she informed the nurses of her pain and her desire to be medicated before it became severe, but it was 2-3 hours before she received the pain medication, Hydromorphone 2 mg (Scheduled II narcotic).
The resident stated she did not receive her routine Morphine (Schedued II narcotic) the night of admission or at all the next day 12/4/24. She stated on 12/5/24 she began receiving a liquid Morphine, not the tablet she received in the hospital or what she took at home. Resident #280 stated she gave up hope of ever getting her pain under control while in the facility, until the liquid Morphine was started on 12/5/24.
The resident also stated by the time she received the liquid Morphine she was experiencing such excruiating pain that she was unable to lie down or sit up without wanting to scream. The resident also stated she could not participate in her care or eat. The resident further stated the first few doses of the liquid Morphine did not have the same effect as the tablets but she was grateful to finally start getting routine pain medication.
Resident #280 reiterated that no one informed her why she was not receiving the Morphine tablets or told her to request the Hydromorphone when needed. The resident stated the nurses allowed her pain to become debilitating by only administering the Hydromorphone once when the scheduled Morphine was not available.
Resident #280 was discharged from the acute care hospital to the rehabilitation facility on Morphine SR 15 milligram(mg) tablet - take one tablet by mouth every 12 hours, Gabapentin 300 mg - take two tablets by mouth three times each day, and Hydromorphone 2 mg, 1-2 tablets by mouth every three hours as needed for pain, maximum daily dose 16 tablets.
The physician order summary revealed the following pain medications, Gabapentin Capsule 300 MG - Give 1 capsule by mouth three times a day for pain (This is half of what she was discharged on) start on 12/4/24, Morphine SR 15 milligram(mg) tablet - take one tablet by mouth every 12 hours (this was discontinued on 12/4/24), Morphine Sulfate (Concentrate) Solution 20 MG/ML - Give 10 mg by mouth three times a day for pain was ordered to start on 12/5/24, and Hydromorphone tablet 2 mg - Give 1 tablet by mouth every 4 hours as needed for Pain give 1-2 tabs every 3 hours for pain, start on 12/3/24.
The person-centered care plan had a problem dated 12/12/24 which stated at risk for alteration in comfort related to pain, Raynaud's syndrome, asthma with SOB while lying flat, GERD, HTN, Hypothyroidism, HF, PVD, Depression, osteoporosis, spinal stenosis, and B&B incontinence. The goals included will alert staff to need for pain medication through next review date, Will have pain/discomfort recognized and controlled by next review date, and Will verbalize relief from discomfort through next review date, 03/12/2025. The interventions included Medicate as ordered, obtain resident rating of the pain scale face/verbal descriptor and document, and offer repositioning, pillows, to get out of bed or to return to bed to increase comfort.
A review of the Medication Administration Record revealed on 12/3/24 the resident received no pain medication even after complaining of pain of 5 out of 10 upon arriving to the facility. On12/4/24, resident #280 received Hydromorphone tablet 2 mg at 8:41 PM for pain rated as 8 out of 10. The Hydromorphone tablet 2 mg was not administered again during the resident's stay at the facility although it was available for administration as needed. The resident only received one-half of the dose of Gabapentin (300 mg three times daily for pain management) the acute care hospital discharged her to receive, and the Morphine SR was discontinued on 12/4/24 at 8:04 PM because it was on backorder from the pharmacy and Morphine Concentrate was ordered on 12/4/24 at 4:54 PM to start on 12/5/24.
On 12/19/24 at approximately 11:34 AM an interview was conducted with the Manager for Unit 4 regarding Resident #280 pain management. The Manager stated We could have done a better job managing her pain.
On 12/19/24 at approximately 6:00 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, the Owner and three Corporate Nurse Consultants. They voiced no concerns regarding the above findings.
Opioids have been regarded for millennia as among the most effective drugs for the treatment of pain. Their use in the management of acute severe pain and chronic pain related to advanced medical illness is considered the standard of care in most of the world (https://pmc.ncbi.nlm.nih.gov/articles/PMC2711509/).
Hydromorphone belongs to the opioid class of medications and is utilized to effectively manage and treat moderate-to-severe acute pain and severe chronic pain in patients. The drug exerts its analgesic effects by interacting with the mu-opioid receptors (https://pubmed.ncbi.nlm.nih.gov/29261877/).
FDA-approved usage of morphine sulfate includes moderate to severe pain that may be acute or chronic. Most commonly used in pain management, morphine provides major relief to patients afflicted with pain (https://pubmed.ncbi.nlm.nih.gov/30252371/).
Gabapentin is an anticonvulsive medication that is beneficial in managing certain types of neural pain and psychiatric disorders(https://www.ncbi.nlm.nih.gov/books/NBK493228/).
Gabapentin at doses of 1800 mg to 3600 mg daily (1200 mg to 3600 mg gabapentin encarbil) can provide good levels of pain relief to some people with postherpetic neuralgia and peripheral diabetic neuropathy (https://pubmed.ncbi.nlm.nih.gov/28597471/).
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
Resident Rights
(Tag F0550)
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 that Residents are tre...
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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 that Residents are treated resident with respect and dignity for 1 Resident (#111) in a survey sample of 29 Residents.
The findings included:
For Resident #111 the facility staff failed to ensure that Resident #111 was treated with respect and dignity during ADL incontinence care.
Resident #111 was admitted to the facility on [DATE]. Diagnoses for Resident #111 included but are not limited to fracture of right femur, aftercare following joint replacement surgery, benign prostatic hyperplasia, major depressive disorder, hx of fall, diabetes type 2, chronic kidney disease, hyperparathyroidism, and dysphagia. Resident #111 ' s Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 3/30/25 coded Resident #111 with a BIMS (Brief Interview of Mental Status) score of 15/15 indicating no cognitive impairment.
On 4/1/25 a review of the clinical record revealed the following progress notes:
3/20/25 11:46 a.m.: More than 2 episodes of Loose BM's. Resident stated he had an upset stomach this morning and is feeling better. [Nurse Practitioner name redacted] CRNP made aware of the above.
3/24/25 10:15 a.m. - Encounter for mental health services for victim of other abuse: Patient reports he was having frequent stools over the weekend. He reports the CNA had an attitude about having to change him frequently. He reports his CNA told him she could not keep coming in here and changing him. Patient denies any physical abuse, denies any injuries. Patient reassured that he is in a safe environment with people that are here to help him. Specifics of allegations reported to the unit manager. Patient unable to tell me specifically which day the event occurred or the name of the CNA.
On the afternoon of 4/3/25 an interview was conducted with the Social Worker, the Administrator and the Unit Manager for Resident #111 ' s unit. The Social Worker stated that when the family member emailed her on 3/23/25, they stated that Resident #111 was pretty upset and told them the One of the cna's / nurses got rough today cleaning up after he had a bowel movement. Slamming stuff down . When asked what she did when she received the email, she stated that she and the Unit Manager for that unit went to interview Resident #111.
The Social Worker stated that when she interviewed the Resident he did not claim to be abused.
When asked about the types of abuse she was able to state the different types of abuse (physical, sexual, financial, verbal, emotional / psychological).
A review of the Grievance Form filled out by the Unit Manager dated 3-24-25 read as follows:
[Resident #111 name redacted] Date: 3-24-25 Grievance / Concern Received by: Daughter & Resident. Reported To: [Unit Manager name redacted]
Summary of Grievance: CNA rude and spraying .
Resolution: CNA counseled.
On the afternoon of 4/3/25 an interview with CNA #1 was conducted and she was asked if she had taken care of Resident #111, and she stated that she had. When asked about the interaction she had with Resident #111, and she stated that he had to be changed, and she admitted to spraying air freshener in the room when she was changing him. She also stated that she was singing while she was changing him. She denied slamming things, she denied being rude or disrespectful. When asked if it could be perceived as rude to be spraying air freshener while cleaning up a resident, she stated that she did not feel it was rude. When asked if she thought it was unprofessional to be singing while caring for a resident, she stated that she Always Sings.
A review of the personnel file for CNA #1 revealed the following excerpts from the Counseling Form related to this incident:
Reason for action: Report of [CNA name redacted] spraying air freshener and mumbling under her breath after providing care to a resident that had a BM [bowel movement], causing the resident to feel embarrassed and uncomfortable
Goals specifically related to employee's recent job performance:
1. Maintain professionalism
2. Remain sensitive to resident's perception
3. Maintain dignity.
A review of the facility policy entitled Abuse Neglect and Exploitation Policy # 10171 revealed the following excerpts:
Definitions:
Verbal Abuse: Means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing
distance regardless of their age, ability to comprehend, or disability.
Mental Abuse: includes but is not limited to, humiliation, harassment, threats of punishment or deprivation .
On 4/3/25, 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 there was a self-administration of medication assessment prior to leaving medications at the bedside for one (1) of 74 residents (Resident #91) in survey sample.
Findings included:
For Resident # 91, the facility staff failed to ensure there was a self-administration of medication assessment prior to leaving medications at the bedside.
Resident # 91 was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Cerebral Infarction, Hypertension, Anxiety Disorder, Hemiplegia and Vascular Dementia.
The most recent Minimum Data Set (MDS) was an Annual Assessment with an Assessment Reference Date (ARD) of 11/3/2024. Resident # 91's BIMS (Brief Interview for Mental Status) Score was a 14 out of 15, indicating no cognitive impairment. Resident # 91 required assistance with Activities of Daily Living.
Review of the clinical record was conducted on 12/10/2024-12/19/2024.
During the initial tour on 12/10/2024 at approximately 2:10 p.m., a medication cup with two white pills was observed on the overbed table by the bed by the window. The pills were white in color; one was oval and the other was round in shape. The resident was not in the room when the surveyor walked into the room.
There was no nursing staff member in the hallway when the surveyor looked for someone to ask about the medications.
After approximately eight (8) minutes, a facility staff member was observed in the hallway. She identified herself as the Admissions Coordinator. She was asked if she knew who resided in the room. She identified the resident's name as Resident # 91. The Admissions Coordinator stated she would find a nursing staff member.
On 12/10/24 at 2:23 p.m., Resident # 91 entered the room as the Admissions Coordinator was leaving the room. When asked about the medication in the cup, Resident # 91 stated that was the medicine from this morning. He stated that he told the nurse he was going to take it. Resident # 91 stated he wanted to take his time taking his medications. He stated he was not sure of the kind of pills but thought one was Trazadone.
On 12/10/2024 at 2:34 p.m., an interview was conducted with the Unit Manager, LPN (Licensed Practical Nurse)- # 1 who stated there was no self administration by any residents on the unit. She stated none of the residents on the unit had assessments with orders for self administration of medications.
On 12/10/2024 at 2:39 p.m. an interview was conducted with the nurse (LPN-3) scheduled to pass medications on that day. LPN-3 stated she administered the morning medications for Resident # 91. LPN-3 stated the medications in the medication cup were not the medications scheduled for administration in the mornings. LPN-3 stated she did not see the medication cup with medications on the overbed table when she administered the medications that morning. LPN-3 stated medications should not be left at the bedside.
The Administrator came to Resident # 91's room with the surveyor. The Administrator observed the medication cup on the overbed table and asked Resident # 91 where the medications had come from. Resident # 91 told the Administrator that medications were from that morning and that he would take them right then. The Unit Manager informed Resident # 91 that the staff needed to determine which medications were in the medicine cup.
The Unit Manager and Administrator removed the medications from the room.
LPN # 3 and the Unit Manager reviewed the December 2024 Medication Administration Record and the Medication pill cards to compare with those found at the bedside. They determined that the two pills were two medications that were scheduled to be administered at bedtime at 2100 (9:00 p.m.): Atorvastatin 40 mg (milligrams) give one tablet by mouth at bedtime for hyperlipidemia and Melatonin 3.1 mg (milligrams) give one tablet by mouth at bedtime for insomnia.
Review of the December 2024 Medication Administration Record revealed the two medications had been documented as administered every night except when refused by the resident on 12/4/2024 and 12/6/2024.
The Unit Manager discarded the medications that were in the medication cup. She stated she did not know when the medications had been left at the bedside.
During the end of day debriefings on 12/10/2024 and 12/11/2024, the Administrator, Director of Nursing and Regional Nurse Consultant 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 Medication Administration Policy dated 11/01/2020, reviewed and revised 12/1/2022 revealed the following policy statement: Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice . Under Policy Explanation and Compliance Guidance were the following excerpts:
15. Observe resident consumption of medication. and
17. Sign MAR after administered . and
19. Report and document any adverse side effects or refusals.
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 F0558
(Tag F0558)
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 Residents were transpo...
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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 Residents were transported to outside medical appointments, for two (2) Residents (#'s 378 and 381) in a survey sample of 74 Residents.
The findings included:
1. For Resident #378 the facility staff failed to ensure transportation to outside medical appointments causing the Resident to miss three (3) appointments.
On 12/11/24 a review of the clinical record revealed that Resident #378 was admitted to the facility on [DATE] with diagnoses that included but were not limited to encephalopathy, type 2 diabetes, UTI (urinary tract infection), surgical amputation of left lower leg, peripheral vascular disease, dysphagia, acquired absence of right lower leg, g-tube dependance due to malnutrition, depression, hypertension, urinary retention, benign prostatic hyperplasia with lower urinary tract symptoms and obstructive sleep apnea
Resident #378's discharge instructions included follow up with the surgeon on 3/5/24. A review of the clinical record revealed that the transportation was not there on 3/5/24 and the appointment was rescheduled to 3/13/24 at 2 p.m. again the record reflects the appointment was rescheduled to 3/27/24 due to transportation issues. According to the progress notes Resident #378 did not attend that appointment because on 3/23/24 he left the facility to go to the emergency room and was subsequently admitted to the hospital.
Excerpts from the progress notes are as follows:
Effective Date: 03/06/2024 11:43 Type: Appointment Note Note Text : Rescheduled to March 13, 2024 @ 2:00p (WHEELCHAIR p/u 1:00pm) Orthotic & Prosthetic [Name address and number of office redacted]
Effective Date: 03/19/2024 4:30 Type: Appointment Note Text Rescheduled to March 27,2024 @ 10:00am (STRETCHER p/u 9:00am) Orthotic & Prosthetic service [Name address and number of office redacted]
3/23/2024 11:31 p.m. -Note Text: admitted to [Hospital name redacted] for encephalopathy and UTI.
On 12/11/24 at approximately 12:00 p.m. an interview was conducted with LPN #4 who stated that the appointments and transportation used to be scheduled by the Unit Managers, when asked what the procedure was if transportation did not arrive, she stated that they were to call the doctor and reschedule and call transportation and reschedule. When asked if this happened more than once for the same appointment what was the procedure, she stated we just call and reschedule again.
On the morning of 12/17/24 an interview was conducted with the DON who stated that unit managers used to schedule the appointments and transportation but now it is done by Social Worker. She stated that the staff do their best to ensure that Residents have transportation to outside appointments.
On 12/19/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.
2. For Resident #381 the facility staff failed to ensure transportation to outside appointment with Cardiology resulting in at least 4 missed appointments.
On 12/16/24 a review of the clinical record revealed that Resident #381 was admitted to the facility on [DATE] with diagnoses that included but were not limited to unspecified dementia, hypertension, dysphagia, anxiety, major depressive disorder, atherosclerotic heart disease, difficulty walking, and cognitive communication deficit.
The following are excerpts from the progress notes regarding scheduling of transportation for outside cardiology appointments.
12/22/21 2:53 p.m. - Note Text: This resident was scheduled to have a cardiology appointment today with Pickup time at 0833. Per medical records personnel, she stated that she would cancel the appointment due to transportation issues. This Nurse reported this information to Unit Manager. No further issues noted at this time, will continue to monitor.
2/3/22 11.34 a.m. - Note Text: [Resident name redacted] was unable to attend her appointment on today. [family member name redacted] son and [family member name redacted], daughter, emailed and stated they would not be able to attend her appointment. [Resident name redacted] appointment is March 17 at 11:30am.
4/12/22 10:34 - Note Text: [NAME] spoke with residents daughter, [NAME] regarding resident pacemaker appointment 4.28.22 at 10:00am. Resident's daughter will accompany resident to her appointment.
DSS also followed up with [Ombudsman name and phone number redacted] regarding who will accompany resident to her appointment.
4/15/2022 12:52 - Note Text: DSS called to confirm transportation on 4/28/22 and called resident's daughter to confirm she will attend the appointment via transportation with resident. Transportation schedule is uploaded in resident's e-chart.
4/28/22 1:14 p.m. - Note Text: On 4.19.22 and 4.27.22, DSS called to confirm residents doctor appointment for 5/28/22.DSS also called resident's daughter to confirm she would ride in the transportation vehicle with her mother. Transportation company and resident's daughter both confirmed. On 4/28/22 at approximately 8:15am, the day of the doctor visit, resident's daughter arrived at the facility to ride along with her mother. Pick up time was 8:55am, check in time was 9:45am and appointment time was 10:00am. At approximately 9:25am, resident's daughter called DSS from the facility to ask the ETA for transportation ' s called transportation [phone number redacted], reference number [redacted]. Transportation informed DSS the vehicle would be late, and transportation would call the doctor's office [phone number and physician name redacted] Cardiology to request a later appointment time. Due to resident no show, the doctor's office cancelled resident's appointment.
On the morning of 12/17/24 an interview was conducted with the DON who stated that unit managers were scheduling the appointments and transportation but now it is done by the social worker. She stated that the staff do their best to ensure that Residents have transportation to outside appointments.
On 12/19/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0560
(Tag F0560)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to afford a resident the ability to refuse a transfer affecting one (1) resident (Resident #226) in a survey sample of 74 Residents.
The findings included:
For Resident #226, who refused a transfer to the locked memory care unit for Residents with dementia and behaviors, the facility staff failed to honor the Resident's request. The staff moved him against his will, for staff convenience.
Resident #226 was admitted to the facility on [DATE] with diagnoses including: End stage renal disease with hemodialysis, history of stroke, anemia, chronic congestive heart failure, hypertension, and diabetes type 2. The Resident did not have a diagnosis of dementia and was his own responsible party and by facility agreement cognitively intact and able to make his own decisions.
Three MDS (minimum data set) federal assessments were reviewed since the resident's admission through the time of survey on 12-10-24. Those follow below:
1. The first MDS admission assessment was dated 6-10-24 and indicated the Resident had a Brief Interview for Mental Status BIMs score of 8 of a possible 15 points upon admission after Acute hospitalization for encephalopathy from a fall and missing hemodialysis. He was coded in the document as able to understand and be understood, no aberrant behaviors, needed only limited assistance with most (activities of daily living) ADLs such as toileting, ambulating, hygiene, transferring, and bed mobility, and was dependant on staff only for bathing, however needed only tray set up and clean up for meals.
2. The second MDS was a quarterly assessment dated [DATE] which indicated the Resident had a Brief Interview for Mental Status BIMs score of 11 of a possible 15 points after a rehospitalization for septic shock due to hypovolemia, as no infection was found to support septic shock, nor sedation as narcan had no effect. He was coded in the document as able to understand and be understood, no aberrant behaviors, and functional abilities were not coded.
3. The third MDS was a quarterly assessment dated [DATE] indicated the Resident had a Brief Interview for Mental Status BIMs score of 10 of a possible 15 points. He was coded in the document as able to understand and be understood, no aberrant behaviors, needed only set up and clean up for bathing, otherwise, was completely independent for all (activities of daily living) ADLs such as toileting, ambulating, hygiene, transferring, and bed mobility, and eating.
On 9-26-24 at 4:42 PM the Resident was moved to the memory care locked unit and the resident's son was notified according to the room change notification document in the clinical record, however, the document stated that the resident's brother agreed to the room change even though these individuals were only emergency contacts and the resident refused and was his own responsible party. The reason given for the move, was elopement risk. The resident had never eloped and on the one occasion that he went outside to sit in the sun after dialysis he did not leave, even though he could have walked away, he simply sat there until staff came to take him back to his room. When asked about this incident the resident stated there is no reason that I can't sit outside for awhile and get some fresh air. I am not a prisoner.
During an initial interview on 12-10-24, at 11:40 AM, Resident #226 was found to be alert and oriented to person, place, time, and situation. He stated that he had requested to stay in his current room after learning that the facility planned to move him rather than discharge him home. Resident #226 stated he was told his son and grandson were not able or willing to care for him in the home that the three of them had formerly shared. The resident insisted on planning a discharge back to the community, or an assisted Living Facility as soon as possible, however, he stated no one listened, no one came to talk to me about it, and nothing ever happened even though I kept telling them.
During this interview, Resident #226 verbalized that he is a dialysis patient and that he received dialysis there in the facility. He further stated he hates the memory care unit because everyone is crazy in here, they wander into my room and take things, my room mate yells and cries all night for something to drink, I don't even get food every meal, the room is nasty and falling apart, and I can't even get a shower in here because the showers are so nasty dirty. He went on to say I like to walk around, it makes the time go faster, if I don't walk now I won't be able to leave, but locked in here I have no where to walk, I don't even have a TV to watch and I love TV, being in here will make you crazy with nothing to do.
The surveyor and resident then immediately walked to the shower room for an initial observation and found it to be dirty, mildewed/moldy, foul smelling, had a strong odor of urine and feces, trash and debris littered the floor, used brown stained wet linens were on the floor, a white crusted substance was on the floor and walls, used soap and shampoo bottles were crusted on the shelves and hand rails in the shower, and the room was being used as a storage area as well for boxes of supplies and durable medical equipment. The resident asked would you want to take a shower in here?
It is notable to mention that no activities were noted to be conducted in the secured unit from 12-10-24 until 12-18-24. The staff were asked why no activities were being conducted for the residents and they replied that we only have one activity person for the whole 150 bed facility.
Facility CNA (Certified nursing Assistant) and LPN (Licensed Practical Nurse) staff on the memory care unit and other units were interviewed, and stated the reason that Resident #226 had been placed on the memory unit was wandering and behaviors When asked what his behaviors were, they were only able to say he went outside and sat in his wheel chair one time after dialysis, and further stated he would wander up and down the halls and that will get you put in here for sure. The surveyor asked why he walked, and there was no response.
The Social worker was interviewed on 12-10-24 and revealed that she had just been hired on 11-19-24. The former Social worker resigned on 6-28-24, and there had been no social worker in the facility from 6-28-24 until 11-19-24. She stated she would be putting in a progress note for Resident #226 on this same day, and she stated that she didn't really know much about him.
On 12-11-24 the social work note was reviewed and revealed a progress note that documented the Resident as long term care during a care planning meeting, and nothing about discharge planning or his desire to be discharged .
On 12-12-24 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 not sufficient for the role.
The Director of Nursing and Administrator were asked for a policy or procedural guidance for moving a Resident onto the memory care locked unit. Both stated that they did not have one, and could not describe a pathway to the decision for moving a resident into the secure unit.
On 12-11-24, through 12-19-24 a clinical record review was conducted. There was no evidence in the clinical record that the physician had been called and notified of the resident's move, nor was a request made for assessment and told that the resident wished to discharge.
On 12-5-24 a PHQ-9 (the only one during his stay) evaluation for depression was conducted and gave a score of 3 which equaled minimal or not at all suffering from depression. The Resident was not ordered to have any psychoactive medications, nor did he have any diagnoses to support the use of them.
On 12-12-24, during an end of day debriefing with the Administrator, Director of Nursing, and Corporate clinical support consultant, the facility staff were made aware of the above concerns and that the Resident had requested to stay in his room, and to be planned for discharge, which was denied and there was no evidence that the physician was notified of this request. Further they were notified that no Social Worker was providing care during the Resident's stay which compounded the incident further, which culminated in the withholding of a resident's rights, and involuntary seclusion.
On 12-19-24, prior to the survey exit the Director of Nursing informed surveyors that Resident #226 and his room mate had been moved back onto regular units last night (12-18-24).
At the time of survey exit on 12-19-24 the facility Administrator, and Director of Nursing stated they had nothing further to provide.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0568
(Tag F0568)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a resident personal funds review, the resident interview, staff interview and facility document review, the facility st...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a resident personal funds review, the resident interview, staff interview and facility document review, the facility staff failed to ensure that one (1) resident out of 74 residents in the survey sample, Resident #24, was afforded the right to receive quarterly statements.
The findings included;
Resident #24 was originally admitted to the facility 11/17/22 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included Schizoaffective Disorder, Bipolar type.
The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 09/19/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #24 was moderatly impaired for the cognitive abilities for daily decision making.
The care plan dated 11/24/23 read that Resident #24 has impaired thought processes as evidenced by delusions secondary to schizoaffective/bipolar disorder. The goal for the resident was for the resident will be able to communicate basic needs on a daily basis through the review date 10/01/24. The Interventions: Present just one thought, idea, question or command at a time and monitor/document/report PRN any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status.
On 12/11/24 at approximately 1:23 PM., during the initial tour Resident #24 said that the facility was not given her money and that she was not receiving quarterly statements.
On 12/18/24 at approximately 2:35 PM., an interview was conducted with the Business Office Manager (BOM) and with the Regional BOM. The BOM said that the resident's funds come to the facility to her resident funds account and to resident's guardian services. The BOM also mentioned that the facility is the Representative Payee (RP). The Regional BOM said that the resident must come to the business office to request funds. The Regional BOM also mentioned that Letters (quarterly statements) are mailed to the Guardian Services and the resident must come to us first to ask for the statement. We're still going to send the statements to her Guardian Services.
On 12/19/24 at approximately 2:56 PM, a meeting was conducted with the BOM concerning the above issues. The BOM said that to her knowledge the Resident requested funds for first time on 12/18/24. The BOM also said that she will give the Resident a statement every month and a quarterly statement.
On 12/19/24 at approximately 5:55 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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, the facility staff failed to ensure the physician was notified of pertinent in...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, the facility staff failed to ensure the physician was notified of pertinent information regarding two (2) residents (Resident # 327 and # 326) in a survey sample of 74 residents.
Findings included:
1. For Resident # 327, the facility staff failed to notify the Physician that medications were not available and not administered as ordered.
Resident # 327 was a [AGE] year old admitted to the facility on [DATE], with diagnoses that included but were not limited to: Asthma, emphysema, Pulmonary Fibrosis, Seizure disorder, Chronic anxiety and depression, Hypothyroidism and Gastroesophageal reflux disease, history of Pulmonary Embolism, orthostatic hypotension and chronic hypoxic respiratory failure-on oxygen at 4 liters per minute via nasal cannula, Congestive Heart Failure. Cerebral Vascular Accident.
The most recent MDS (Minimum Data Set) assessment was coded as an admission assessment with an ARD (Assessment Reference Date) of [DATE]. The BIMS (brief interview for mental status) assessment was coded as 15 out of possible 15, indicating no cognitive impairment. The assessment also coded Resident # 327 as requiring assistance with activities of daily living; and frequently incontinent of bowel and always incontinent of bladder.
The resident was readmitted to the facility on [DATE] and expired in the facility on [DATE].
Review of the clinical record was conducted [DATE]-[DATE].
Note Text : Lidocaine HCl (PF) Injection Solution 1 %
Inject 3.5 ml intramuscularly one time a day for UTI for 2 Days
awaiting from rx- The medication was prescribed for 2 days. Review of the MAR revealed only one dose was given on [DATE]. There was no documentation of the second dose being given as ordered. There was no documentation that the physician was notified the second dose of Lidocaine was not administered as ordered.
Topiramate Tablet 100 MG (milligrams)
Give 1 tablet by mouth three times a day for Seizure three times per day
Review revealed that 4 doses of Topiramate were not available on:
[DATE] at 8 a.m.
[DATE] at 8 a.m.
[DATE] at midnight
[DATE] at 8 a.m.
There was no documentation of the physician being informed of 2 consecutive doses of Topiramate not being administered.
Adderall XR Capsule Extended Release 24 Hour 15 MG
Give 1 capsule by mouth two times a day for ADHD (Attention Deficient Hyperactivity Disorder) (scheduled at 9 a.m. and 9 p.m.
Review revealed that 3 doses of Adderall were not available on: [DATE] at 9 a.m.
[DATE] at 9 p.m.
[DATE] at 9 a.m.
There was no documentation of the physician being informed of 2 consecutive doses of Adderall not being administered on [DATE] and another missed morning dose on [DATE]. Therefore, there were 3 missed doses in 36 hours.
On [DATE] at 3:05 p.m., an interview was conducted with LPN (Licensed Practical Nurse) # 3 who stated if the medication was not available, the nurse was expected to check the Cubex (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 and notify the physician that the medication was not available for administration as ordered.
On [DATE] at 10:20 a.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 and check the Cubex. The Director of Nursing stated the nurses should notify the physician if the medication was not available to be administered in case the physician might want to order another medication or change the treatment plan.
On [DATE] at 11 a.m., an interview was conducted with the Regional Nurse Consultant (Corporate # 1) who stated medications should be available for administration as ordered by the physician. Corporate # 1 stated the Pharmacy should have ensured the medication was available for administration. She also stated the nurses should have checked the Cubex (in house Stat box) for an available supply of the medication.
During the end of day debriefing on [DATE], the Facility Administrator, Regional Nurse Consultant and and Director of Nursing were informed of the findings.
No further information was provided.
2. For Resident # 326, the facility staff failed to notify the physician that wound care was not provided as ordered by the physician.
Resident # 326 was a [AGE] year old admitted to the facility on [DATE], with diagnoses that included but were not limited to: Calciphylaxis a rare serious disease that involves build up of calcium in small blood vessels of fat tissue and skin. People with the disease usually have kidney failure or receive dialysis.
The most recent MDS (Minimum Data Set) assessment was coded as an admission assessment with an ARD (Assessment Reference Date) of [DATE]. The BIMS (brief interview for mental status) was coded as 15 out of possible 15 indicating no cognitive impairment. The assessment also coded Resident # 326 as requiring assistance with activities of daily living;
Review of the clinical record was conducted on [DATE] to [DATE].
Review of the clinical record revealed documentation of wound care not being provided for Resident # 326 as ordered by the physician. There was missing documentation of wound care being administered 6 times during the stay at the facility. The missing documentation of wound care included the following dates: [DATE] at 8 p.m., [DATE] at 8 a.m. and 8 p.m., [DATE] at 8 a.m. and 8 p.m., and [DATE] at 8 a.m.
Left breast wound cleanse with DWC (Dakin's Wound Cleanser) pack BID (twice a day) with
Dakin's solution cover with Mepilex or Border gauze
two times a day for wound care
-Start Date-
[DATE] 2000
-D/C Date-
[DATE] 1315
Scheduled BID (twice a day) for 8 a.m. and 8 p.m.
On [DATE] at 9:45 a.m., an interview was conducted during Medication Pour and Pass Observation with Licensed Practical Nurse # 1 who stated medications and treatments should be signed off at the time of administration. She stated there should be no blanks in the documentation because there was a code for refusals. Any blanks would be an indication the administration did not occur. She stated the nurse could also write a progress note about any refusals.
On [DATE] at 2:10 p.m., an interview was conducted with the Director of Nursing who stated the Wound care specialist made rounds weekly on the residents with wounds. The Director of Nursing stated wound care was expected to be provided as ordered by the Physician.
Review of the Weekly skin Assessments revealed assessments were done on [DATE] and [DATE].
Wound care Specialist's notes revealed wound care assessments were done on [DATE] and [DATE].
Review of note of the Wound Care Specialist's evaluation on [DATE] at 8:34 a.m. revealed the following description:
Location: left breast
Wound ID:____ (redacted)
Measurements
Length: 2.67 cm (centimeters) -- Red: 13.23 cm² --
Width: 7.70 cm -- Black: 0.00 cm² --
LxW: 20.56 cm² -- Yellow: 0.21 cm² --
Depth: -- -- Pink: 3.11 cm² --
Total: 16.56 cm² -- Other: 0.00 cm² --
Observations
% granulation 100.00
Depth (cm) 0.20
------------------------------------------ Calciphylaxis
Other Normal saline wet to dry gauze BID
Wound Status Present on admission
Acquired in House? No
Etiology Other
Margin Detail Attached edges
Drain Amount Moderate
Drain Description Serosanguinous
Odor No Odor
Periwound Intact
Pain 4
Dressing Change Frequency BID
Cleanse Wound With Wound Cleanser
Dressings Other: See Notes
Secondary Dressing Bordered gauze
PUSH Score 0
Signature
Review of note of the evaluation on [DATE] at 8:11 a.m. revealed the following description:
Length: 9.77 cm (+265.7) Red: 25.99 cm² (+96.4)
Width: 3.80 cm (-50.7) Black: 0.00 cm² (+0.0)
LxW: 37.13 cm² -- Yellow: 0.00 cm² (-100.0)
Depth: -- -- Pink: 2.01 cm² (-35.5)
Total: 28.00 cm² (+69.1) Other: 0.00 cm² (+0.0)
Observations
% granulation 100.00
Depth (cm) 0.20
------------------------------------------ Calciphylaxis
Other Normal saline wet to dry gauze BID
Wound Status Worsening
Acquired in House? No
Etiology Other
Additional woundbed details Bleeding
Margin Detail Attached edges
Drain Amount Heavy
Drain Description Sanguinous
Odor No Odor
Periwound Intact
Pain 4
Dressing Change Frequency BID
Cleanse Wound With Wound Cleanser
Dressings Other: See Notes
Secondary Dressing Bordered gauze
PUSH Score 0
Review revealed the Wound Care Specialist evaluated the wound on [DATE] and described it as worsening and with heavy sanguinous drainage. Resident # 326 was transferred emergently to the emergency room on [DATE] with complaints of bleeding from the left breast and hypotension, Resident # 326 ultimately expired in the hospital on that same day.
There was no documentation that wound care was provided as ordered by the physician. Documentation revealed that two days prior to the day Resident # 326 was transferred emergently to the hospital, wound care was not provided three times consecutively ([DATE] at 8 a.m., [DATE] at 8 p.m. and [DATE] at 8 a.m.) The documentation during the week prior revealed there had been three consecutive times when wound care was not provided ([DATE] at 8 p.m., [DATE] at 8 a.m. and 8 p.m.) There was no documentation that the physician was notified that wound care had not been provided as ordered.
During the end of day debriefing on [DATE], the Facility Administrator and Director of Nursing were informed of the findings.
No further information was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review, the facility staff failed to maintain the confidentiality of m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review, the facility staff failed to maintain the confidentiality of medical records for two residents (Residents #'s 39, 74) in a survey sample of 74 residents.
Findings included:
1. For Resident # 39, the facility staff failed to honor the resident's right to privacy and maintain confidentiality of medical records when the screen for documentation of Activities of Daily Living was left open for others to easily view on 12/10/2024.
Resident # 39 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, Chronic Obstructive Pulmonary Disease, Emphysema, Primary Hypertension, Anxiety, Depression, Gastrpesophageal Reflux Disease, Barrett's Esophagus, Dysphagia and Insomnia.
The most recent Minimum Data Set (MDS) was a Quarterly Assessment Quarterly with an Assessment Reference Date (ARD) of 11/17/2024. Resident # 161's BIMS (Brief Interview for Mental Status) Score was a 15 out of 15, indicating no cognitive impairment.
Review of the clinical record was conducted on 12/10/2024-12/19/2024.
While the survey team was entering the facility for the initial tour on 12/10/2024 at approximately 11:40 a.m., the Point of Care Kiosk where the Certified Nursing Assistants document the Activities of Daily Living into the electronic health records was observed to be open and unattended by a staff member. The personal information for a resident was openly displayed on the screen. The surveyors could read the information clearly. There was no staff member observed in the hallway. The Kiosk was located on Unit One at the end of the hallway nearest to the lobby entrance to the unit. The resident was identified and placed in the sample as Resident # 39.
The surveyor waited at the Kiosk until a staff member was observed walking toward the nurses station. The staff member identified herself as the Unit Manager, LPN (Licensed Practical Nurse) # 1 on Unit one. An interview was conducted with LPN # 1 who stated the facility staff should not leave the Kiosk unattended. LPN # 1 stated she would determine who left the Kiosk unattended.
While the surveyor was talking with LPN # 1, a nursing staff member -CNA (Certified Nursing Assistant) # 1- came out of one of the rooms near the end of the hall close to the Kiosk. She identified herself as the one who had left the screen open for viewing. CNA# 1 apologized and stated that she thought she had closed the screen prior to going to help another resident.
On 12/10/2024 at 2:25 p.m., an interview was conducted with CNA # 1 who stated that she normally would stay at the Kiosk until the screen closes but that she responded to the call light in the room of another patient who needed help immediately. CNA # 1 stated she understood that it was important to keep the residents' information confidential and to protect their privacy.
Review of the facility census revealed that Resident # 39 was a resident on Unit One.
During the end of day debriefing on 12/11/2024, the Facility Administrator and Director of Nursing were informed of the findings. They stated that residents information should be kept confidential and privacy protected.
No further information was provided.
2. For Resident # 74, the facility staff failed to honor the resident's right to privacy and maintain confidentiality of medical records when the screen for documentation of Activities of Daily Living was left open for others to easily view on 12/12/2024.
Resident # 74 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, Dementia, Diabetes, Major Depressive Disorder, Anxiety, Depression, Vitamin B 12 deficiency and Dysphagia.
The most recent Minimum Data Set (MDS) was a Quarterly Assessment Quarterlywith an Assessment Reference Date (ARD) of 11/7/2024. Resident # 74's BIMS (Brief Interview for Mental Status) Score was a 00 out of 15, indicating severe cognitive impairment.
Review of the clinical record was conducted on 12/13/2024-12/19/2024.
While the survey team was exiting the facility on 12/12/2024 at 5:40 p.m., the Point of Care Kiosk where the Certified Nursing Assistants document the Activities of Daily Living was observed to be open and unattended by a staff member. The personal information for a resident was openly displayed on the screen. The surveyors could read the information clearly. There was no staff member observed in the hallway. The Kiosk was located on Unit One at the end of the hallway nearest to the lobby entrance to the unit. There were meal serving carts in the hallway. There were visitors observed walking in the hallway at the other end of the hall.
The resident was identified and placed in the survey sample as Resident # 74.
Review of the facility census revealed that Resident # 74 did not reside on Unit One where the Kiosk was open. Resident # 74 resided on the locked Memory Care unit which was down the other end of the hallway.
On 12/16/2024 at 10:50 a.m., an interview was conducted with the Director of Nursing who stated the staff should not leave the Kiosks open and unattended where others can view the information. The Director of Nursing was asked to determine who was assigned to work with Resident # 74 on 12/12/2024 and was documenting in the record around the time the surveyors were leaving.
During the end of day debriefing on 12/18/2024, the facility Administrator and Director of Nursing were informed of the findings. The information about who was had been documenting in the clinical record on 12/12/2024 was not provided by the end of the survey.
No further information was provided.
CONCERN
(D)
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 resident interview and staff interview, the facility staff prohibited and discouraged a resident from communicating wit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview and staff interview, the facility staff prohibited and discouraged a resident from communicating with the state surveyor for one (1) of 74 residents (Resident #226), in the survey sample.
The findings included:
Resident #226 was originally admitted to the facility 6/6/2024 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included end stage renal disease requiring hemodialysis, dementia and atrial fib.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/13/2024 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #226's cognitive abilities for daily decision making were moderately impaired.
On 12/12/24 at approximately 12:20 PM an interview was conducted with Resident 226. Resident #226 stated he did not know why he had to continue to live on the Memory Care unit. The resident pointed out that no one who resided on the unit wore shoes and it was his desire to no longer be confined to the locked unit for he enjoyed going outside for fresh air and buying coffee from the 7/11 store.
A review of the resident's care plan revealed a care plan problem dated 10/16/2024 which stated (name of the resident) has little or no activity involvement related to disinterest and physical limitations. The goal stated (name of the resident) will participate in activities of choice 2-3 times per week by review date, 3/18/25. The interventions included explain to (name of the resident) the importance of social interaction, leisure activity time, encourage the resident's participation by inviting him to games, crafts, and listening to music. There was no intervention to ensure the resident is offered the opportunity to go outside for fresh air.
On 12/13/24 at approximately 12:03 PM the resident stated he was informed by a staff member, who he was unable to name, that if approached by a surveyor that he could not talk to the surveyors anymore because he had told the state surveyor too much and it would cause them (the facility) trouble.
On 12/19/24 at approximately 6:00 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, the Owner and three Corporate Nurse Consultants. The Corporate Nurse Consultant stated they were aware that residents should not be discouraged from talking with the surveyors.
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 interview, clinical record review and facility documentation the facility staff failed to implement the abuse policy fo...
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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 implement the abuse policy for reporting allegations of abuse for 1 Resident (#111) in a survey sample of 29 Residents.
The findings included:
For Resident #111 the facility staff failed to follow abuse reporting guidelines set forth in the State Operations Manual and the facility abuse policy.
Resident #111 was admitted to the facility on [DATE]. Diagnoses for Resident #111 included but are not limited to fracture of right femur, aftercare following joint replacement surgery, benign prostatic hyperplasia, major depressive disorder, hx of fall, diabetes type 2, chronic kidney disease, hyperparathyroidism, and dysphagia. Resident #111 ' s Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 3/30/25 coded Resident #111 with a BIMS (Brief Interview of Mental Status) score of 15/15 indicating no cognitive impairment.
On 4/1/25 a review of the clinical record revealed the following progress notes:
3/20/25 11:46 a.m.: More than 2 episodes of Loose BM's. Resident stated he had an upset stomach this morning and is feeling better. [Nurse Practitioner name redacted] CRNP made aware of the above.
3/24/25 10:15 a.m. - Encounter for mental health services for victim of other abuse: Patient reports he was having frequent stools over the weekend. He reports the CNA had an attitude about having to change him frequently. He reports his CNA told him she could not keep coming in here and changing him. Patient denies any physical abuse, denies any injuries. Patient reassured that he is in a safe environment with people that are here to help him. Specifics of allegations reported to the unit manager. Patient unable to tell me specifically which day the event occurred or the name of the CNA.
On the afternoon of 4/3/25 an interview was conducted with the Social Worker, the Administrator and the Unit Manager for Resident #111's unit. The Social Worker stated that when the family member emailed her on 3/23/25, they stated that Resident #111 was pretty upset and told them that One of the cna's / nurses got rough today cleaning up after he had a bowel movement. Slamming stuff down . When asked what she did when she received the email, she stated that she and the Unit Manager for that unit went to interview Resident #111. The Social Worker stated that when she interviewed the Resident he did not claim to be abused. When asked about the types of abuse she was able to state the different types of abuse (physical, sexual, financial, verbal, emotional / psychological). When asked if other Residents cared for by this CNA were interviewed for possible abuse the Social Worker stated that they were not.
The Administrator was asked what are the steps that should be taken with an abuse allegation, and he stated that first ensure Resident safety, then report to the APS, OLC and Ombudsman and local law, if need be, then investigate the allegations. When asked if this allegation was reported he indicated that it had not been reported because the staff felt abuse had not taken place. When asked if that is the correct order in which to proceed after an abuse allegation, according to the SOM and facility policy, and he stated that the SOM and facility policy indicate reporting should be done immediately but no later than 2 hours after an allegation of abuse is made. When asked was this done in this case, he stated that it was not.
A review of the facility policy entitled Abuse Neglect and Exploitation Policy # 10171 revealed the following excerpts:
Page 1
Definitions:
Verbal Abuse: Means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing
distance regardless of their age, ability to comprehend, or disability.
Mental Abuse: includes but is not limited to, humiliation, harassment, threats of punishment or deprivation .
Page 5 Paragraph 2
VII. Reporting / Response
The company will have written procedures that include:
1.
Reporting of all alleged violations to the Administrator, state agency, adult protective services, and all other required agencies (e.g. law enforcement when applicable) within specified timeframes:
a.
Immediately but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury
On 4/3/25 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
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, 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 report an accident hazard which resulted in bodily harm, to the State Survey and Certification Agency for one (1) or 74 residents, (Resident #56) in the survey summary.
The findings included:
Resident #56 was originally admitted to the facility 08/22/19 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Unsteadiness on feet and Impulsiveness, Burn of first degree of left forearm, initial encounter. Burn of unspecified degree of single right finger (nail) except thumb, initial encounter. Unspecified dementia without behavioral disturbance. Unsteadiness on feet. Impulsiveness.
The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/01/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #56 cognitive abilities for daily decision making were intact.
In sectionGG(Functional Abilities and Goals) the resident was coded as independent with eating, oral care, toileting hygiene, personal hygiene, bathing/showering self. Sub section: GG0120 coded resident as using a walker as a Mobility Device.
The care plan focus dated 10/14/24 read that Resident #56 has actual impairment to skin integrity of the left third finger and right forearm burn r/t impaired safety awareness. The Goal was that resident will have no complications r/t burn of the right forearm and left third finger through the review date. The interventions: Encourage good nutrition and hydration in order to promote healthier skin, follow facility protocols for treatment of injury, identify/document potential causative factors and eliminate/resolve where possible and Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations.
During the initial rounds on 12/11/24 at approximately 10:27 AM., an interview was conducted with another resident, Resident #5 concerning warming her foods. Resident #5 mentioned We had a communal microwave in the break room. They took it away after a lady burned herself. Resident #5 also said that she didn't know the resident but after she was burned the microwave was removed and they could no longer warm their foods.
A review of the synopsis of event report revealed the following: Date of incident: 6/03/24. Time: 6:00 PM. Location: Dining Area., Type of Injury: Burn to include redness, swelling and pain. Assessment: Redness, blistering, and swelling noted to left forearm, and right middle finger. Description of event: Resident was heating up coffee in a microwave in the Unit 2 dining area. When attempting to pick the coffee up, resident spilled hot coffee on her hand. According to the investigative document, Resident #56 was interviewed by staff at 10:00 AM., then Unit 2 manager, now currently, the Infection Preventionist (IP) OSM #5. The resident confirmed that she reheated the coffee in the microwave and spilled the hot coffee on her hand. According to the staff interview, the resident was heard yelling out from the dining room.
A review of the June 2024 Treatment Administration Record revealed daily wound care of the Right-Hand 3rd Digit. Cleanse with wound cleanser, apply bacitracin and cover with dry bandage every day shift for wound care -Start Date= 06/08/2024 0700. Discontinue Date =06/19/2024. Apply Skin Prep and LOA to Left Forearm every day and evening shift for Blister. Start Date= 06/07/2024 3:00 PM. discharge date =06/12/2024.
A review of the Nurse Practitioner's Skin and Wound note on 06/05/2024 at 12:46 PM., read: Patient being evaluated for new left dorsal forearm burn and right middle finger burn secondary to coffee spill by the patient. Right middle finger with pink epithelial tissue and left dorsal forearm with intact blister. Recommend skin prep to forearm and bacitracin to right middle finger.
WOUND ASSESSMENTS: Date wounds were acquired: 6/03/24
6/05/24- Wound #1 Location: right middle finger, Primary Etiology: Burn, Stage/Severity: Partial Thickness, Wound Status: New, Odor Post Cleansing: None, Size: 2.2 cm x 0.9 cm x 0.1 cm. Calculated area is 1.98 sq cm. Wound Base: 100% epithelial, Wound Edges: Attached, Peri wound: Intact, Exposed Tissues: Epithelium, Exudate: Scant amount of Serosanguineous, Wound Pain at Rest: 6.
Wound: 2=6/04/24 Location: left forearm, Primary Etiology: Burn, Stage/Severity: Partial Thickness, Wound Status: New, Odor Post Cleansing: None, Size: 1.2 cm x 1.1 cm x 0.1 cm. Calculated area is 1.32 sq cm., Wound Base: 100% epithelial, Wound Edges: Attached, Peri wound: Intact, Exposed Tissues: Epithelium, Exudate: None amount of None, Wound Pain at Rest: 5.
PLAN: Wound #1 right middle finger Burn Treatment Recommendations: 1. Cleanse with wound cleanser. 2. apply Bacitracin ointment to base of the wound. 3. secure with Bordered gauze. 4. change BID, and PRN.
PLAN: Wound #2 left forearm Burn. Treatment Recommendations: 1. Cleanse with wound cleanser. 2. apply Skin Prep to base of the wound. 3. secure with Leave open to air. 4. change BID.
PLAN: Wound #1=6/12/24 Location: right middle finger Burn, Partial Thickness, Improving without complications. Size: 1.0 cm x 0.20 cm x 0.10. 100% epithelial, wound edges attached, peri wound intact, scant exudate, serosanguinous, no odor. Treatment Recommendations: 1. Cleanse with wound cleanser. 2. apply Bacitracin ointment to base of the wound. 3. secure with Bordered gauze. 4. change Daily and PRN.
PLAN: Wound #2=6/12/24-24 Location: left forearm, Primary Etiology: Burn, Stage/Severity: Partial Thickness, Wound Status: Improving without complications: None, Size: 1.2 cm x 0.60 cm x 0.10 cm. Wound Base: 100% epithelial, Wound Edges: Attached, Peri wound: Intact, Exposed Tissues: Epithelium, Exudate: scant, serosanguineous, no odor. Treatment recommendations: Change dressing daily, Cleanse with wound Cleanser, apply bacitracin ointment use bordered gauze.
PLAN: Wound #1=6/19/24 Location: right middle finger Burn. Wound Resolved.
PLAN: Wound #2=6/19/24-24 Location: left forearm. Wound Resolved.
On 12/12/24 at approximately 5:00 PM., during the end of day meeting. The Director of Nursing (DON), the Administrator and Corporate Staff #2., were asked if they had a Communal Microwave on Unit 2, and requested accident hazard reports on residents receiving burns. The DON said that she remembered an accident that took place months ago. The DON was asked if the microwave was still in the communal dining room. The DON said that the microwave had been removed since the resident burn, but she did not remember when it was removed.
On 12/13/24 at approximately 10:10 AM., the DON and Corporate Staff #1 informed surveyor of Resident #56 receiving a coffee burn months ago. Documents of the incident were given to the survey staff. The DON said that a Facility Synopsis of the event was not completed and sent to the State Survey and Certification Agency.
On 12/13/24 at approximately 3:55 PM., Resident #56 was not available to interview. Staff states the resident was on Leave of Absence with activities.
On 12/17/24 at approximately 11:15 AM., Resident not available to interview. Staff states resident was at an appointment.
On 12/17/24 at approximately, 11:15 AM., an interview was conducted with Other Staff Member (OSM) #5. OSM #5 said that the room was for staff to heat up food, but the residents would use the microwave also. OSM #2 said that she took the microwave off the unit to keep everyone safe after the resident was burned. OSM #2 said they provided First aide to Resident #56. The forearm looked red and was swollen. Nurse didn't physically see the resident as she was warming up her coffee who used a walker for mobility on and off the unit.
On 12/17/24 at approximately 3:25 PM., an interview was conducted with Certified Nursing Assistant (CNA) #11. CNA #11 said that she heard about the incident but didn't witness it. CNA #11 also mentioned that the incident occurred in the dining room on Unit 2. CNA #11 also said that initially a resident had the microwave in his room, but it was removed and put in the dining room. Licensed Practical Nurse (LPN) #7 wrapped her hand.
On 12/17/24 at approximately 4:25 PM., an interview was conducted with Resident #56 concerning her incident. Resident #56 said that after she heated and removed her cup of coffee from the microwave, she spilled it on her hand and arm as she was using her walker.
The Abuse Policy Revised on 12/01/22 read: It is the policy of the facility to provide protection of health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of property. Reporting: The facility will have written procedures that include: Reporting all alleged violations to the administrator, state agency's or adult protective services and to all other required agencies with in specified timeframes. Immediately but no more than 2 hours. If the events that caused serious bodily injury or not later than 24 hours if the injury did not result in serious bodily injury.
On 12/19/24 at approximately 5:55 p.m., 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 prior to survey exit.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
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 allegations of abuse a...
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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 allegations of abuse and neglect are thoroughly investigated for 1 Resident (#111) in a survey sample of 29 Residents.
The findings included:
For Resident #111 the facility failed to thoroughly investigate allegations of abuse.
Resident #111 was admitted to the facility on [DATE]. Diagnoses for Resident #111 included but are not limited to fracture of right femur, aftercare following joint replacement surgery, benign prostatic hyperplasia, major depressive disorder, hx of fall, diabetes type 2, chronic kidney disease, hyperparathyroidism, and dysphagia. Resident #111 ' s Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 3/30/25 coded Resident #111 with a BIMS (Brief Interview of Mental Status) score of 15/15 indicating no cognitive impairment.
On 4/1/25 a review of the clinical record revealed the following progress notes:
3/20/25 11:46 a.m.: More than 2 episodes of Loose BM's. Resident stated he had an upset stomach this morning and is feeling better. [Nurse Practitioner name redacted] CRNP made aware of the above.
3/24/25 10:15 a.m. - Encounter for mental health services for victim of other abuse: Patient reports he was having frequent stools over the weekend. He reports the CNA had an attitude about having to change him frequently. He reports his CNA told him she could not keep coming in here and changing him. Patient denies any physical abuse, denies any injuries. Patient reassured that he is in a safe environment with people that are here to help him. Specifics of allegations reported to the unit manager. Patient unable to tell me specifically which day the event occurred or the name of the CNA.
On the afternoon of 4/3/25 an interview was conducted with the Social Worker, the Administrator and the Unit Manager for Resident #111 ' s unit. The Social Worker stated that when the family member emailed her on 3/23/25, they stated that Resident #111 was pretty upset and told them the One of the cna's / nurses got rough today cleaning up after he had a bowel movement. Slamming stuff down . When asked what she did when she received the email, she stated that she and the Unit Manager for that unit went to interview Resident #111. When asked what steps were taken to protect Residents while the investigation was ongoing, and the Administrator stated that they filled out a grievance form and, interviewed CNA #1 and wrote up a counseling statement for her as they did not feel this was abuse.
The Social Worker stated that when she interviewed the Resident he did not claim to be abused. When asked about the types of abuse she was able to state the different types of abuse (physical, sexual, financial, verbal, emotional / psychological). When asked if other Residents cared for by this CNA were interviewed, she stated that they were not. When asked about the interview with the Resident she stated that the Resident complained of the CNA spraying air freshener and mumbling under the breath.
A review of the Grievance Form filled out by the Unit Manager dated 3-24-25 read as follows:[Resident #111 name redacted] Date: 3-24-25 Grievance / Concern Received by: Daughter & Resident. Reported To: [Unit Manager name redacted]
Summary of Grievance: CNA rude and spraying .
Resolution: CNA counseled.
On the afternoon of 4/3/25 an interview with CNA #1 was conducted and she was asked if she had taken care of Resident #111, and she stated that she had. When asked about the interaction she had with Resident #111, and she stated that he had to be changed, and she admitted to spraying air freshener in the room when she was changing him. She also stated that she was singing while she was changing him. She denied slamming things, she denied being rude or disrespectful. When asked if it could be perceived as rude to be spraying air freshener while cleaning up a resident, she stated that she did not feel it was rude. When asked if she thought it was unprofessional to be singing while caring for a resident, she stated that she Always Sings.
A review of the personnel file for CNA #1 revealed the following excerpts from the Counseling Form related to this incident:
Reason for action: Report of [CNA name redacted] spraying air freshener and mumbling under her breath after providing care to a resident that had a BM [bowel movement], causing the resident to feel embarrassed and uncomfortable
Goals specifically related to employee's recent job performance:
1. Maintain professionalism
2. Remain sensitive to resident's perception
3. Maintain dignity.
A review of the facility policy entitled Abuse Neglect and Exploitation Policy # 10171 revealed the following excerpts:
Definitions:
Verbal Abuse: Means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing
distance regardless of their age, ability to comprehend, or disability.
Mental Abuse: includes but is not limited to, humiliation, harassment, threats of punishment or deprivation .
On 4/3/25, 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
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review, staff interviews and facility document reviews, the facility staff failed to notify the Office ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review, staff interviews and facility document reviews, the facility staff failed to notify the Office of the State Long-Term Care Ombudsman in writing of discharges for one (1) resident (Resident #32) in the sample of 74 residents.
The findings included:
Resident #32 was originally admitted to the facility 11/17/22 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Peripheral Vascular Disease, unspecified.
The significant change, annual quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 06/29/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 7 out of a possible 15. This indicated Resident #32 cognitive abilities for daily decision making were severely impaired.
According to the Admission/Discharge Report Resident #32 was discharged to the hospital on 6/10/24.
The Discharge MDS assessment was dated for 06/10/24 - discharged assessment - return anticipated.
The Re-entry MDS assessments was dated for 06/29/24 - return from local hospital.
On 12/19/24 at approximately 3:38 PM., an interview was conducted with the Social Services Worker (SSW) concerning Resident #32. The SSW said that no Ombudsman notifications were sent out due to the facility not having a Social Worker at the time and it was the SSW responsibility.
On 12/19/24 at approximately 5:55 P.M., 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 prior to survey exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review, and clinical record review the facility staff failed to complete a Comp...
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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 complete a Comprehensive 14 day full admission assessment and submit it to CMS (Centers for Medicare and Medicaid Services) in a timely manner for one (1) Resident (Residents #117) in a survey sample of 74 Residents.
The findings included:
For Resident #117, the facility staff did not complete and submit a Comprehensive admission MDS assessment timely.
Resident #117 was originally admitted to the facility on [DATE]. Resident #117 had a medical diagnosis history including; Congestive heart failure with diuretic use, unspecified dementia without behaviors, hypertension, depression, anxiety, dysphagia, gastro-esophageal reflux disease, and cardiac disease.
Resident #117's most recent Minimum Data Set (MDS) assessment was a Significant change assessment with an assessment reference date of 11-28-24. Resident #117 had a Brief Interview of Mental Status score of 99 indicating severe cognitive impairment. He was dependant on staff for eating, bathing and personal hygiene. He was coded to have no skin impairment, and at risk for skin impairment. He was coded with no weight loss (which was incorrect), a weight of 123 pounds, no swallowing difficulty, and having a mechanically altered diet.
The only previous MDS assessment completed in the facility was dated 9-23-24, and was the Resident's Comprehensive MDS admission assessment. This MDS had not been signed as completed until 11-23-24, and submitted over 2 months late and found during the 7 day look back time the second (significant change) MDS was being completed. The document revealed that the Resident's weight at that time to be 139 pounds.
This indicated a greater than 10% weight loss in the 2 prior months before the significant change MDS was derived. It is notable to mention that the Resident was admitted with a weight of 145.3 pounds on 9-6-24. This revealed a significant weight loss of 22.3 pounds since admission, equaling a greater weight loss than 15% in the 3 month period from admission to the current survey which was well documented in the clinical record.
On 12-13-24, and 12-18-24 during a meeting with the Administrator, Director of Nursing, and Corporate clinical support consultant, the facility staff were made aware of the above concerns of late MDS submissions, and incorrect submissions, leading to failures in care planning for the Resident.
At the time of survey exit on 12-19-24 the facility Administrator, and Director of Nursing stated they had nothing further to provide.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility's staff failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days after a determi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility's staff failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days after a determination of Resident #105's discontinuation of hospice services.
Resident #105 was originally admitted to the facility 10/27/23 and he was readmitted [DATE] after an acute care hospital stay. The current diagnoses included a major neurocognitive disorder with Lewy Bodies dementia.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/17/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 4 out of a possible 15. This indicated Resident #105's cognitive abilities for daily decision making were severely impaired.
A review of Resident #105's clinical record revealed an election of hospice services was identified as beginning on 11/13/23 and on 5/20/24 hospice services were discontinued due to his extended prognosis but a significant change in condition MDS assessment was not completed within 14 days after a determination
The CMS RAI Version 3.0 Manual, Page 2-25-26 stated a Significant Change in Status Assessment (SCSA) is required to be performed when a resident is receiving hospice services and then decides to discontinue those services (known as revoking of hospice care). The ARD must be within 14 days from one of the following: 1) the effective date of the hospice election revocation (which can be the same or later than the date of the hospice election revocation statement, but not earlier than); 2) the expiration date of the certification of terminal illness; or 3) the date of the physician's or medical director's order stating the resident is no longer terminally ill.
On 12/17/24 at 2:40 PM an interview was conducted with the MDS Coordinator. The MDS Coordinator stated the interdisciplinary team missed the significant change assessment for the resident's discharged from hospice services and when they realized it, they completed the significant change assessment on 7/17/24. The MDS Coordinator stated the significant change MDS assessment was not completed within CMS's specified timeframe.
On 12/19/24 at approximately 5:00 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, the Owner and three Corporate Nurse Consultants. The Consultant Reimbursement stated the required timeframe was within 14 days.
Based on staff interview, facility documentation review, and clinical record review the facility staff failed to complete a correct Significant Change full MDS assessment for two (2) Residents (Residents #117 & #105) in a survey sample of 74 Residents.
The findings included:
1. For Resident #117, the facility staff did not complete and submit a correct Significant Change MDS assessment, with significant weight loss identified.
Resident #117 was originally admitted to the facility on [DATE]. Resident #117 had a medical diagnosis history including; Congestive heart failure with diuretic use, unspecified dementia without behaviors, hypertension, depression, anxiety, dysphagia, gastro-esophageal reflux disease, and cardiac disease.
Resident #117's most recent Minimum Data Set (MDS) assessment was a Significant change assessment with an assessment reference date of 11-28-24. Resident #117 had a Brief Interview of Mental Status score of 99 indicating severe cognitive impairment. He was dependant on staff for eating, bathing and personal hygiene. He was coded to have no skin impairment, and at risk for skin impairment. He was coded with no weight loss (which was incorrect), a weight of 123 pounds, no swallowing difficulty, and having a mechanically altered diet.
The only previous MDS assessment completed in the facility was dated 9-23-24, and was the Resident's Comprehensive MDS admission assessment. This MDS had not been signed as completed until 11-23-24, and submitted over 2 months late and found during the 7 day look back time the second (significant change) MDS was being completed. The document revealed that the Resident's weight on 9-23-24 was 139 pounds.
This indicated a greater than 10% weight loss in the 2 prior months before the significant change MDS was derived. It is notable to mention that the Resident was admitted with a weight of 145.3 pounds on 9-6-24. This revealed a significant weight loss of 22.3 pounds since admission, equaling a greater weight loss than 15% in the 3 month period from admission to the current survey which was well documented in the clinical record.
On 12-13-24, and 12-18-24 during a meeting with the Administrator, Director of Nursing, and Corporate clinical support consultant, the facility staff were made aware of the above concerns of late MDS submissions, and incorrect submissions, leading to failures in care planning for the Resident.
At the time of survey exit on 12-19-24 the facility Administrator, and Director of Nursing stated they had nothing further to provide.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #128 was no longer a resident of the facility; therefore, a closed record review was conducted. Resident #128 was or...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #128 was no longer a resident of the facility; therefore, a closed record review was conducted. Resident #128 was originally admitted to the facility [DATE]. The diagnoses included; unspecified dementia, chronic kidney disease, essential hypertension, anorexia, and muscle weakness.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE] coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 01 out of a possible 15. This indicated Resident #128's cognitive abilities for daily decision making were severely impaired.
A review of Resident #128's nurses note dated [DATE] at 9:50 AM read that Resident #128 was found on the floor in the dining room. The nurses note further read that a 1.5cm open area to the left forehead was cleansed and the area was covered with a 2x2 adhesive dressing.
On [DATE] at 12:45 PM an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that no neuro-checks were conducted for Resident #128 following the unwitnessed fall that occurred on [DATE]. The ADON also stated that it is standard nursing protocol for neuro-checks to be conducted after a resident has an unwitnessed fall and neuro-checks should have been conducted on Resident #128 after the unwitnessed fall on [DATE].
The Facility's Fall Prevention Program document with a revision date of [DATE] read:
When any resident experiences a fall, the facility will:
i. Begin neurologic assessment using Neurological Record assessment tool in PCC
Tool 3N: Postfall Assessment, Clinical Review: Record vital signs and neurologic observations at least hourly for 4 hours and then review. Continue observations at least every 4 hours for 24 hours, then as required.
Notify treating medical provider immediately if any change in observations (https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/postfall-assessment.html).
On [DATE] at approximately 6:25 p.m., a final interview was conducted with the Regional [NAME] President of Operations, Administrator, Regional Nursing Consultant, Regional MDS Consultant, Director of Nursing, Assistant Director of Nursing, and Owner. 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. 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 for four (4)residents (Resident #'s 326, 91, 128 and 48) in survey sample of 74 residents.
Findings included:
1. For Resident # 326, the facility staff failed to ensure wound care was provided as ordered by the physician.
Resident # 326 was a [AGE] year old admitted to the facility on [DATE], with diagnoses that included but were not limited to: Calciphylaxis a rare serious disease that involves build up of calcium in small blood vessels of fat tissue and skin. People with the disease usually have kidney failure or receive dialysis.
The most recent MDS (Minimum Data Set) assessment was coded as an admission assessment with an ARD (Assessment Reference Date) of [DATE]. The BIMS (brief interview for mental status) was coded as 15 out of possible 15 indicating no cognitive impairment. The assessment also coded Resident # 326 as requiring assistance with activities of daily living;
Review of the clinical record was conducted on [DATE] to [DATE].
Review of the clinical record revealed documentation of wound care not being provided for Resident # 326 as ordered by the physician. There was missing documentation of wound care being administered 6 times during the stay at the facility. The missing documentation of wound care included the following dates: [DATE] at 8 p.m., [DATE] at 8 a.m. and 8 p.m., [DATE] at 8 a.m. and 8 p.m., and [DATE] at 8 a.m.
Left breast wound cleanse with DWC (Dakin's Wound Cleanser) pack BID (twice a day) with
Dakin's solution cover with Mepilex or Border gauze
two times a day for wound care
-Start Date-
[DATE] 2000
-D/C Date-
[DATE] 1315
Scheduled BID (twice a day) for 8 a.m. and 8 p.m.
On [DATE] at 9:45 a.m., an interview was conducted during Medication Pour and Pass Observation with Licensed Practical Nurse # 1 who stated medications and treatments should be signed off at the time of administration. She stated there should be no blanks in the documentation because there was a code for refusals. Any blanks would be an indication the administration did not occur. She stated the nurse could also write a progress note about any refusals.
On [DATE] at 2:10 p.m., an interview was conducted with the Director of Nursing who stated the Wound care specialist made rounds weekly on the residents with wounds. The Director of Nursing stated wound care was expected to be provided as ordered by the Physician.
Review of the Weekly skin Assessments revealed assessments were done on [DATE] and [DATE].
Wound care Specialist's notes revealed wound care assessments were done on [DATE] and [DATE].
Review of note of the Wound Care Specialist's evaluation on [DATE] at 8:34 a.m. revealed the following description:
Location: left breast
Wound ID:____ (redacted)
Measurements
Length: 2.67 cm (centimeters) -- Red: 13.23 cm² --
Width: 7.70 cm -- Black: 0.00 cm² --
LxW: 20.56 cm² -- Yellow: 0.21 cm² --
Depth: -- -- Pink: 3.11 cm² --
Total: 16.56 cm² -- Other: 0.00 cm² --
Observations
% granulation 100.00
Depth (cm) 0.20
------------------------------------------ Calciphylaxis
Other Normal saline wet to dry gauze BID
Wound Status Present on admission
Acquired in House? No
Etiology Other
Margin Detail Attached edges
Drain Amount Moderate
Drain Description Serosanguinous
Odor No Odor
Periwound Intact
Pain 4
Dressing Change Frequency BID
Cleanse Wound With Wound Cleanser
Dressings Other: See Notes
Secondary Dressing Bordered gauze
PUSH Score 0
Signature
Review of note of the evaluation on [DATE] at 8:11 a.m. revealed the following description:
Length: 9.77 cm (+265.7) Red: 25.99 cm² (+96.4)
Width: 3.80 cm (-50.7) Black: 0.00 cm² (+0.0)
LxW: 37.13 cm² -- Yellow: 0.00 cm² (-100.0)
Depth: -- -- Pink: 2.01 cm² (-35.5)
Total: 28.00 cm² (+69.1) Other: 0.00 cm² (+0.0)
Observations
% granulation 100.00
Depth (cm) 0.20
------------------------------------------ Calciphylaxis
Other Normal saline wet to dry gauze BID
Wound Status Worsening
Acquired in House? No
Etiology Other
Additional woundbed details Bleeding
Margin Detail Attached edges
Drain Amount Heavy
Drain Description Sanguinous
Odor No Odor
Periwound Intact
Pain 4
Dressing Change Frequency BID
Cleanse Wound With Wound Cleanser
Dressings Other: See Notes
Secondary Dressing Bordered gauze
PUSH Score 0
Review revealed the Wound Care Specialist evaluated the wound on [DATE] and described it as worsening and with heavy sanguinous drainage. Resident # 326 was transferred emergently to the emergency room on [DATE] with complaints of bleeding from the left breast and hypotension, Resident # 326 ultimately expired in the hospital on that same day.
There was documentation that there was a lack of wound care provided as ordered by the physician. Two days prior to the day Resident # 326 was transferred emergently to the hospital, wound care was not provided three times consecutively ([DATE] at 8 a.m., [DATE] at 8 p.m. and 2/20/ 2023 at 8 a.m.) The documentation during the week prior revealed there had been three consecutive times when wound care was not provided (on [DATE] at 8 p.m., [DATE] at 8 a.m. and 8 p.m.)
During the end of day debriefing on [DATE], the Facility Administrator and Director of Nursing were informed of the findings.
No further information was provided.
2. For Resident # 91, the facility staff failed to follow professional standards regarding Medication Administration by leaving medications at the bedside.
Resident # 91 was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Cerebral Infarction, Hypertension, Anxiety Disorder, Hemiplegia and Vascular Dementia.
The most recent Minimum Data Set (MDS) was an Annual Assessment with an Assessment Reference Date (ARD) of [DATE]. Resident # 91's BIMS (Brief Interview for Mental Status) Score was a 14 out of 15, indicating no cognitive impairment. Resident # 91 required assistance with Activities of Daily Living.
Review of the clinical record was conducted on [DATE]-[DATE].
During the initial tour on [DATE] at approximately 2:10 p.m., a medication cup with two white pills was observed on the overbed table by the bed by the window. The pills were white in color; one was oval and the other was round in shape. The resident was not in the room when the surveyor walked into the room.
There was no nursing staff member in the hallway when the surveyor looked for someone to ask about the medications.
After approximately 8 minutes, a facility staff member was observed in the hallway. She identified herself as the Admissions Coordinator. She was asked if she knew who resided in the room. She identified the resident's name as Resident # 91. The Admissions Coordinator stated she would find a nursing staff member.
At 2:23 p.m., Resident # 91 entered the room as the Admissions Coordinator was leaving the room. When asked about the medication in the cup, Resident # 91 stated that was the medicine from this morning. He stated that he told the nurse he was going to take it. Resident # 91 stated he wanted to take his time taking his medications. He stated he was not sure of the kind of pills but thought one was Trazadone.
On [DATE] at 2:34 p.m., an interview was conducted with the Unit Manager, LPN (Licensed Practical Nurse)- # 1 who stated there was no self administration by any residents on the unit. She stated none of the residents on the unit had assessments with orders for self administration of medications. The Unit Manager stated medications should be documented at the time of administration and/or any refusals should be documented immediately. She stated the nurse should observe the resident consume the medications and that medications should never be left at the bedside for the resident to consume later.
On [DATE] at 2:39 p.m. an interview was conducted with the nurse (LPN-3) scheduled to pass medications on that day. LPN-3 stated she administered the morning medications for Resident # 91. LPN-3 stated the medications in the medication cup were not the medications scheduled for administration in the mornings. She stated she observed Resident # 91 consume the medications she prepared for him that morning. LPN-3 stated she did not see that medication cup with those two medications on the overbed table when she administered the medications that morning. LPN-3 stated that the expectation was for medications to be documented at the time of administration. She stated that if the resident refuses to take the medication, the medication should be taken back to the medication cart, discarded and the nurse should document the refusal in the clinical record. LPN-3 stated medications should not be left at the bedside.
The Administrator came to Resident # 91's room with the surveyor. The Administrator observed the medication cup on the overbed table and asked Resident # 91 where the medications had come from. Resident # 91 told the Administrator that medications were from that morning and that he would take them right then. The Unit Manager informed Resident # 91 that the staff needed to determine which medications were in the medicine cup.
The Unit Manager and Administrator removed the medications from the room.
LPN # 3 and the Unit Manager reviewed the [DATE] Medication Administration Record and the Medication pill cards (blister packs) to compare with those medications found at the bedside. They determined that the two pills were two medications that were scheduled to be administered at bedtime at 2100 (9:00 p.m.): Atorvastatin 40 mg (milligrams) give one tablet by mouth at bedtime for hyperlipidemia and Melatonin 3.1 mg (milligrams) give one tablet by mouth at bedtime for insomnia.
Review of the [DATE] Medication Administration Record revealed the two medications had been documented as administered every night except when refused by the resident on [DATE] and [DATE].
The Unit Manager discarded the medications that were in the medication cup. She stated she did not know when the medications had been left at the bedside.
During the end of day debriefings on [DATE] and [DATE], the Administrator, Director of Nursing and Regional Nurse Consultant 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.
The copy of Medication Administration Policy was received on [DATE].
Review of the Medication Administration Policy dated [DATE], reviewed and revised [DATE], on page 1 of 2, revealed the following policy statement: Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice . Under Policy Explanation and Compliance Guidance were the following excerpts:
15. Observe resident consumption of medication. and
17. Sign MAR after administered . and
19. Report and document any adverse side effects or refusals.
According to Lippincott Nursing Procedures, Eighth Edition, Chapter 2, Standards of Care, Ethical and Legal Issues, on page 17 read, Common Departures from the Standards of Nursing Care. Claims most frequently made against professional nurses include failure to make appropriate assessments, follow physician orders, follow appropriate nursing measures, communicate information about the patient, follow facility policy and procedures, document appropriate information in the medical record .
Guidance from the National Institutes of Health in the article The nurses medication day stated that Nurses serve as a barrier, protecting residents from potential hazards. Calls were also common to request 'missing meds' (medications) followed by waits until they were delivered. Waiting reflected system failures
ncbi.nlm.nih.gov accessed [DATE].
During the end of day debriefings on [DATE], the Administrator, Director of Nursing and Regional Nurse Consultant were informed of the findings.
No further information was provided.
4. The facility's staff failed to obtain vital signs prior to transferring Resident #48 to a local hospital's emergency room (ER).
Resident #48 was originally admitted to the facility [DATE] and readmitted [DATE] after an acute care hospital stay. The current diagnoses included a stroke with right hemiparesis, dysphagia causing pulmonary aspiration, enteral feedings are required.
The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of [DATE] coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #14's cognitive abilities for daily decision making were intact.
A review of a nurse's notes dated [DATE] 9:30 PM stated Resident #48 was admitted to a local hospital for pneumonia. A further review of the nurse's note revealed that on [DATE] at 1:04 PM the resident experienced a change in condition and the following vital signs were charted, the resident's weight was obtained by a Hoyer lift scale on [DATE] at 7:04 PM and it was 172.0 pounds, all of the following vital signs were obtained on [DATE] at 11:59 PM; blood pressure in the left arm while lying down was 128/86, the pulse was regular at 89 beats per minute, his respirations were 18 breaths per minute, a non-contact temperature of his forehead was 98.6 a pulse oximetry reading of 98.0 % on room air, and a blood glucose reading of 139 obtained on [DATE] at 6:27 AM.
The nurse did not document any vital signs were obtained at the time the resident's change in condition was identified and the above vital signs were recorded on the document conveyed to the receiving hospital's emergency room staff.
A review was also conducted of the primary Nurse Practitioner's (NP) documentation dated [DATE] 1:45 PM. The NP's note stated Resident #45 was found leukocytosis and poor oral intake. The NP's note included a chronological review of vital signs but, there were not a set of vital signs obtained on [DATE] prior to the resident's transfer to a local hospital.
Under the NP's Assessment and Plan was the following data, elevated white blood cell count, unspecified; resident continues to have leukocytosis despite negative chest x-ray, urine, and blood cultures. Kidney, Ureter, and Bladder (KUB) was negative for ileus. Discussed with patient's daughter who requested transfer to ER. Patient being sent to ER per family request for further evaluation and management of persistent leukocytosis.
Further down in the NP note, she stated tachycardia unspecified, heart rate noted to be tachycardic on examination. No chest pain or discomfort reported. Discussed with resident's daughter who requested transfer to ER. Patient being sent to ER per family request for further evaluation and management of tachycardia. The tachycardia rate per minute was not documented so increases or decreases could not be evaluated.
An interview was conducted with the NP on [DATE] at 2:04 PM. The NP stated that she assessed the resident, and she considered Resident #48 ongoing issues were stable with acute issues therefore she simply charted the tachycardia. The NP further stated all the test she had requested came back negative and she was continuing to monitor the resident's poor nutritional intake, the leukocytosis and the failure to thrive. The NP did not obtain vital signs at the time of her assessment of resident or prior to the transfer to the local ER for evaluation.
On [DATE] at approximately 2:50 P.M., a final interview was conducted with the Administrator, Director of Nursing, and three Corporate Nurse Consultants. The above information was conveyed to the administrative staff, they all looked at each other but voiced no comments/concerns regarding the above findings.
An interview was also conducted with the Medical Director (MD) on [DATE] at 1:55 PM. The MD stated the NP would make an addendum to the progress note dated [DATE] to add in the tachycardia numbers. The MD also stated it is a professional standard which has not changed to obtain real time vital signs at the time of a change in condition and when a transfer to the hospital is necessary.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a clinical record review and staff interview the facility staff failed to provide a resident with as much discharge inf...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a clinical record review and staff interview the facility staff failed to provide a resident with as much discharge information as possible at the time of discharge for one (1) of 74 residents (Resident #278), in the survey sample.
The findings include:
Resident #278 was admitted to the facility on [DATE] after a hospital stay and left the facility against medical advice on 11/9/22. The resident's diagnoses included end-stage renal disease with dialysis, diabetes, and infected left hip hardware.
The 5-Day Medicare Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/9/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #278's cognitive abilities for daily decision making were intact. The resident required supervision after set-up with most of his activities of daily living.
A review of the nurse's notes revealed on 11/8/22 at 4:57 PM the nurse received a call from the Resident #278's sister because the resident desired to be discharge immediately from the facility. The nurse's note further stated that the nurse informed the resident and the sister that a discharge at this time would be considered against medical advice (AMA) and both voiced understanding.
The nurse's note also stated that the resident requested his prescriptions and to go medications and the resident was informed that if he leaves AMA no medications, prescriptions or orders would be given, therefore the resident stated he would use what medications he already had at home. Failure to provide the resident with current medication orders and the hospital's discharge summary may have resulted in the resident resuming medications which were discontinued or started while in the hospital.
The nurse's note stated Social Services was notified of the resident's decision and Social Services was unable to get the resident to stay long enough for his discharge to be planned, for the resident continued to voice that he desired to discharge at this time. The nurse completed the AMA document, and it was signed by the resident, and he waited for transportation arranged by his family. A nurse's note dated 11/8/22 at 6:03 PM stated the resident left AMA at 5:30 PM. The facility's staff failed to obtain as much information as possible to promote continuity of care and the best wellbeing for the resident.
On 12/19/24 at approximately 6:00 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, the Owner and three Corporate Nurse Consultants. 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 F0692
(Tag F0692)
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 staff failed to pr...
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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 staff failed to prevent a significant weight loss and dehydration for one (1) Resident (Residents #117) in a survey sample of 74 Residents.
The findings included:
For Resident #117, the facility staff did not provide meals consistently, and did not provide hydration consistently, resulting in significant weight loss and dehydration.
Resident #117 was originally admitted to the facility on [DATE], and was hospitalized 10 days later on 9-15-24 for a colonic hemorrhage caused by a Stercoral ulcer (impacted hard stool at the anus and distal rectum) which pierced the bowel wall, after having had no bowel movements. The ulcer/perforation of the bowel wall resulted in blood loss requiring 2 blood transfusions according to hospital records.
The Resident was again sent out to the hospital on [DATE] through 10-15-24 for a severe urinary tract infection causing sepsis and septic shock, and acute kidney injury which was reversed successfully in the hospital with IV (intravenous) fluids for dehydration and IV antibiotics.
Resident #117 had a medical diagnosis history including; Congestive heart failure with diuretic use, unspecified dementia without behaviors, hypertension, depression, anxiety, dysphagia, gastro-esophageal reflux disease, and cardiac disease.
Resident #117's most recent Minimum Data Set (MDS) assessment was a Significant change assessment with an assessment reference date of 11-28-24. Resident #117 had a Brief Interview of Mental Status score of 99 indicating severe cognitive impairment. He was dependant on staff for eating, bathing and personal hygiene. He was coded to have no skin impairment, and at risk for skin impairment. He was coded with no weight loss (which was incorrect), a weight of 123 pounds, no swallowing difficulty, and having a mechanically altered diet.
The only previous MDS assessment to the 11-28-24 MDS was dated 9-23-24, and was the Resident's admission assessment. This MDS had not been signed as completed until 11-23-24, and submitted late. The document revealed the Resident's weight at that time to be 139 pounds. This indicated a greater than 10% weight loss in the previous 2 months. It is notable to mention that the Resident was admitted with a weight of 145.3 pounds on 9-6-24. This revealed a significant weight loss of 22.3 pounds since admission, equaling a greater weight loss than 15% in the 3 month period from admission to the current survey which was well documented in the clinical record.
Before hospitalization and after hospitalization the Resident's diet remained the same. Regular diet, Dysphagia pureed texture, thin consistency. On 10-16-24 mighty shakes 4 ounces was ordered at bedtime for a supplement. No other diet changes nor supplements were ever ordered during the Resident's stay.
During the entire survey Resident #117 was never observed during the day shift out of bed, and asked the surveyors often for something to drink stating Please, Please bring me some water I'm so thirsty. The Residents lips were noted to be cracked and dry, and his eyes were sunken. His skin was flaking and dry and when the skin on his hand was examined it tented when pulled gently in an upward fashion and stayed that way. His mucus membranes were sticky and when he spoke his lips would stick together with thick saliva briefly. He constantly complained my butt hurts, my butt hurts. Staff were made aware that the Resident was thirsty, and complaining of butt pain. Staff stated they would have the NP look at him.
On 12-10-24 A Certified Nursing Assistant (CNA) was found in the hallway after Resident #117 was found begging for water. The CNA brought in 120 milliliters of tea for the Resident, and was again told he asked for water. She stated oh he just wants to drink, not eat. The CNA was asked if she was aware that the caffeine in tea was a diuretic and could further dehydrate the Resident. She did not respond.
On 12-10-24 the Kitchen manager was interviewed and stated that they did not keep track of percentages of meals and fluids consumed, and stated that the nursing staff were responsible for that. She was asked if she had decaffeinated tea on hand, and she stated she had decaf coffee but not tea.
On 12-12-24 A CNA was interviewed and stated, he (Resident #117) went out to the hospital with altered mental status, low blood pressure, dehydration and a UTI (urinary tract infection), and when he came back he went on hospice. He's been in bed now since then. The Resident had actually returned on 10-15-24, and was not placed on hospice until 11-19-24 (one month later). The CNA was asked for his hospice notes, and she went to the LPN (Licensed Practical Nurse) unit manager with the surveyor accompanying her and asked for the notes. The LPN stated I will look for them, and later stated I don't have any. The entire clinical record was reviewed and no hospice notes were in the clinical record.
Staff were then asked if hard copy notes could be located in a binder, and they stated they had no such binder. There was an observed notice taped to the Resident's closet door from the new social worker addressed to the hospice staff. The document instructed that the Resident's hospice supplies had been found in the general supply closet in the facility with normal inventory. The document instructed hospice staff to inform the nurses on the unit when hospice supplies were brought in for the Resident. It appeared that the facility staff and hospice staff were not communicating.
On 12-13-24 from 11:30 AM until 1:00 PM a second surveyor was observing lunch service on the memory care secured unit until the meal was finished. Resident #117 was never fed, and his tray was removed from his room. The tray was placed back on the tray cart to return to the kitchen for disposal, untouched. The CNA was asked why he was not fed, and she replied oh he's hospice he don't want it. The Resident received no food, and no fluids from 9:00 AM breakfast to 5:00 PM dinner (8 hours). No water was in any Resident room on the secured unit during the entire survey.
Resident #117's clinical record was reviewed. Weight documents all completed by chair scale revealed the following;
9-06-24 - 145.3 pounds on admission.
9-10-24 - 143.0 pounds out to hospital on 9-15-24 with bleeding, returned 9-20-24.
9-21-24 - 139.0 pounds
9-24-24 - 139.0 pounds
10-29-24 - 123.0 pounds
11-05-24 - 122.6 pounds
No further weights were being recorded as staff stated well, he's hospice now, so no need really. The Resident was not placed on hospice until 11-19-24, (2 weeks later with no weights completed) and remained a Full Code CPR status.
The Registered Dietician (RD) was called via cellular phone for interview and was unable to be contacted. A message was left on voicemail, however, surveyors received no call back. No RD notes were found in the clinical record, however, on 12-17-24 at 12:11 PM, the Administrator and Director of Nursing (DON) supplied the only note they had received from the RD dated 10-23-24 (8 days after returning from the hospital with sepsis and dehydration). The RD note was reviewed and revealed continued weight loss and the following 4 recommendations, none of which were followed:
1. Consider benefit of appetite stimulant medication due to poor oral intake.
2. when poor oral intake less than 50% offer alternate meal options.
3. weekly weights for one month due to readmit.
4. RD to monitor for significant changes in weight poor oral intake or skin integrity and follow up as needed.
Staff were interviewed on 12-11-24 and asked what interventions could be offered to a Resident to prevent significant weight loss. The Director of Nursing (DON) provided two policies on Nutritional Management, and Weight Monitoring that documented the following;
1. Nutritional Management. Nutritional Status includes both nutrition and hydration status. The document describes a systematic approach to optimize a Resident's nutritional status. Staff are to identify risk factors, evaluate and analyze assessment information, develop and consistently implement approaches, and monitor the effectiveness of interventions and to revise interventions as necessary which would be reflected in the Resident's plan of care. The document goes on to describe that a comprehensive assessment will be completed by the Registered Dietician (RD) within 72 hours of a change in condition to include persistent hunger, poor intake, or continued weight loss, or evidence of fluid loss. One intervention included diet liberalization, and feeding assistance.
2. Weight Monitoring. Significant unintended changes in weight (loss or gain) .may indicate a nutritional problem. A comprehensive nutritional assessment, The Nutritional Data Collection Tool will be completed and that information would identify risk which would then drive the care planning process development to include;
Identified causes of impaired nutritional status, reflect the Resident's personal goals and preferences, identify resident specific interventions, time frame and parameters for monitoring, be updated as needed during Resident's condition changes, interventions are ineffective, or new problems are identified, and be conducted as per professional standards. Residents with weight loss monitor weights weekly. Documentation will include notification of physician, if significant weight loss is identified the RD should be consulted to assist the interdisciplinary (IDT) care plan team with interventions who could initiate the care planning process, as well as the nursing department may initiate the care planning process. The IDT communicates care instructions to staff.
On 12-11-24 the NP documented on a Wound Assessment Report location sacrum, 14 centimeter (cm) length x width total measurement of the wound, 0.1 cm deep date acquired 12-11-24 in house, wound status new, stage/severity Full Thickness, 20% granulation, 80% slough, Erythema peri wound (red and inflamed), exposed tissue Epithelium, Dermis. Treatment daily and as needed cleanse with wound cleanser, hydrogel primary treatment, dressing bordered gauze.
The DON was asked if Foley catheters to keep skin dry and for intake and output assessments were available, and she stated yes. She was asked if formal protein supplements, fluids, diet changes, and moisture barrier creams, and positioning devices were available for Resident's with known significant weight loss and wounds and she stated yes. She was asked if she was aware that the mattress for Resident #117 was the same as the ones used for the ambulatory residents on the memory care unit, and she stated she was not aware of that. None of the above prevention strategies were afforded Resident #117 for prevention of further significant weight loss and the pressure sore indicating this ulcer was potentially avoidable. On 12-11-24 a redistribution air mattress was ordered for the Resident, however did not arrive until after his move to another unit on 12-18-24.
On 12-12-24 Review and copy of Physician's orders revealed only 1 order for weight management;
1. Mighty shake 4 ounces at bedtime was ordered by the physician on 10-16-24 after the Resident returned from the hospital after experiencing dehydration and sepsis. Mighty Shakes nutrition facts included; Only 220 calories per each 4 ounces which equals approximately 2 tablespoons of peanut butter which would contain 8 grams of protein whereas the mighty shake only had 6 grams. The Might Shake was not given on the following nights, with no reason documented as to why it was withheld;
October - 10-20-24, 10-26-24.
November - 11-8-24, 11-19-24, 11-16-24, 11-29-24.
December - 12-3-24, 12-12-24, 12-14-24.
The Care plan was reviewed and included focuses, goals and interventions for malnutrition Risk related to history of rectal bleed constipation created on 9-11-24 with a goal to be free of significant weight changes. A new care plan revision entry was created on 12-11-24, however, none of the interventions were changed, and none were added. The care plan identified only the following 5 interventions;
1. Administer medications as ordered, observe for side effects and effectiveness alert MD (doctor) as needed.
2. Provide, serve diet as ordered. Monitor intake and record every meal.
3. RD to evaluate and make diet change recommendations as needed.
4. Receives a mechanical soft pureed diet, related to diagnosis.
5. weight per facility protocol/MD order.
The care plan was not Resident specific and did not specify feeding needs, fluid provision, supplements, diet changes, alternate diet changes, nor RD interventions/recommendations, and was not followed with regard to weights. It did not specify any measures/interventions to be instituted to prevent dehydration which the Resident had been hospitalized previously for. No treatments were specified in the care plan for the care of a pressure sore after it developed and was identified at a stage 3 further complicating significant weight loss and a history of dehydration.
It is also notable to mention that the care plan was not derived by an interdisciplinary team and the only 2 individuals who were present for the most recent care plan update was the LPN (Licensed Practical Nurse) unit manager, and the Social Worker who was found to not have been vetted properly, and had insufficient qualifications for the Role.
Resident #117 experienced a potentially avoidable pressure ulcer injury which was not identified until it became a full thickness wound with dead yellow slough tissue obscuring the base of the wound by 80%. The Resident was at risk for skin breakdown after being continuously bed ridden for months, was experiencing continued significant weight loss, and was hospitalized for fecal impaction with hemorrhage, and hospitalized for a urinary tract infection, dehydration, and severe sepsis.
On 12-13-24 at 11:15 a.m., the Administrator, Director of Nursing, and Corporate Nurse were notified that the facility staff failed to prevent significant weight loss and dehydration, and further had not intervened during the known weight loss. The facility staff was given the opportunity to provide any further information or explanation. They stated they had no further information to provide.
On 12-13-24, and 12-18-24 during a meeting with the Administrator, Director of Nursing, and Corporate clinical support consultant, the facility staff were made aware of the above concerns for this Resident.
On 12-19-24, prior to the survey exit the Director of Nursing informed surveyors that Resident #117 had been moved back onto a regular unit last night (12-18-24).
At the time of survey exit on 12-19-24 the facility Administrator, and Director of Nursing stated they had nothing further to provide.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #109 did not receive the physician ordered scheduled doses of Insulin.
Resident #109 was originally admitted to the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #109 did not receive the physician ordered scheduled doses of Insulin.
Resident #109 was originally admitted to the facility 1/4/24. The resident's diagnoses included chronic obstructive pulmonary disease, type 2 diabetes mellitus without complications, essential hypertension, chronic kidney disease, and anxiety disorder.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/23/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #109's cognitive abilities for daily decision making were intact.
On 12/10/24 at 2:15 PM an interview was conducted with Resident #109. Resident #109 stated, I did not receive scheduled doses of my Insulin on a Sunday in November. I was not sure why and could not get a clear answer from the staff.
The Physician's Order Summary (POS) for November 2024 read: Insulin Aspart FlexPen 100 Unit/ML Solution pen-injector Inject 20 unit subcutaneously with meals related to Type 2 Diabetes Mellitus without complications with a start date of 11/8/2024 and Insulin Glargine-yfgn 100 Unit/ML Solution pen injector Inject 55 unit subcutaneously at bedtime for DM Administer Emergency Glucagon for hypoglycemia<60 blood glucose notify provider with a start date of 11/1/2024.
A review of the Medication Administration Record (MAR) revealed that Resident #109 missed 1 dose of Insulin Aspart FlexPen 100 Unit/ML Solution pen-injector Inject 20 unit subcutaneously with meals related to Type 2 Diabetes Mellitus without complications on the following date: 11/10/24 and missed 1 dose of Insulin Glargine-yfgn 100 Unit/ML Solution pen injector Inject 55 unit subcutaneously at bedtime for DM on the following date: 11/10/24.
Insulin aspart is used to treat type 1 diabetes (condition in which the body does not produce insulin and therefore cannot control the amount of sugar in the blood) in adults and children. It is also used to treat people with type 2 diabetes (a condition in which the body does not use insulin normally and therefore cannot control the amount of sugar in the blood who need insulin to control their diabetes. https://medlineplus.gov/druginfo/meds/a605013.html).
Insulin glargine products are used to treat type 1 diabetes (condition in which the body does not produce insulin and therefore cannot control the amount of sugar in the blood). Insulin glargine products are also used to treat people with type 2 diabetes (condition in which the body does not use insulin normally and, therefore, cannot control the amount of sugar in the blood) who need insulin to control their diabetes. https://medlineplus.gov/druginfo/meds/a600027.html
On 12/18/24 at 2:43 PM an interview was conducted with the Licensed Practical Nurse (LPN) #2. LPN #2 stated that the medications were available for Resident #109, and she could not explain why the resident was not administered these medications on 11/10/24.
On 12/19/24 at approximately 6:25 p.m., a final interview was conducted with the Regional [NAME] President of Operations, Administrator, Regional Nursing Consultant, Regional MDS Consultant, Director of Nursing, Assistant Director of Nursing, and Owner. 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.
Based on observation, interview, clinical record review and facility documentation the facility staff failed to ensure Residents are free from significant medication errors for three (3) Residents (378, 109, and 327) in a survey sample of 74 Residents.
The findings included:
1. For Resident # 378 the facility staff failed to ensure Vancomycin (an anti-biotic used to treat infection) was administered as prescribed by physician, delaying treatment by 4 days for C-Diff (Clostridium difficile a bacteria that causes watery diarrhea, abdominal pain and cramping, fever, nausea, and dehydration).
On 12/12/24 a review of the clinical record revealed that Resident #378's admission order for Vancomycin read:
2/15/24 Vancomycin HCl Oral Capsule 125 MG (Vancomycin HCl) Give 5 ml via PEG-Tube one time a day for C. Diff for 6 Days -Start Date- 02/16/2024 1200
The following progress notes were entered regarding the Vancomycin administration or lack thereof:
2/16/24 1:36 p.m. - Vancomycin HCl Oral Capsule 125 MG Give 5 ml via PEG-Tube one time a day for C. Diff for 6 Days AWITING [sic] Pharmacy, NP notified. 2/16/24 1:42 p.m. - ON HOLD UNTIL COMES FROM PHARMACY, NP NOTIFIED
2/18/24 1:09 p.m. - Note Text: Vancomycin HCl Oral Capsule 125 MG Give 5 ml via PEG-Tube one time a day for C. Diff for 7 Days. Pharmacy needs clarification. Left a message with on call if corrected by 1530 it can be sent on the next run today.
On 2/19/24 the following Physician note was entered to clarify the Vancomycin order:
Chief Complaint / Nature of Presenting Problem: New admission 2/15/2024F/u and monitoring C-Diff and left BKA. Medication List: Vancomycin HCl, Vancomycin HCl Oral Suspension 50 MG/ML, Give 2.5 ml by mouth one time a day for c-diff for 7 Days, 50MG/ML, ACTIVE, 2/19/2024 to 2/26/2024.
A review of the MAR (Medication Administration Record) revealed that the Vancomycin was started on 2/19/24 at 12:00 p.m. This resulted in a delay in treatment and 4 days of missed medications.
On 12/18/24 at 11:00 a.m. an interview was conducted with LPN #3 who was asked what the nurses do if a medication is unavailable, LPN #3 stated they notify the physician and get an order to hold it until it becomes available. When asked if this is facility policy to obtain a hold order, she stated that it was what she was told to do. When asked if they had a backup pharmacy or a stat box, she stated that they do have stat boxes but that sometimes the med or the dose needed was not in the stat box.
On 12/18/24 an interview was conducted with the DON who was asked if there is a backup pharmacy, and she stated that there was. When asked if it is acceptable to make a Resident wait 4 days for an antibiotic, she stated that it was not.
On 2/19/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.3. For Resident # 327, the facility staff failed to ensure that intravenous antibiotics were available for administration and administered as ordered by the physician.
Resident # 327 was a [AGE] year old admitted to the facility on [DATE], with diagnoses that included but were not limited to: Asthma, emphysema, Pulmonary Fibrosis, Seizure disorder, Chronic anxiety and depression, Hypothyroidism and Gastroesophageal reflux disease, historyof Pulmonary Embolism, orthostatic hypotension and chronic hypoxic respiratory failure-on oxygen at 4 liters per minute via nasal cannula, Congestive Heart Failure. Cerebral Vascular Accident.
The most recent MDS (Minimum Data Set) assessment was coded as an admission assessment with an ARD (Assessment Reference Date) of 8/1/2023. The BIMS (brief interview for mental status) assessment was coded as 15 out of possible 15, indicating no cognitive impairment. The assessment also coded Resident # 327 as requiring assistance with activities of daily living; and continent of bowel and bladder.
Review of the clinical record was conducted on 12/10/2024 to 12/19/2024.
Review of the Progress Notes on pages 329-336 of 339 revealed documentation of an encounter on 8/2/2023 for a history and physical with a problem that listed tx (treatment) with IV (Intravenous fluids) and Rocephin. The note documented a diagnosis of sepsis secondary to urinary tract infection and treatment with IV fluids and antibiotics.
Further review of the Progress Notes revealed documentation of an encounter by the physician on 08/03/2023 that was listed as a new evaluation involving the chief complaint of Follow-up regarding cough.
The note also stated
History Of Present Illness:
[AGE] year-old female seen for follow-up for complaints of cough. On arrival patient was lying in the bed she complains of cough congestion generalized fatigue and weakness. Discussed with nursing staff with [sic]obtain further overview medication lab and chart reviewed patient anticipated to receive antibiotic course of Rocephin however a slight delay in delivery. Discussed with nursing staff to ensure medication arrives notify provider of any complications we will further delay in antibiotic course the verbalized understanding. Discussed with patient reporting persistent cough or congestion will recommend further x-rays should verbalized understanding. Further evaluation conducted
Review of the Progress Notes revealed Rocephin was not administered until the evening of 8/4/2023. the note written on 8/5/2023 stated this resident is on IV (intravenous) Rocephin X 3 (times 3.) This resident received her first dose and tolerated it well. The note also stated when passing meds, this writer observed the PIV (peripheral intravenous) to her (L) hand had come out and the resident stated that she did not want to put another one because it hurt her hand.
The Medication Administration Record did not show documentation of administration of Rocephin until 8/5/2023 and again on 8/6/2023.
Review of the Cubex Stat box contents list revealed on page 1 of 6 that the medication, Rocephin 1000 milligrams vial -two vials was available for use.
Rocephin IV change to IM
Effective Date: 08/05/2023 20:17 Type: eMar - Medication Administration Note
Note Text: Ceftriaxone Sodium Solution Reconstituted 1 GM (gram)
Use 1 gram intravenously every 24 hours for UTI (urinary tract infection)for 3 Days
order changed to IM (intramuscularly)
On 12/10/2024 at 3:05 p.m., an interview was conducted with LPN(Licensed Practical Nurse) # 3 who stated the medications come in a blister pack for each resident. The blister pack should have the medications for each scheduled dose. LPN # 3 stated if the medication was not available, the nurse was expected to check the Cubex (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 12/11/2024 at 10:20 a.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 Cubex 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.
On 12/11/2024 at 11 a.m., an interview was conducted with the Regional Nurse Consultant (Corporate # 1) who stated medications should be available for administration as ordered by the physician. Corporate # 1 stated the Pharmacy should have ensured the medication was available for administration. She also stated the nurses should have checked the Cubex (in house Stat box) for an available supply of the medication.
She stated medications should be available for administration and administered as ordered.
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 that the antibiotic was ordered on 8/2/2023 but not started until the evening on 8/4/2023. The staff had access to the medication in the Cubes in house supply.
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 F0840
(Tag F0840)
Could have caused harm · This affected 1 resident
Based on staff interviews, the facility staff failed to obtain agreements for dental services and audiology services.
The findings included:
On 12/18/24 at 1:20 PM an interview was conducted with the...
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Based on staff interviews, the facility staff failed to obtain agreements for dental services and audiology services.
The findings included:
On 12/18/24 at 1:20 PM an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that the facility does not have written agreements for dental services and audiology services. The ADON also stated that if a resident requires dental services, the facility will make an appointment with a dentist the resident requests or recommends.
On 12/19/24 at approximately 6:25 p.m., a final interview was conducted with the Regional [NAME] President of Operations, Administrator, Regional Nursing Consultant, Regional MDS Consultant, Director of Nursing, Assistant Director of Nursing, and Owner. 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
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to maintain accur...
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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 maintain accurate and readily accessible medical records for one (1) resident (Resident # 327) in a sample size of 74 residents.
The findings included:
For Resident # 327, the Social Worker did not document social services notes in the clinical record regarding details of a grievance that was filed on [DATE].
Resident # 327 was a [AGE] year old admitted to the facility on [DATE], with diagnoses that included but were not limited to: Asthma, emphysema, Pulmonary Fibrosis, Seizure disorder, Chronic anxiety and depression, Hypothyroidism and Gastroesophageal reflux disease, history of Pulmonary Embolism, orthostatic hypotension and chronic hypoxic respiratory failure-on oxygen at 4 liters per minute via nasal cannula, Congestive Heart Failure. Cerebral Vascular Accident.
The most recent MDS (Minimum Data Set) assessment was coded as an admission assessment with an ARD (Assessment Reference Date) of [DATE]. The BIMS (brief interview for mental status) assessment was coded as 15 out of possible 15, indicating no cognitive impairment. The assessment also coded Resident # 327 as requiring assistance with activities of daily living; and frequently incontinent of bowel and always incontinent of bladder.
The resident was readmitted to the facility on [DATE] and expired in the facility on [DATE].
Review of the clinical record was conducted on [DATE] to [DATE].
For Resident # 327, the Social Worker did not document Social Services notes in the clinical record regarding details of a grievance that was filed on [DATE]. The note specifically stated the resident requested to be transferred to another facility and that a grievance had been completed. The note stated information was faxed to two facilities per the resident's request. There was no follow up documentation noted in the clinical record.
The facility Administrator was asked to provide copies of grievances for [DATE]. The Administrator stated she did not know if she could find any grievances for that time period. She stated she was hired in March of 2024 and had no knowledge about a grievance for Resident # 327. She stated she recognized the resident's name due to another admission to the facility in June of 2024 until [DATE].
The clinical record was reviewed and revealed no social worker notes were written regarding documentation of a grievance completed on [DATE]. Further review of the Progress Notes revealed documentation by the nursing staff on [DATE] that Resident # 327 requested a room change. There were no details regarding a reason for the request. Nor was there any documentation of any follow up.
On [DATE] at approximately 11:40 AM, an interview with the Social Worker (Administration # 4) was conducted. When asked about the social services process for grievances, the Social Worker stated all residents have the right to file grievances and that they should be documented. She stated the residents and their responsible parties were informed of the grievance policies upon admission. When asked if she was familiar with Resident #327, she stated, Yes. The Social Worker stated she reviewed the clinical record and saw the note about a grievance that was filed on [DATE]. The Social Worker stated she did not remember what the grievance was about. She stated she checked the files in her office and could not find anything regarding the grievance. The Social Worker stated she typically would complete the Grievance form and give it to the Administrator for review and signature. She stated the Administrator would sign off and return the form.
The Social Worker stated she did not see any records of the grievance and did not know what happened to it. She stated she remembered assisting Resident # 327 with securing utilities at her home prior to discharge in [DATE] based on her notes but did not remember anything else. When asked about the process for documenting Social Services information, she stated she normally would document issues in the electronic health record but would document grievances on paper to be kept it in her office. When asked if the information in the grievance was considered part of the clinical record, she stated, Yes. When asked why it was important to put social services notes in the hard chart as part of the clinical record, the Social Worker stated, It would allow staff members to follow up on the issues or grievance. A copy of social services grievance policy was requested.
Review of the facility documentation revealed grievances for [DATE]. However, none were listed for Resident # 327.
On [DATE] during the end of day debriefing, the Facility Administrator and Director of Nursing were informed of the findings. The Administrator and Director of Nursing stated they had no knowledge of the grievance filed on [DATE] but that there should have been documentation.
No further information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #78 the facility staff failed to include the Hospice Nurses notes and the Hospice CNA notes in the clinical reco...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #78 the facility staff failed to include the Hospice Nurses notes and the Hospice CNA notes in the clinical record.
On 12/11/24 a review of the clinical record revealed that Resident #78 was admitted to the facility on [DATE] with diagnoses that included but were not limited to cognitive communication deficit, dysphagia, muscle weakness, dementia, severe without behavioral disturbance, psychotic mood disturbance and anxiety, abnormalities of gait and mobility, hypertension, hx (history) of renal cancer, and hx of repeated falls. Resident #78 had a BIMS (Brief Interview of Mental Status) score of 13/15 on admission indicating mild cognitive impairment. On 2/13/24 (one month prior to falls) Resident #78 BIMS was assessed at 5/15 indicating severe cognitive impairment. Resident #78 was admitted to Hospice on 3/29/24.
On 12/16/24 at 10 a.m. Resident #78 was observed in bed dressed in hospital gown and had an odor of urine. When CNA 3 was asked about her bathing she stated, She will be getting a bath from hospice today.
On 12/16/24 at 12 p.m. a review of the clinical record revealed that there were no weekly visit notes from Hospice in the clinical record.
On 12/16/24 at approximately p.m. an interview was conducted with the DON who was asked how the Hospice nurses communicate with the facility about the care they provide, and she stated they speak with the nurses on the floor. When asked if they document in the Resident chart, she stated that they did not have access to the Resident chart, but they documented on Hospice charts and were scanned into the Resident chart at the facility. When the DON was asked to show this documentation in the electronic health record, she also could not find it. When asked how the physicians and nurses at the facility would know what care was provided if they did not have access to the notes, she stated that she was unaware they did not have access to the notes and that they had not been scanned in the chart. When asked if it was important to have that information, she stated that it was.
On the morning of 12/18/24 a review of the clinical record revealed that the facility had scanned in over 30 documents related to Hospice care provided to Resident #78.
On 12/19/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.
Based on Observation, staff interview, clinical record review, and facility document review the facility staff failed to provide services for two Residents receiving hospice care (Resident #117, and #78) in a survey sample of 74 Residents.
The findings included;
1. For Resident #117, The facility staff failed to provide the following federally required areas for a Resident receiving hospice care;
Provision of MDS assessments timely, and accurate.
Provision of timely ADL care.
Provision of a comprehensive care plan for services.
Provision of medication regimen reviews.
Provision of social work.
Provision of a hospice communication process.
Provision of nutritional support.
Resident #117 was originally admitted to the facility on [DATE], and was hospitalized 10 days later on 9-15-24 for a colonic hemorrhage caused by a Stercoral ulcer (impacted hard stool at the anus and distal rectum) which pierced the bowel wall, after having had no bowel movements. The ulcer/perforation of the bowel wall resulted in blood loss requiring 2 blood transfusions according to hospital records.
The Resident was again sent out to the hospital on [DATE] through 10-15-24 for a severe urinary tract infection causing sepsis and septic shock, and acute kidney injury which was reversed successfully in the hospital with IV (intravenous) fluids for dehydration and IV antibiotics.
Resident #117 had a medical diagnosis history including; Congestive heart failure with diuretic use, unspecified dementia without behaviors, hypertension, depression, anxiety, dysphagia, gastro-esophageal reflux disease, and cardiac disease.
Resident #117's most recent Minimum Data Set (MDS) assessment was a Significant change assessment with an assessment reference date of 11-28-24. Resident #117 had a Brief Interview of Mental Status score of 99 indicating severe cognitive impairment. He was dependant on staff for eating, bathing and personal hygiene. He was coded to have no skin impairment, and at risk for skin impairment. He was coded with no weight loss (which was incorrect), a weight of 123 pounds, no swallowing difficulty, and having a mechanically altered diet. The document denotes hospice care, however, the question of life expectancy being less than 6 months was documented as no.
The only previous MDS assessment to the 11-28-24 MDS was dated 9-23-24, and was the Resident's admission assessment. This MDS had not been signed as completed until 11-23-24, and submitted late. The document revealed the Resident's weight at that time to be 139 pounds. This indicated a greater than 10% weight loss in the previous 2 months. It is notable to mention that the Resident was admitted with a weight of 145.3 pounds on 9-6-24. This revealed a significant weight loss of 22.3 pounds since admission, equaling a greater weight loss than 15% in the 3 month period from admission to the current survey which was well documented in the clinical record.
Before hospitalization and after hospitalization the Resident's diet remained the same. Regular diet, Dysphagia pureed texture, thin consistency. On 10-16-24 mighty shakes 4 ounces was ordered at bedtime for a supplement. No other diet changes nor supplements were ever ordered during the Resident's stay.
The Resident was observed during initial tour of the facility on 12-10-24 immediately following a shower room observation with Resident #117's room mate. The room tour included but was not limited to the following being observed;
A urine soaked bathroom, 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 bed divider curtain had brown stains and smeared feces on it.
Resident #117 was in bed covered with only a bed sheet with no blanket and wore no clothing nor gown, and only an incontinence brief under the bed sheet. The fitted bed sheet under the Resident had a yellow halo around the Resident which appeared to be dried urine with a strong odor. The Residents incontinence brief was obviously soaked with urine and wrinkled down at the waist with the heaviness of the liquid it contained. The Residents hair was matted to his head, greasy, dandruff lay in his bed and on his pillow, and body odor/sweat could be clearly smelled.
During the entire survey Resident #117 was never observed during the day shift out of bed, and asked the surveyors often for something to drink stating Please, Please bring me some water I'm so thirsty. The Residents lips were noted to be cracked and dry, and his eyes were sunken. His skin was flaking and dry and when the skin on his hand was examined it tented when pulled gently in an upward fashion and stayed that way. His mucus membranes were sticky and when he spoke his lips would stick together with thick saliva briefly. He constantly complained my butt hurts, my butt hurts. Staff were made aware that the Resident was thirsty, and complaining of butt pain. Staff stated they would have the NP look at him.
On 12-11-24 the Resident was assessed by the Registered Nurse Practitioner (NP) and found to have a stage 3 sacral pressure sore. Each day of survey the Resident was visited and observed to be in bed lying on his back or right side facing the window. No support devices and repositioning was ever observed.
The Residents had no television, no clock, no telephone, no radio and the room had no personal items in it nor on the walls. Each room on the unit was then inspected by all surveyors and found to be in the same condition as Resident #117's room. There were no televisions in any room, and no water to drink in any room.
Staff on the memory care unit were interviewed and asked why Resident #117 was not clean, they stated well, he refuses a lot, and (name) Resident #117 is hospice now and doesn't like to be moved much. Staff were taken to the Residents' room and #117 was asked if he would like a shower or bath, and he simply shook his head yes.
ADL (activities of daily living) care records were reviewed for Resident #117 and revealed that the Resident was totally dependant on one staff member. The document indicated that a bath was given every morning, however, the Resident was observed every day during survey and found to be dirty and unkempt with flaking skin, dandruff, greasy hair, and in a soiled bed with soiled linens. At times the Resident was found wearing only an incontinence brief, and at other times wearing a white stained T-shirt and also an incontinence brief. The Resident was never seen out of bed during daytime hours for the entire survey.
On 12-10-24 A Certified Nursing Assistant (CNA) was found in the hallway after Resident #117 was found begging for water. The CNA brought in 120 milliliters of tea for the Resident, and was again told he asked for water. She stated oh he just wants to drink, not eat. The CNA was asked if she was aware that the caffeine in tea was a diuretic and could further dehydrate the Resident. She did not respond.
On 12-10-24 the Kitchen manager was interviewed and stated that they did not keep track of percentages of meals and fluids consumed, and stated that the nursing staff were responsible for that. She was asked if she had decaffeinated tea on hand, and she stated she had decaf coffee but not tea.
On 12-12-24 A CNA was interviewed and stated, he (Resident #117) went out to the hospital with altered mental status, low blood pressure, dehydration and a UTI (urinary tract infection), and when he came back he went on hospice. He's been in bed now since then. The Resident had actually returned on 10-15-24, and was not placed on hospice until 11-19-24 (one month later). The CNA was asked for his hospice notes, and she went to the LPN (Licensed Practical Nurse) unit manager with the surveyor accompanying her and asked for the notes. The LPN stated I will look for them, and later stated I don't have any. The entire clinical record was reviewed and no hospice notes were in the clinical record.
Staff were then asked if hard copy notes could be located in a binder, and they stated they had no such binder. There was an observed notice taped to the Resident's closet door from the new social worker addressed to the hospice staff. The document instructed that the Resident's hospice supplies had been found in the general supply closet in the facility with normal inventory. The document instructed hospice staff to inform the nurses on the unit when hospice supplies were brought in for the Resident. It appeared that the facility staff and hospice staff were not communicating.
On 12-13-24 from 11:30 AM until 1:00 PM a second surveyor was observing lunch service on the memory care secured unit until the meal was finished. Resident #117 was never fed, and his tray was removed from his room. The tray was placed back on the tray cart to return to the kitchen for disposal, untouched. The CNA was asked why he was not fed, and she replied oh he's hospice he don't want it. The Resident received no food, and no fluids from 9:00 AM breakfast to 5:00 PM dinner (8 hours). No water was in any Resident room on the secured unit during the entire survey.
Resident #117's clinical record was reviewed. Weight documents all completed by chair scale revealed the following;
9-06-24 - 145.3 pounds on admission.
9-10-24 - 143.0 pounds out to hospital on 9-15-24 with bleeding, returned 9-20-24.
9-21-24 - 139.0 pounds
9-24-24 - 139.0 pounds
10-29-24 - 123.0 pounds
11-05-24 - 122.6 pounds
No further weights were being recorded as staff stated well, he's hospice now, so no need really. The Resident was not placed on hospice until 11-19-24, (2 weeks later with no weights completed) and remained a Full Code CPR status.
The Registered Dietician (RD) was called via cellular phone for interview and was unable to be contacted. A message was left on voicemail, however, surveyors received no call back. No RD notes were found in the clinical record, however, on 12-17-24 at 12:11 PM, the Administrator and Director of Nursing (DON) supplied the only note they had received from the RD dated 10-23-24 (8 days after returning from the hospital with sepsis and dehydration). The RD note was reviewed and revealed continued weight loss and the following 4 recommendations, none of which were followed:
1. Consider benefit of appetite stimulant medication due to poor oral intake.
2. when poor oral intake less than 50% offer alternate meal options.
3. weekly weights for one month due to readmit.
4. RD to monitor for significant changes in weight poor oral intake or skin integrity and follow up as needed.
Staff were interviewed on 12-11-24 and asked what interventions could be offered to a Resident to prevent significant weight loss. The Director of Nursing (DON) provided two policies on Nutritional Management, and Weight Monitoring that documented the following;
1. Nutritional Management. Nutritional Status includes both nutrition and hydration status. The document describes a systematic approach to optimize a Resident's nutritional status. Staff are to identify risk factors, evaluate and analyze assessment information, develop and consistently implement approaches, and monitor the effectiveness of interventions and to revise interventions as necessary which would be reflected in the Resident's plan of care. The document goes on to describe that a comprehensive assessment will be completed by the Registered Dietician (RD) within 72 hours of a change in condition to include persistent hunger, poor intake, or continued weight loss, or evidence of fluid loss. One intervention included diet liberalization, and feeding assistance.
2. Weight Monitoring. Significant unintended changes in weight (loss or gain) .may indicate a nutritional problem. A comprehensive nutritional assessment, The Nutritional Data Collection Tool will be completed and that information would identify risk which would then drive the care planning process development to include;
Identified causes of impaired nutritional status, reflect the Resident's personal goals and preferences, identify resident specific interventions, time frame and parameters for monitoring, be updated as needed during Resident's condition changes, interventions are ineffective, or new problems are identified, and be conducted as per professional standards. Residents with weight loss monitor weights weekly. Documentation will include notification of physician, if significant weight loss is identified the RD should be consulted to assist the interdisciplinary (IDT) care plan team with interventions who could initiate the care planning process, as well as the nursing department may initiate the care planning process. The IDT communicates care instructions to staff.
On 12-11-24 the NP documented on a Wound Assessment Report location sacrum, 14 centimeter (cm) length x width total measurement of the wound, 0.1 cm deep date acquired 12-11-24 in house, wound status new, stage/severity Full Thickness, 20% granulation, 80% slough, Erythema peri wound (red and inflamed), exposed tissue Epithelium, Dermis. Treatment daily and as needed cleanse with wound cleanser, hydrogel primary treatment, dressing bordered gauze.
The DON was asked if Foley catheters to keep skin dry and for intake and output assessments were available, and she stated yes. She was asked if formal protein supplements, fluids, diet changes, and moisture barrier creams, and positioning devices were available for Resident's with known significant weight loss and wounds and she stated yes. She was asked if she was aware that the mattress for Resident #117 was the same as the ones used for the ambulatory residents on the memory care unit, and she stated she was not aware of that. None of the above prevention strategies were afforded Resident #117 for prevention of further significant weight loss and the pressure sore indicating this ulcer was potentially avoidable. On 12-11-24 a redistribution air mattress was ordered for the Resident, however did not arrive until after his move to another unit on 12-18-24.
On 12-12-24 Review and copy of Physician's orders revealed only 1 order for weight management;
1. Mighty shake 4 ounces at bedtime was ordered by the physician on 10-16-24 after the Resident returned from the hospital after experiencing dehydration and sepsis. Mighty Shakes nutrition facts included; Only 220 calories per each 4 ounces which equals approximately 2 tablespoons of peanut butter which would contain 8 grams of protein whereas the mighty shake only had 6 grams. The Might Shake was not given on the following nights, with no reason documented as to why it was withheld;
October - 10-20-24, 10-26-24.
November - 11-8-24, 11-19-24, 11-16-24, 11-29-24.
December - 12-3-24, 12-12-24, 12-14-24.
For Resident #117, the pharmacist recommendations were either not obtained, or not acted upon, and none were in the clinical record in 2 of the preceding 3 months of survey (September, and October 2024).
Resident #117's clinical record was reviewed and for the last 3 months prior to survey (September through November), as December had not yet been completed, The Registered Pharmacist (RPH) Monthly Medication Regimen Reviews (MMR) were reviewed.
Resident #117 was receiving anticoagulants, blood pressure medication, psychotropic medication, anti seizure medication, diuretics, pain medication, heart medication, was on a fluid restriction, and had a history of kidney disease, congestive heart failure, bleeding, and dehydration.
On 12-16-24 the Director of Nursing (DON) was interviewed and asked when the MMR's were conducted and how they were conducted. She stated that the RPH reviewed a percentage of the Resident's medications every month. When asked what that percentage was, she stated I will have to check, I am not sure how many they do every month. She was asked if irregularities occurred how the staff would be made aware of that, and again she stated I'm not sure, I don't get that, I will have to find out.
On 12-16-24 the DON and Administrator returned with the Monthly Reviews and revealed that not all Residents were being reviewed monthly. The reviews also revealed that the physician had not been notified of those residents with recommendations for changes, which would have required a documented explanation by the physician of what their decision was in regard to the RPH recommendations for each resident listed. The DON and Corporate RN consultant stated that the recommendations had not been printed from the system where the RHP had documented them and so were not made available to the physician to act upon timely. They stated that the procedure had some cracks in it and that the DON would now be responsible to track this for 100% of the Residents monthly and that she would make sure the physician (MD) received these recommendations and acted upon them.
The MMR reviews were as follows;
September 2024 - Resident #117 - Not evaluated by the RPH.
October 2024 - Resident #117 - Recommendation for psychoactive medication Geodon. Not acted on by MD.
November 2024 - Resident #117 - Resident reviewed with no new recommendations.
The Care plan was reviewed and included focuses, goals and interventions for the following 4 areas (1. weight loss, 2. Pressure sores, 3. Hospice, 4. ADL care);
1. (Weight loss), Malnutrition Risk related to history of rectal bleed constipation created on 9-11-24 with a goal to be free of significant weight changes through review date of 3-7-25. A new care plan revision entry was created on 12-11-24, however, none of the interventions were ever changed, and none were added even after significant weight loss continued and a supplement was ordered on 10-16-24. The care plan identified only the following (5) interventions, and never identified significant weight loss, only intake documentation and diet type were followed;
(1). Administer medications as ordered, observe for side effects and effectiveness alert MD (doctor) as needed.
(2). Provide, serve diet as ordered. Monitor intake and record every meal.
(3). RD to evaluate and make diet change recommendations as needed.
(4). Receives a mechanical soft pureed diet, related to diagnosis.
(5). weight per facility protocol/MD order.
2. (Pressure sores), The Resident has actual impairment to skin integrity created on 12-11-24 with a goal to have no complications related to skin impairment through the review date of 3-7-25. The Care plan was reviewed and included focuses, goals and interventions for potential for pressure ulcer development created on 10-1-24 related to Dementia and bowel and bladder incontinence. A new care plan entry was created on 12-11-24 which identified the first actual impairment to skin integrity with interventions for the (3) following items; No treatments were ever specified.
(1). Follow facility protocols for treatment of injury.
(2). Use caution during transfers and bed mobility to prevent striking arms, legs, and hands to avoid striking any sharp or hard surface.
(3). Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate, and any other notable changes or observations.
3. Hospice, (Resident name) is receiving hospice services from (name of company) and phone number, created on 11-27-24 with a goal of (Resident name) needs will be met through the next review period 3-7-25. Interventions were for the following (2) items. No specific care was specified to be given by the hospice agency, nor by the facility to direct staff in the care required to be performed by each participant, and no collaboration/communication was ever documented between the 2 care givers.
(1). Collaborate with all disciplines, family, Hospice to meet (Resident name) needs.
(2). (Resident name) will be made comfortable.
4. ADL Care, Has bladder incontinence related to dementia, unsteady gait, diuretic use created on 10-1-24, with a goal of The Resident will remain free of skin breakdown due to incontinence through the review date 3-7-25. Interventions were for the following (4) items. The Resident was also incontinent of bowel, fluids were not encouraged leading to dehydration, bowel impaction, and hospitalization. The Resident was non-ambulatory, and only diagnostic testing ordered by a physician could be conducted to diagnose the causes of incontinence in the #(4) intervention.
(1). Clean peri-area with each incontinence episode.
(2). Encourage fluids during the day to promote prompted voiding responses.
(3). Ensure the Resident has unobstructed path to the bathroom.
(4). Observe/report as needed any possible causes of incontinence, bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, stroke, medication side effects.
The care plan was not Resident specific and did not specify feeding needs, supplements, diet changes, alternate diet changes, nor RD interventions. It did not specify any measures/interventions to be instituted to prevent a pressure sore from forming/worsening, like treatments, positioning devices and moisture barrier creams, or support devices. No treatments were specified for the care of a pressure sore after it developed and was identified at a stage 3. Hospice services were never care planned, and ADL care was never care planned for bathing, feeding, hygiene, and toileting as an interdisciplinary care plan team would be expected to produce.
It is also notable to mention that the care plan was not derived by an interdisciplinary team and the only 2 individuals who were present for the most recent care plan update was the LPN (Licensed Practical Nurse) unit manager, and the Social Worker who was found to not have been vetted properly, and had insufficient qualifications for the Role.
On 12-18-24 at 11:15 a.m., the Administrator, Director of Nursing, and Corporate Nurse were notified that the care planning for Resident #117 was insufficient to inform and drive care, was not interdisciplinary, and was not comprehensive per diagnosis and need of the Resident.
The facility Administrator and staff were further notified that no hospice care plan was derived for this Resident to indicate what services would be provided by the facility and or by the hospice company for the long list of needs for this Resident, nor was communication between hospice and facility staff occurring.
The facility staff was given the opportunity to provide any further information or explanation. They stated they had no further information to provide.
On 12-19-24, prior to the survey exit the Director of Nursing informed surveyors that Resident #117 had been moved from the secure unit back onto a regular unit last night (12-18-24).
At the time of survey exit on 12-19-24 the facility Administrator, and Director of Nursing stated they had nothing further to provide.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
Based on clinical record review and staff interviews, the facility staff failed to administer the influenza vaccine for 1 of 5 residents reviewed for immunization (Resident #34), in a survey sample of...
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Based on clinical record review and staff interviews, the facility staff failed to administer the influenza vaccine for 1 of 5 residents reviewed for immunization (Resident #34), in a survey sample of 74 Residents.
The findings included:
Resident #34 was originally admitted to the facility 4/1/16. The current diagnoses included; Alzheimer's Disease with early onset, hyperlipidemia, depression, dysphagia, and muscle weakness.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/8/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 00 out of a possible 15. This indicated Resident #34's cognitive abilities for daily decision making were severely impaired.
The facility's policy on Influenza Vaccination with a revision date of 10/15/2024 was reviewed. The policy stated influenza vaccinations will be routinely offered annually from October 1st through March 31st unless such immunization is medically contraindicated, the individual has already been immunized during this time period or refuses to receive the vaccine.
A review of Resident #34's medical record revealed that the Responsible Party for Resident #34 consented by signature for the influenza vaccine to be administered on the Vaccine Consent Form dated 9/24/24.
On 12/17/24 at 11:40 AM the Infection Preventionist (IP) stated that regarding the influenza immunization, Resident #34 has not received this immunization. The IP also stated that this was an oversight, and the consent documentation for the influenza immunization was signed by the responsible party in September of 2024 and this immunization should have been administered by now.
On 12/19/24 at approximately 6:25 p.m., a final interview was conducted with the Regional [NAME] President of Operations, Administrator, Regional Nursing Consultant, Regional MDS Consultant, Director of Nursing, Assistant Director of Nursing, and Owner. 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 F0887
(Tag F0887)
Could have caused harm · This affected 1 resident
Based on clinical record review and staff interviews, the facility staff failed to administer the Covid-19 vaccine for 1 of 5 residents reviewed for immunization (Resident #34), in a survey sample of ...
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Based on clinical record review and staff interviews, the facility staff failed to administer the Covid-19 vaccine for 1 of 5 residents reviewed for immunization (Resident #34), in a survey sample of 74 Residents.
The findings included:
Resident #34 was originally admitted to the facility 4/1/16. The current diagnoses included; Alzheimer's Disease with early onset, hyperlipidemia, depression, dysphagia, and muscle weakness.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/8/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 00 out of a possible 15. This indicated Resident #34's cognitive abilities for daily decision making were severely impaired.
The facility's policy and procedures on Influenza, Pneumococcal and Covid-19 Disease Prevention with a date of May 2022 was reviewed. The policy and procedures stated the resident's medical record includes: Documentation that the resident either received the influenza, pneumococcal and Covid-19 immunization or did not receive it due to medical contraindications or refusal.
A review of Resident #34's medical record revealed that the Responsible Party for Resident #34 consented by signature for the Covid-19 vaccine to be administered on the Vaccine Consent Form dated 10/28/24.
On 12/17/24 at 11:40 AM the Infection Preventionist (IP) stated that regarding the Covid-19 immunization, Resident #34 has not received this immunization. The IP also stated that this was an oversight, and the consent documentation for the Covid-19 immunization was signed by the responsible party in October of 2024 and this immunization should have been administered by now.
On 12/19/24 at approximately 6:25 p.m., a final interview was conducted with the Regional [NAME] President of Operations, Administrator, Regional Nursing Consultant, Regional MDS Consultant, Director of Nursing, Assistant Director of Nursing, and Owner. 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
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on observation, interview, clinical record review and facility documentation the facility staff failed to ensure functional, and sanitary environment for the residents, staff and the public.
The...
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Based on observation, interview, clinical record review and facility documentation the facility staff failed to ensure functional, and sanitary environment for the residents, staff and the public.
The findings included:
For the facility, the facility staff failed to ensure all 3 dryers were operational to ensure Residents had clean personal laundry as well as staff having adequate linens to care for the Resident population.
On 12/11/2024 at 3pm a Resident Council meeting was held and in the meeting several Residents mentioned the delay in getting laundry back in a timely manner and the shortage of linens was also mentioned.
Excerpts from the Resident council minutes revealed the following:
On 8/14/24, 9/26/24, and 10/24/24 - Resident council minutes reflected complaints of needing more linens, (towels, sheets), long turnaround time for getting laundry back from housekeeping, and personal items missing from laundry, as well as unclean bathrooms and shower rooms.
On 12/11/24 - Linen carts were observed low of linens such as washcloths and towels as well as sheets.
On 12/12/24 at approximately 1:30 p.m. an interview was conducted with Other Employee #7 who was asked about staff cutting towels up to use as wash cloths, he stated that it was not something done or sanctioned by the housekeeping dept. it was the nursing staff who were doing it. When asked why they would do this he stated that there was a shortage of linen due to the dryers being broken. When asked about the dryers and how long they had been broken he stated that they have 3 dryers and 2 have been broken for a couple of months. When asked how they have managed with only 1 dryer he stated that it has not been easy they have been using it all day long. When asked if he was concerned about the possibility of damage to the one remaining dryer due to constant use, and he stated that he was.
On 12/13/24 the Administrator was asked to supply the work orders for the dryers. The work orders revealed the following:
5/28/24 - Repair company fixed dryer - Replaced contactor and put covers back in place. Customer provided contactor and connector. All dryers were operational.
6/13/24 - Repair company fixed two of three dryers and made the following recommendation: Found bad connection of power to motor on upper contactor. Cleaned up for temporary fix. Need contactor and wire harness for permanent repair. Recommend replacing all 3 dryers due to age and poor condition.
7/1/24 - Found contact connectors and wire connectors loose/ broken replaced parts listed. Two of three dryers were operational.
8/5/24 - Replaced parts listed. for two of the three dryers.
No further repair orders were presented.
On 12/19/24 the Administrator was made aware of the findings. The Administrator provided a requisition dated 12/10/24 to purchase one new dryer.
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 F0565
(Tag F0565)
Could have caused harm · This affected multiple residents
Based on interview, observation, and facility documentation the facility staff failed to promptly act upon the grievances and recommendations of regularly attending Resident council members.
The findi...
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Based on interview, observation, and facility documentation the facility staff failed to promptly act upon the grievances and recommendations of regularly attending Resident council members.
The findings included:
The facility staff failed to promptly address the concerns brought forth by the Resident council group members.
On 12/11/24 at 3 p.m. a Resident Council meeting was held with the Resident Council President and 6 other members who regularly attended. During the meeting it was discussed that the facility fails to act, in a timely manner, on suggestions, or concerns brought forth by the Resident Council.
On 12/12/24 a review of the Resident council minutes revealed that several issues were repeatedly brought up in Resident council.
Excerpts from the Resident council minutes revealed the following:
On 8/14/24, 9/26/24, and 10/24/24 - Resident council minutes reflected complaints of needing more linens, (towels, sheets), long turnaround time for getting laundry back from housekeeping, and personal items missing from laundry, as well as bathrooms needing to be cleaner (unclean bathrooms / shower rooms were also noted during survey).
On 8/14/24 and 9/26/24 - Resident council minutes reflected complaints that there were no clocks in the hallway or the activity room (identified during the survey).
On 10/24/24 and 11/25/24 - Resident council minutes reflect that Nursing staff make Residents feel as if they are In the way. Complaints of Unit 4 included staff not giving medications on night shift, and Nursing staff are on the cell phones. Resident council also claimed Nursing staff Talking about other Residents in common areas where others can hear them. Resident council also complained that Administration is not following up or following through on grievances.
On 12/17/24 at approximately 2:00 p.m. an interview was conducted with Other Employee #4 who stated that there has been a Turn over in Activity Staff as well as the Social Worker so this slowed things down a bit.
On 12/19/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
Based a clinical record review and staff interview the facility staff failed to accurately code the Minimum Data Set (MDS) assessment and trackings for 1 of 29 residents (Resident #123), in the survey...
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Based a clinical record review and staff interview the facility staff failed to accurately code the Minimum Data Set (MDS) assessment and trackings for 1 of 29 residents (Resident #123), in the survey sample.
The findings included:
Resident #123 was originally admitted to the facility 6/10/2022 and was last readmitted to the facility 11/10/2024 after an acute care hospital stay. The current diagnoses included a stroke with hemiparesis, dysphagia requiring enteral feedings.
The quarterly MDS assessment with an assessment reference date (ARD) of 3/28/2025 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #14's cognitive abilities for daily decision making were intact.
An interview was conducted with the Business Office Manager (BOM) on 4/1/25 at approximately 1:38 PM. The BOM revealed the resident had resided in the facility since 6/10/2022 except for short stays in the acute care hospital. A review of the resident's MDS assessment with an ARD of 3/28/25 was coded at A1900 that the resident's admission date (date this episode of care in this facility began) was 12/15/2023 instead of 6/10/2022.
A further review of the resident MDS history revealed the resident was discharged return not anticipated to a local acute care hospital 3/10/2024 and returned to the facility 3/12/2024. The entry tracking record was coded at A1700 (Type of Entry) as a reentry.
Also when the resident was discharged return not anticipated to a local acute care hospital 12/5/2023 upon his return to the facility the entry tracking record dated 12/15/2023 was coded at A1700 (Type of Entry) as an admission not a reentry, yet an admission MDS assessment was not conducted.
The requirements for a resident discharged Return not Anticipated according to the CMS RAI Version 3.0 Manual dated October 2023, stated in Chapter 2 page 2-37 to use the following coding for Entry Trackings:
07. Entry Tracking Record (Item A0310F = 01)
There are two types of entries - admission and reentry.
admission (Item A1700 = 1)
Entry tracking record is coded an admission every time a resident:
- is admitted for the first time to this facility; or
- is readmitted after a discharge return not anticipated; or
- is readmitted after a discharge return anticipated when return was not within 30 days
of discharge.
The CMS RAI Version 3.0 Manual dated October 2023, stated in Chapter 2 page 2-8 and 2-9:
2.5 Completion of an OBRA admission assessment must occur in any of the following admission situations:
- when the resident has never been admitted to this facility before; OR
-when the resident has been in this facility previously and was discharged return not
anticipated; OR when the resident has been in this facility previously and was discharged return anticipated and did not return within 30 days of discharge (see Discharge assessment
below).
On 4/3/25 at approximately 5:25 PM, a final interview was conducted with the Administrator, Director of Nursing, the Assistant Director of Nursing and four Corporate Consultants. The above information was reviewed, and the facility's Team voiced no concerns.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to complete a PASARR assessment for Resident #24.
Resident #24 was originally admitted to the faci...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to complete a PASARR assessment for Resident #24.
Resident #24 was originally admitted to the facility 11/17/22 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included Schizoaffective Disorder, Bipolar.
The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 09/19/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #24 cognitive abilities for daily decision making were intact.
The care plan dated 11/24/23 read that Resident #24 has impaired thought processes as evidenced by delusions secondary to schizoaffective/bipolar disorder. The goal for the resident was for the resident will be able to communicate basic needs on a daily basis through the review date 10/01/24. The Interventions: Present just one thought, idea, question or command at a time and monitor/document/report PRN any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status.
A review of the resident's medical record reveal that no PASARR assessment was completed.
On 12/17/24 at approximately 3:39 PM., an interview was conducted with the Social Services Director (SSD). The SSD said that she will complete a PASARR assessment today for Resident #24.
On 12/19/24 at approximately 5:55 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.3. The facility's staff failed to ensure Resident #80 was screened through the PASARR process prior to admission to the facility or shortly thereafter.
Resident # 80 was admitted on [DATE] with diagnoses including but not limited to: Bipolar Disorder,Vascular Dementia, Diabetes, Depression, anxiety disorder, and Post Traumatic Stress Disorder.
Resident #80's most recent MDS (Minimum Data Set) was a Quarterly Assessment with an ARD (Assessment Reference Date) of 11/22/2024 coded the Resident as having a BIMS (Brief Interview of Mental Status) score of 12 out of 15 indicating moderate cognitive impairment.
Review of the clinical record revealed that Resident #80 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:
Escitalopram 5 milligrams one tablet per day for depression
Olanzapine 5 milligrams one tablet at bedtime for psychotic disturbance
Further review of Resident # 80's clinical record was conducted on 12/17/2024. No previous to admission PASARR (preadmission screening & resident review) for mental illness or intellectual disability was found in the Electronic Health Record (EHR). Facility staff were asked to locate any previous PASARR documents, and they stated none had been completed prior to that date.
On 12/17/2024 at approximately 1:00 p.m., an interview was conducted with the Social Worker 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.
On 12/17/2024 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.
On 12/18/2024 at approximately 10:00 a.m, the Director of Nursing and Administrator presented a copy of the PASSAR that was completed on 12/17/2024 by the Social Worker for Resident # 80 and uploaded into the clinical record.
On 12/18/2024 during the end of day meeting, the Administrator and Director of Nursing were made aware of the issues.
No further information was provided.
3. The facility's staff failed to ensure Resident #47 was screened through the PASARR process prior to admission to the facility or shortly thereafter.
Resident #47 was originally admitted to the facility 11/14/2024. The current diagnoses included a subarachnoid hemorrhage and a bipolar disorder.
The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/21/2024 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 0 out of a possible 15. This indicated Resident #47's cognitive abilities for daily decision making were severely impaired.
Review of the clinical record failed to reveal the resident was screened for a possible serious mental disorder, intellectual disability and related conditions through the PASARR process. The resident is ordered Effexor and Lamictal for a bipolar disorder, yet the Level 1 screening could not be in located the clinical record.
An interview was conducted with the Social Services Director (SSD) on 12/18/24 at approximately 1:03 PM. The SSD stated the Level 1 was not sent with the resident at the time of admission, but she would complete the screening. The SSD completed the Level 1 screening for Resident #47 on 12/18/24 and presented it to the Team.
On 12/19/24 at approximately 6:00 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, the Owner and three Corporate Nurse Consultants. They voiced no concerns regarding the above findings.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 or shortly thereafter for 4 Residents (Residents #49, #24, #47, and #80) in a sample of 74 residents.
The findings include:
1. For Resident #49, facility staff failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed correctly prior to admission or shortely thereafter.
Resident #49 was admitted on [DATE] with diagnoses including: Major depressive disorder with psychotic symptoms, anxiety disorder, and Post Traumatic Stress Disorder (PTSD).
Physicians orders for medications were reviewed and revealed psychotropic medications actively being administered for anxiety, and ongoing behavior monitoring.
On 12-10-24, an observation was conducted of Resident #49. The Resident was sitting in her room and refused to respond to the surveyor who had entered the room and addressed her in a greeting while attempting conversation and interview. The Resident was talking to herself with questions and answers to an apparent inner monolog with herself.
On 12-12-24 a review of Resident #49's clinical record was conducted. No previous to admission PASARR (preadmission screening & resident review) for mental illness or intellectual disability was found in the Electronic Health Record (EHR). Facility staff were asked to locate any previous PASARR documents, and they stated none had been completed.
On 12-17-24 the new social worker completed a PASARR document for the Resident, however there were errors and the document was incomplete. It was signed by the new social worker and dated 12-17-24.
It is notable to mention that the new Social worker was interviewed on 12-10-24 and revealed that she had just been hired on 11-19-24. The former Social worker resigned on 6-28-24, and there had been no social worker in the facility from 6-28-24 until 11-19-24.
On 12-12-24 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 not sufficient for the role.
The Administrator and Director of Nursing were informed of the findings at the end of day meeting on 12-18-24. The Administrator stated, we will correct this immediately and indicated they would be auditing residents' PASARR's. No further documents were 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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #379 the facility staff failed to ensure the Resident had a care plan that included interventions for prevention...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #379 the facility staff failed to ensure the Resident had a care plan that included interventions for prevention of pressure ulcers.
Resident #379 was admitted to the facility on [DATE] with diagnoses that included but was not limited to sepsis, CVA malnutrition, metabolic encephalopathy, dysphagia, Alzheimer's disease, dementia, acute kidney failure, atherosclerotic heart disease, hypothyroidism, hypertension and insomnia. Resident #379 was dependent on g-tube feedings for nutrition. The discharge instructions stated that the Resident skin on discharge was warm and dry with no mention of open areas, wounds or pressure sores.
On 12/12/24 a review of the clinical record revealed that the admission Screening done on 1/12/24 section C showed skin normal, dry and no open areas. His Braden Scale for Predicting Pressure Sore Risk score was 13 indicating he was a moderate risk for development of pressure sores. The MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1-19-24 coded Resident # 379 as being dependent on staff for turning repositioning and all aspects of ADL (Activities of Daily Living) care.
On 12/12/24 a review of the clinical record revealed that Daily Skin Assessment document dated 1/15/24 was not filled out. The Weekly Skin Assessment document dated 1/17/24 was not filled out, however the following pressure injuries were documented in the clinical record:
Left Heel DTI (Deep Tissue Injury)
Left Lateral Ankle DTI
Right Foot DTI
Right Lateral Ankle DTI
On 12/13/24 a review of the clinical record revealed that the comprehensive care plan was started on 1/24/24 read as follows:
FOCUS:
(Name redacted) has DTI pressure ulcer to left hell, [sic] left lateral ankle, right later ankle pressure or potential for pressure ulcer and potential for skin breakdown development r/t Dehydration, disease process, incontinence, Hx of ulcers, Immobility. Date Initiated: 01/24/2024 Created on: 01/24/2024.
GOAL:
Pressure ulcer will show signs of healing and remain free from infection by/through review date. Date Initiated: 01/24/2024
Target Date: 04/11/2024
INTERVENTIONS:
Administer medications as ordered. Observe/document for side effects and effectiveness. Date Initiated: 01/24/2024
Created on: 01/24/2024
Administer treatments as ordered and observe for effectiveness. Date Initiated: 01/24/2024Created on: 01/24/2024
Follow facility policies/protocols for the prevention/treatment of skin breakdown. Date Initiated: 01/24/2024 Created on: 01/24/2024
If the resident refuses treatment, confer with the resident, IDT and family to determine why and try alternative methods to gain compliance. Document alternative methods. Date Initiated: 01/24/2024 Created on: 01/24/2024
Inform the resident/family/caregivers of any new area of skin breakdown. Date Initiated: 01/24/2024 Created on: 01/24/2024
On 12/13/24 an interview was conducted with the DON who was asked the purpose of a care plan. The DON answered that the care plan should direct all aspects of the Residents care. When asked if this included pressure ulcer prevention for a non ambulatory Resident who is dependent on staff for all aspects of ADL care. She stated that all Resident who have limited mobility should have pressure ulcer prevention in the care plan. When asked if that was done in the case of Resident #379 she stated that according to the care plan Resident #379 did not have interventions in place until after he developed pressure areas.
On 12/16/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.
3. For Resident # 91, the care plan was not resident-centered to describe issues or behaviors related to Resident # 91 refusing to allow bedding/linens to be placed on the bed.
Resident # 91 was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Cerebral Infarction, Hypertension, Anxiety Disorder, Hemiplegia and Vascular Dementia.
The most recent Minimum Data Set (MDS) was an Annual Assessment with an Assessment Reference Date (ARD) of 11/3/2024. Resident # 91's BIMS (Brief Interview for Mental Status) Score was a 14 out of 15, indicating no cognitive impairment. Resident # 91 required assistance with Activities of Daily Living.
Review of the clinical record was conducted on 12/10/2024-12/19/2024.
During observations on all of the days of the survey, there was no sheet on the mattress nor linens on the bed at any time. Resident # 91 was observed lying in the bed with no sheet or bedding covering the mattress. The resident was lying on the uncovered vinyl mattress.
On 12/17/2024, at approximately 03:45 PM, Resident #91 was observed walking into his room. Bed observed unmade no sheets. Air condition unit set at 62 degrees. Resident states I don't want sheets on my bed its too hot. Everyone here knows not to put sheets on my bed and to keep my curtain drawn.
Review of the care plan revealed no documentation of a concern or problem regarding Resident # 91 not wanting sheets or any bedding/linens on the bed.
Review of the Progress Notes revealed no documentation about Resident # 91 refusing to allow the staff to put sheets/linens on the bed.
During the end of day debriefing on 12/17/2024, the Administrator and Director of Nursing were informed of the findings that the care plan was not resident specific for Resident # 91. The Director of Nursing stated the care plan should represent any concerns or issues involving the resident and should have had documentation about the resident refusing to allow linens on the bed.
No further information was provided.
4. For Resident # 39, the facility staff failed to develop and implement a resident-centered care plan regarding the problem of a Candida infection.
Resident # 39 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, Chronic Obstructive Pulmonary Disease, Emphysema, Primary Hypertension, Anxiety, Depression, Gastrpesophageal Reflux Disease, Barrett's Esophagus, Dysphagia and Insomnia.
The most recent Minimum Data Set (MDS) was a Quarterly Assessment Quarterlywith an Assessment Reference Date (ARD) of 11/17/2024. Resident # 39's BIMS (Brief Interview for Mental Status) Score was a 15 out of 15, indicating no cognitive impairment.
Review of the clinical record was conducted on 12/10/2024-12/19/2024.
Review of the care plan revealed documentation of a problem stating the resident has Candida infection. The location of the infection was not noted. The Goal was written as will remain free from infection through the review date. The intervention was Observe, document report PRN (as needed) signs and symptoms of infection, fever, redness, drainage or swelling around wounds or catheter sites, cough, dysuria, hematuria, flank pain, and foul smelling urine.
Review of the Progress Notes revealed documentation of the following:
8/1/2023- Nurse Practitioner note- On page 591 of 702 seen for follow up of complaints of burning and itching. Patient was recently checked for UTI (urinary tract infection) discussed with patient her recent lab results and negative findings. However, patient complained of discharge itching and irritation to her groin area discussed with patient starting medications for concerns with the yeast she verbalized understanding . The note documented on page 597 of 702 a genitourinary exam was deferred due to positive suprapubic tenderness to palpation. On page 598 of 702, the diagnosis was listed as Candida Infection. The plan was listed patient start with Diflucan for Candida Infection 150 mg by mouth x 3 days monitor closely notify provider if any persistent complications maintain adequate hygiene assist patient with her laundry continue supportive care . The note was signed by the Nurse Practitioner on 8/5/2023 at 7:04 p.m
8/5/2023 at 10:56 a.m. the Nursing Progress note was written stating- resident complaining of itching in private area, Patient completed Fluconazole today 8/5/23 as prescribed by doctor. Patient stated it is not helping I feel like I could itch my privates with a hairbrush. After I use the bathroom in the morning, it feels like a relief but only briefly. I am itching and uncomfortable. Reassured resident that NP will be notified of persistent discomfort. NP notified, will continue to monitor at this time.
8/6/2023 at 6:12 p.m., Nursing Progress Note Patient states 'The problem in my vagina area is 60% better than it was yesterday. Notified NP that the issue is getting better.
8/14/2023 at 8:43 p.m.-Nurses Progress Note stated the Resident complained of severe vaginal itching with some light-yellow discharge. Encourage fluid intake and personal hygiene. Notified NP-awaiting assessment. Resident accepting.
8/15/2023 at 1:00 a.m.-NP encounter visit- stated resident was seen for follow up of vaginal itching and irritation. The note stated the resident had complications of a Candida infection and had been treated with Diflucan for 3 days. However, patient complains of some ongoing itching and irritation. Discussed with patient will recommend possibly a topical agent- On assessment she does not have any odorous discharge she does have some redness externally,,,
On 12/18/2024 at 3:20 p.m., an interview was conducted with Licensed Practical Nurse # 1 who stated the care plan should reflect the problems affecting the resident. Licensed Practical Nurse # 1 stated the nursing staff use the care plan as a guide for providing care to the residents. She also stated interventions should be written that would help to resolve the problem. Licensed Practical Nurse # 1 stated the nurses should monitor the residents to see if the interventions were helpful and if the issue was resolved.
The care plan did not specifically address the location of the Candida Infection. There was no mention of the severe vaginal itching and irritation that Resident # 39 was experiencing. There were no specific interventions related to resolving the problem. The care plan appeared to be from a template but not resident specific.
During the end of day debriefing on 12/18/2024, the Administrator and Director of Nursing were informed of the issues of the care plan not being person-centered. The Director of Nursing stated the care plan should represent any concerns or issues involving the resident and should have interventions to address the issue/problem.
No further information was provided.
Based on observation, staff interview, facility documentation review, and clinical record review the facility staff failed to develop and implement a comprehensive care plan for 4 Residents (Residents #117, #379, #91 and #39) in a survey sample of 74 Residents.
The findings included:
1. For Resident #117, the facility staff failed to derive and implement a comprehensive care plan for prevention of significant weight loss and dehydration, Pressure sores, Hospice, and provision of ADL (Activities of Daily Living) care.
Resident #117 was originally admitted to the facility on [DATE], and was hospitalized 10 days later on 9-15-24 for a colonic hemorrhage caused by a Stercoral ulcer (impacted hard stool at the anus and distal rectum) which pierced the bowel wall, after having had no bowel movements. The ulcer/perforation of the bowel wall resulted in blood loss requiring 2 blood transfusions according to hospital records.
The Resident was again sent out to the hospital on [DATE] through 10-15-24 for a severe urinary tract infection causing sepsis and septic shock, and acute kidney injury which was reversed successfully in the hospital with IV (intravenous) fluids for dehydration and IV antibiotics.
Resident #117 had a medical diagnosis history including; Congestive heart failure with diuretic use, unspecified dementia without behaviors, hypertension, depression, anxiety, dysphagia, gastro-esophageal reflux disease, and cardiac disease.
Resident #117's most recent Minimum Data Set (MDS) assessment was a Significant change assessment with an assessment reference date of 11-28-24. Resident #117 had a Brief Interview of Mental Status score of 99 indicating severe cognitive impairment. He was dependant on staff for eating, bathing and personal hygiene. He was coded to have no skin impairment, and at risk for skin impairment. He was coded with no weight loss (which was incorrect), a weight of 123 pounds, no swallowing difficulty, and having a mechanically altered diet.
The only previous MDS assessment to the 11-28-24 MDS was dated 9-23-24, and was the Resident's admission assessment. This MDS had not been signed as completed until 11-23-24, and submitted late. The document revealed the Resident's weight at that time to be 139 pounds. This indicated a greater than 10% weight loss in the previous 2 months. It is notable to mention that the Resident was admitted with a weight of 145.3 pounds on 9-6-24. This revealed a significant weight loss of 22.3 pounds since admission, equaling a greater weight loss than 15% in the 3 month period from admission to the current survey which was well documented in the clinical record.
Before hospitalization and after hospitalization the Resident's diet remained the same. Regular diet, Dysphagia pureed texture, thin consistency. On 10-16-24 mighty shakes 4 ounces was ordered at bedtime for a supplement. No other diet changes nor supplements were ever ordered during the Resident's stay.
The Resident was observed during initial tour of the facility on 12-10-24 immediately following a shower room observation with Resident #117's room mate. The room tour included but was not limited to the following being observed;
A urine soaked bathroom, 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 bed divider curtain had brown stains and smeared feces on it.
Resident #117 was in bed covered with only a bed sheet with no blanket and wore no clothing nor gown, and only an incontinence brief under the bed sheet. The fitted bed sheet under the Resident had a yellow halo around the Resident which appeared to be dried urine with a strong odor. The Residents incontinence brief was obviously soaked with urine and wrinkled down at the waist with the heaviness of the liquid it contained. The Residents hair was matted to his head, greasy, dandruff lay in his bed and on his pillow, and body odor/sweat could be clearly smelled.
During the entire survey Resident #117 was never observed during the day shift out of bed, and asked the surveyors often for something to drink stating Please, Please bring me some water I'm so thirsty. The Residents lips were noted to be cracked and dry, and his eyes were sunken. His skin was flaking and dry and when the skin on his hand was examined it tented when pulled gently in an upward fashion and stayed that way. His mucus membranes were sticky and when he spoke his lips would stick together with thick saliva briefly. He constantly complained my butt hurts, my butt hurts. Staff were made aware that the Resident was thirsty, and complaining of butt pain. Staff stated they would have the NP look at him.
On 12-11-24 the Resident was assessed by the Registered Nurse Practitioner (NP) and found to have a stage 3 sacral pressure sore. Each day of survey the Resident was visited and observed to be in bed lying on his back or right side facing the window. No support devices and repositioning was ever observed.
The Residents had no television, no clock, no telephone, no radio and the room had no personal items in it nor on the walls. Each room on the unit was then inspected by all surveyors and found to be in the same condition as Resident #117's room. There were no televisions in any room, and no water to drink in any room.
Staff on the memory care unit were interviewed and asked why Resident #117 was not clean, they stated well, he refuses a lot, and (name) Resident #117 is hospice now and doesn't like to be moved much. Staff were taken to the Residents' room and #117 was asked if he would like a shower or bath, and he simply shook his head yes.
ADL (activities of daily living) care records were reviewed for Resident #117 and revealed that the Resident was totally dependant on one staff member. The document indicated that a bath was given every morning, however, the Resident was observed every day during survey and found to be dirty and unkempt with flaking skin, dandruff, greasy hair, and in a soiled bed with soiled linens. At times the Resident was found wearing only an incontinence brief, and at other times wearing a white stained T-shirt and also an incontinence brief. The Resident was never seen out of bed during daytime hours for the entire survey.
On 12-10-24 A Certified Nursing Assistant (CNA) was found in the hallway after Resident #117 was found begging for water. The CNA brought in 120 milliliters of tea for the Resident, and was again told he asked for water. She stated oh he just wants to drink, not eat. The CNA was asked if she was aware that the caffeine in tea was a diuretic and could further dehydrate the Resident. She did not respond.
On 12-10-24 the Kitchen manager was interviewed and stated that they did not keep track of percentages of meals and fluids consumed, and stated that the nursing staff were responsible for that. She was asked if she had decaffeinated tea on hand, and she stated she had decaf coffee but not tea.
On 12-12-24 A CNA was interviewed and stated, he (Resident #117) went out to the hospital with altered mental status, low blood pressure, dehydration and a UTI (urinary tract infection), and when he came back he went on hospice. He's been in bed now since then. The Resident had actually returned on 10-15-24, and was not placed on hospice until 11-19-24 (one month later). The CNA was asked for his hospice notes, and she went to the LPN (Licensed Practical Nurse) unit manager with the surveyor accompanying her and asked for the notes. The LPN stated I will look for them, and later stated I don't have any. The entire clinical record was reviewed and no hospice notes were in the clinical record.
Staff were then asked if hard copy notes could be located in a binder, and they stated they had no such binder. There was an observed notice taped to the Resident's closet door from the new social worker addressed to the hospice staff. The document instructed that the Resident's hospice supplies had been found in the general supply closet in the facility with normal inventory. The document instructed hospice staff to inform the nurses on the unit when hospice supplies were brought in for the Resident. It appeared that the facility staff and hospice staff were not communicating.
On 12-13-24 from 11:30 AM until 1:00 PM a second surveyor was observing lunch service on the memory care secured unit until the meal was finished. Resident #117 was never fed, and his tray was removed from his room. The tray was placed back on the tray cart to return to the kitchen for disposal, untouched. The CNA was asked why he was not fed, and she replied oh he's hospice he don't want it. The Resident received no food, and no fluids from 9:00 AM breakfast to 5:00 PM dinner (8 hours). No water was in any Resident room on the secured unit during the entire survey.
Resident #117's clinical record was reviewed. Weight documents all completed by chair scale revealed the following;
9-06-24 - 145.3 pounds on admission.
9-10-24 - 143.0 pounds out to hospital on 9-15-24 with bleeding, returned 9-20-24.
9-21-24 - 139.0 pounds
9-24-24 - 139.0 pounds
10-29-24 - 123.0 pounds
11-05-24 - 122.6 pounds
No further weights were being recorded as staff stated well, he's hospice now, so no need really. The Resident was not placed on hospice until 11-19-24, (2 weeks later with no weights completed) and remained a Full Code CPR status.
The Registered Dietician (RD) was called via cellular phone for interview and was unable to be contacted. A message was left on voicemail, however, surveyors received no call back. No RD notes were found in the clinical record, however, on 12-17-24 at 12:11 PM, the Administrator and Director of Nursing (DON) supplied the only note they had received from the RD dated 10-23-24 (8 days after returning from the hospital with sepsis and dehydration). The RD note was reviewed and revealed continued weight loss and the following 4 recommendations, none of which were followed:
1. Consider benefit of appetite stimulant medication due to poor oral intake.
2. when poor oral intake less than 50% offer alternate meal options.
3. weekly weights for one month due to readmit.
4. RD to monitor for significant changes in weight poor oral intake or skin integrity and follow up as needed.
Staff were interviewed on 12-11-24 and asked what interventions could be offered to a Resident to prevent significant weight loss. The Director of Nursing (DON) provided two policies on Nutritional Management, and Weight Monitoring that documented the following;
1. Nutritional Management. Nutritional Status includes both nutrition and hydration status. The document describes a systematic approach to optimize a Resident's nutritional status. Staff are to identify risk factors, evaluate and analyze assessment information, develop and consistently implement approaches, and monitor the effectiveness of interventions and to revise interventions as necessary which would be reflected in the Resident's plan of care. The document goes on to describe that a comprehensive assessment will be completed by the Registered Dietician (RD) within 72 hours of a change in condition to include persistent hunger, poor intake, or continued weight loss, or evidence of fluid loss. One intervention included diet liberalization, and feeding assistance.
2. Weight Monitoring. Significant unintended changes in weight (loss or gain) .may indicate a nutritional problem. A comprehensive nutritional assessment, The Nutritional Data Collection Tool will be completed and that information would identify risk which would then drive the care planning process development to include;
Identified causes of impaired nutritional status, reflect the Resident's personal goals and preferences, identify resident specific interventions, time frame and parameters for monitoring, be updated as needed during Resident's condition changes, interventions are ineffective, or new problems are identified, and be conducted as per professional standards. Residents with weight loss monitor weights weekly. Documentation will include notification of physician, if significant weight loss is identified the RD should be consulted to assist the interdisciplinary (IDT) care plan team with interventions who could initiate the care planning process, as well as the nursing department may initiate the care planning process. The IDT communicates care instructions to staff.
On 12-11-24 the NP documented on a Wound Assessment Report location sacrum, 14 centimeter (cm) length x width total measurement of the wound, 0.1 cm deep date acquired 12-11-24 in house, wound status new, stage/severity Full Thickness, 20% granulation, 80% slough, Erythema peri wound (red and inflamed), exposed tissue Epithelium, Dermis. Treatment daily and as needed cleanse with wound cleanser, hydrogel primary treatment, dressing bordered gauze.
The DON was asked if Foley catheters to keep skin dry and for intake and output assessments were available, and she stated yes. She was asked if formal protein supplements, fluids, diet changes, and moisture barrier creams, and positioning devices were available for Resident's with known significant weight loss and wounds and she stated yes. She was asked if she was aware that the mattress for Resident #117 was the same as the ones used for the ambulatory residents on the memory care unit, and she stated she was not aware of that. None of the above prevention strategies were afforded Resident #117 for prevention of further significant weight loss and the pressure sore indicating this ulcer was potentially avoidable. On 12-11-24 a redistribution air mattress was ordered for the Resident, however did not arrive until after his move to another unit on 12-18-24.
On 12-12-24 Review and copy of Physician's orders revealed only 1 order for weight management;
1. Mighty shake 4 ounces at bedtime was ordered by the physician on 10-16-24 after the Resident returned from the hospital after experiencing dehydration and sepsis. Mighty Shakes nutrition facts included; Only 220 calories per each 4 ounces which equals approximately 2 tablespoons of peanut butter which would contain 8 grams of protein whereas the mighty shake only had 6 grams. The Might Shake was not given on the following nights, with no reason documented as to why it was withheld;
October - 10-20-24, 10-26-24.
November - 11-8-24, 11-19-24, 11-16-24, 11-29-24.
December - 12-3-24, 12-12-24, 12-14-24.
The Care plan was reviewed and included focuses, goals and interventions for the following 4 areas (1. weight loss, 2. Pressure sores, 3. Hospice, 4. ADL care);
1. (Weight loss), Malnutrition Risk related to history of rectal bleed constipation created on 9-11-24 with a goal to be free of significant weight changes through review date of 3-7-25. A new care plan revision entry was created on 12-11-24, however, none of the interventions were ever changed, and none were added even after significant weight loss continued and a supplement was ordered on 10-16-24. The care plan identified only the following (5) interventions, and never identified significant weight loss, only intake documentation and diet type were followed;
(1). Administer medications as ordered, observe for side effects and effectiveness alert MD (doctor) as needed.
(2). Provide, serve diet as ordered. Monitor intake and record every meal.
(3). RD to evaluate and make diet change recommendations as needed.
(4). Receives a mechanical soft pureed diet, related to diagnosis.
(5). weight per facility protocol/MD order.
2. (Pressure sores), The Resident has actual impairment to skin integrity created on 12-11-24 with a goal to have no complications related to skin impairment through the review date of 3-7-25. The Care plan was reviewed and included focuses, goals and interventions for potential for pressure ulcer development created on 10-1-24 related to Dementia and bowel and bladder incontinence. A new care plan entry was created on 12-11-24 which identified the first actual impairment to skin integrity with interventions for the (3) following items; No treatments were ever specified.
(1). Follow facility protocols for treatment of injury.
(2). Use caution during transfers and bed mobility to prevent striking arms, legs, and hands to avoid striking any sharp or hard surface.
(3). Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate, and any other notable changes or observations.
3. Hospice, (Resident name) is receiving hospice services from (name of company) and phone number, created on 11-27-24 with a goal of (Resident name) needs will be met through the next review period 3-7-25. Interventions were for the following (2) items. No specific care was specified to be given by the hospice agency, nor by the facility to direct staff in the care required to be performed by each participant, and no collaboration/communication was ever documented between the 2 care givers.
(1). Collaborate with all disciplines, family, Hospice to meet (Resident name) needs.
(2). (Resident name) will be made comfortable.
4. ADL Care, Has bladder incontinence related to dementia, unsteady gait, diuretic use created on 10-1-24, with a goal of The Resident will remain free of skin breakdown due to incontinence through the review date 3-7-25. Interventions were for the following (4) items. The Resident was also incontinent of bowel, fluids were not encouraged leading to dehydration, bowel impaction, and hospitalization. The Resident was non-ambulatory, and only diagnostic testing ordered by a physician could be conducted to diagnose the causes of incontinence in the #(4) intervention.
(1). Clean peri-area with each incontinence episode.
(2). Encourage fluids during the day to promote prompted voiding responses.
(3). Ensure the Resident has unobstructed path to the bathroom.
(4). Observe/report as needed any possible causes of incontinence, bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, stroke, medication side effects.
The care plan was not Resident specific and did not specify feeding needs, supplements, diet changes, alternate diet changes, nor RD interventions. It did not specify any measures/interventions to be instituted to prevent a pressure sore from forming/worsening, like treatments, positioning devices and moisture barrier creams, or support devices. No treatments were specified for the care of a pressure sore after it developed and was identified at a stage 3. Hospice services were never care planned, and ADL care was never care planned for bathing, feeding, hygiene, and toileting as an interdisciplinary care plan team would be expected to produce. It is also notable to mention that the care plan was not derived by an interdisciplinary team and the only 2 individuals who were present for the most recent care plan update was the LPN (Licensed Practical Nurse) unit manager, and the Social Worker who was found to not have been vetted properly, and had insufficient qualifications for the Role.
On 12-18-24 at 11:15 a.m., the Administrator, Director of Nursing, and Corporate Nurse were notified that the care planning for Resident #117 was insufficient to inform and drive care, not interdisciplinary, and not comprehensive per diagnosis and need of the Resident. The facility staff was given the opportunity to provide any further information or explanation. They stated they had no further information.
On 12-19-24, prior to the survey exit the Director of Nursing informed surveyors that Resident #117 and his room mate had been moved back onto regular units last night (12-18-24).
At the time of survey exit on 12-19-24 the facility Administrator, and Director of Nursing stated they had nothing further to provide.
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 observation, interview, clinical record review and facility documentation, the facility staff failed to review and revi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review and facility documentation, the facility staff failed to review and revise a care plan for two (2) Residents (#'s 78 and 105) in a survey sample of 74 Residents.
The findings included:
1. For Resident #78 the facility staff failed to review and revise care plan to include add each actual fall and update or add new interventions.
On 12/11/24 a review of the clinical record revealed that Resident #78 was admitted to the facility on [DATE] with diagnoses that included but were not limited to cognitive communication deficit, dysphagia, muscle weakness, dementia, severe without behavioral disturbance, psychotic mood disturbance and anxiety, abnormalities of gait and mobility, hypertension, hx (history) of renal cancer, and hx of repeated falls. Resident #78 had a BIMS (Brief Interview of Mental Status) score of 13/15 on admission indicating mild cognitive impairment. On 2/13/24 (one month prior to falls) Resident #78 BIMS was assessed at 5/15 indicating severe cognitive impairment.
A review of Resident #78's complete care plan revealed that on admission the Resident was identified as being a high fall risk as evidenced by the following entry in the initial comprehensive care plan dated 4/30/23:
FOCUS:
[Resident #78 name redacted] is High, risk for falls r/t Confusion, Gait/balance problems, Incontinence, Unaware of safety needs Date Initiated: 04/30/2023 Created on: 04/30/2023
GOAL:
[Resident #78 name redacted] will be free of falls through the review date. Date Initiated: 03/05/2024 Revision on: 04/18/2024 Target Date: 10/09/2023
INTERVENTION:
Anticipate and meet her needs. Date Initiated: 04/30/2023 Created on: 04/30/2023
Be sure call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Date Initiated: 04/30/2023 Created on: 04/30/2023
Follow facility fall protocol. Date Initiated: 04/30/2023 Created on: 04/30/2023
Pt evaluate and treat as ordered or PRN. Date Initiated: 04/30/2023 Created on: 04/30/2023.
A review of the clinical record revealed that Resident #78 had 6 falls from 3/23/24 through 11/24/24 (3/23/24, 3/30/24, 7/1/24, 8/5/24, 11/23/24 and 11/24/24). The care plan update was not updated, reviewed and revised after the falls on 3/23, 3/30, 7/1, 11/23 & 11/24/24. The following revision to the care plan was made after the fall on 8/5/24.
FOCUS:
[Resident #78 name redacted] has had an actual fall with no injury, R/T Poor communication/comprehension Date Initiated: 08/05/2024 Created on: 08/05/2024
GOAL:
[Resident #78 name redacted] will resume usual activities without further incident through the review date. Date Initiated: 08/05/2024 Revision on: 08/05/2024
INTERVENTIONS:
Continue interventions on the at-risk plan. Low bed, Rt & Lt fall mats, repositioning every shift Date Initiated: 08/05/2024 Created on: 08/05/2024
Observe and report PRN to MD for s/sx: Pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. Date Initiated: 08/05/2024 Created on: 08/05/2024
Neuro checks per protocol. Date Initiated: 08/05/2024 Created on: 08/05/2024.
On 12/18/24 an interview with LPN 1 (Unit Manager), who was asked what the expectation is for nursing staff after a fall occurs and she stated that Nurses are expected to assess the Resident for injuries, notify physician and family, follow any new orders from physician pertaining to the incident, and document the fall as well as the post fall follow up, and the care plan should be updated to add new interventions after a fall. When asked if this was done after each fall, she stated that it was not.
On 12/18/24 a review of the facility FALL POLICY revealed the following excerpts:
9. When any resident experiences a fall, the facility will:
a. Assess the resident.
b. Complete a Post fall review and a Post fall follow up note in PCC [the electronic health record]
c. Complete an incident report in PCC
d. Notify physician and family.
e. Review the resident's care plan and update as indicated
f. Document all assessments and actions
g. Obtain witness statements in the case of injury
h. If there are signs of serious injury or there are concerns about the circumstances of the fall notify the Director of Nursing and or the Administrator.
i. Begin neurologic assessment using Neurological Record assessment tool in PCC
On 12/18/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.2. The facility's staff failed to review and revise Resident #105's care plan after hospice services were discontinued.
Resident #105 was originally admitted to the facility 10/27/23 and he was readmitted [DATE] after an acute care hospital stay. The current diagnoses included a major neurocognitive disorder with Lewy Bodies dementia.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/17/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 4 out of a possible 15. This indicated Resident #105's cognitive abilities for daily decision making were severely impaired.
On 11/13/23 hospice services were elected for Resident #105. On 5/20/24 hospice services were discontinued due to an extended prognosis.
A review of the person-centered care plan revised on 10/24/24 stated (name of resident) has a problem or potential nutritional problem related to diagnoses of dementia, CHF, advanced age and hospice. The goal stated (name of resident) will maintain adequate nutritional status as evidenced by no significant weight changes, no signs/symptoms of malnutrition, and consuming greater than/equal to 50 percent of most meals daily through review date,1/24/25. The interventions included provide, serve diet as ordered. Monitor intake and record after each meal.
On 12/19/24 at approximately 6:00 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, the Owner and three Corporate Nurse Consultants. They voiced no concerns regarding the above findings.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The facility staff failed to ensure the Certified Nursing Assistant (CNA) provided incontinent care/peri care correctly for R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The facility staff failed to ensure the Certified Nursing Assistant (CNA) provided incontinent care/peri care correctly for Resident #18 that was dependent in Activity of Daily Living (ADL) care. Resident #18 was originally admitted to the facility 10/14/24 after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Urinary Tract Infection.
The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/24/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 10 out of a possible 15. This indicated Resident #18 cognitive abilities for daily decision making were moderately impaired.
In sectionGG(Functional Abilities Goals) the resident was coded as requiring dependence with eating, oral hygiene, toileting hygiene, shower/bathing and personal hygiene.
The care plan dated 12/12/24 read that Resident #18 had an ADL (Activity of Daily Living) self-care performance deficit r/t Activity Intolerance. The Goal for the resident is that they will maintain their current level of function. The interventions are as follows: PERSONAL HYGIENE/ORAL CARE: The resident is totally dependent on (1) staff for personal hygiene and oral care, TOILET USE: The resident is totally dependent on (2) staff for toilet use, the resident will maintain current level of function, provide sponge bath when a full bath or shower cannot be tolerated.
On 12/18/24 at approximately 4:30 PM., Resident #18 was observed during peri care/incontinent care. The Infection Preventionist (IP) and Certified Nursing Assistant (CNA) #13 were present. CNA #13 was observed filling two basins and placing them on the bedside table. 1 basin had water inside with a bar of soap, and the other basin had just (clear) rinse water in it. Several clean washcloths were available. Peri care was observed without difficulty. CNA #13 placed a washcloth in the soapy water and started wiping the resident, noticed Stool like substance was observed on the washcloth, placed the soiled washed cloth in the rinse water, grabbed a clean washed cloth placed it in the rinse water that now had the soiled wash cloth and proceeded to rinse the resident's vaginal area. Shortly thereafter the peri care was complete, CNA #13 was asked by the surveyor if he had noticed a soiled washcloth in the rinse water. CNA #13 said that he hadn't noticed the soiled washcloth in the rinse water. The IP said that she had noticed it and will provide education and training on peri care.
On 12/19/24 at approximately 5:55 p.m., 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's staff failed to provide ongoing and consistent oral care to a dependent resident receiving enteral feedings, Resident #48.
Resident #48 was originally admitted to the facility 12/15/2023 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included a stroke with hemiparesis, dysphagia causing pulmonary aspiration, enteral feedings are required.
The annual 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 14 out of a possible 15. This indicated Resident #14's cognitive abilities for daily decision making were intact.
The resident's care plan dated 10/19/22 stated (name of resident) has an ADL self-care performance deficit related to a CVA with hemiparesis. The goal stated (name of resident) will improve current level of function in ADLs through the review date, 2/17/25. The intervention dated 7/22/22 stated Or al care routine (AM, PC, HS): brush (name of resident) teeth, rinse dentures, CNA clean gums with toothette, rinse mouth with wash.
An observation was made of Resident #48 on 12/10/24 at approximately 3:36 PM. The resident was in bed and attempted to answer when spoken to, but his mouth was full of dry mucus and his lips had a dry glaze over them. The resident's response was not verbalized.
On 12/11/24 at approximately 11:05 PM an observation was made of Resident #48. Again, he was in bed, Glucerna was infusing at 60 milliliters per hour. Again, the resident attempted to speak but only sounds were audible. The resident's mouth was with a large amount of dried mucus and his lips were glazed over with a dry matter.
On 12/19/24 at approximately 6:00 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, the Owner and three Corporate Nurse Consultants. They voiced no concerns regarding the above findings.
Good oral hygiene is important for tube feeders to prevent infections such as tooth decay and gum disease 1. Regular dental cleanings are recommended to protect oral health 2. Routine oral care reduces the potential for aspiration of oral materials. (https://www.[NAME].com/search?q=mayo+clinic+the+importance+of+good+oral+hygiene+for+tube+feeders&qs=n&form=QBRE&sp=-1&lq=0&pq=mayo+clinic+the+importance+of+good+oral+hygiene+for+tube+feeders&sc=0-64&sk=&cvid=ED99509A56CC44C5A78D379EB87EACEA&ghsh=0&ghacc=0&ghp)
Based on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to provide Activity of Daily Living (ADL) care to four (4) dependant Residents (Resident #226, #117, #18, and #48) in a survey sample of 74 Residents.
The findings included:
1. For Resident #226, the Resident was dirty and unkempt.
2. For Resident #117, the Resident was dirty, unclothed, and unkempt.
1. Resident #226 was admitted to the facility on [DATE] with diagnoses including: End stage renal disease with hemodialysis, history of stroke, anemia, chronic congestive heart failure, hypertension, and diabetes type 2. The Resident did not have a diagnosis of dementia and was his own responsible party and by facility agreement cognitively intact and able to make his own decisions. The Resident had a room mate, Resident #117.
2. Resident #117 was admitted to the facility on [DATE] with diagnoses including: Dementia without behavioral disturbance, hypertension, major recurrent depression. dysphagia, chronic kidney disease, cardiac disease, history of malignant cancer of nasal cavity, and congestive heart failure. The Resident had a room mate, Resident #226.
During an initial interview on 12-10-24, at 11:40 AM, Resident #226 was found to be alert and oriented to person, place, time, and situation.
During this interview, Resident #226 verbalized that he is a dialysis patient and that he received dialysis there in the facility. He further stated he hates the memory care unit because everyone is crazy in here, they wander into my room and take things, my room mate yells and cries all night for something to drink, I don't even get food every meal, the room is nasty and falling apart, and I can't even get a shower in here because the showers are so nasty dirty.
The Resident was noted to have food debris and crumbs firmly stuck to his shirt and pants. His hair was greasy and stuck to his head, He exhibited dandruff flakes all over this shoulders and back. His bed smelled of urine, and in fact the entire room had a pervasive odor of urine, feces, and body odor. The Resident wore socks which were meant to be white, however had brown stains on them which were dried on. The Resident wore flat surgical walking shoes and not regular closed toe shoes. He stated he had a pair of tennis shoes but they had gotten wet and the staff had thrown them under the sink.
The surveyor and Resident then immediately walked to the shower room for an initial observation and found it to be dirty, mildewed/moldy, foul smelling, had a strong odor of urine and feces, trash and debris littered the floor, used brown stained wet linens were on the floor, a white crusted substance was on the floor and walls, used soap and shampoo bottles were crusted on the shelves and hand rails in the shower, and the room was being used as a storage area as well for boxes of supplies and durable medical equipment. The Resident asked would you want to take a shower in here?
Resident #117 was in bed covered with only a bed sheet with no blanket and wore no clothing nor gown, and only an incontinence brief under the bed sheet. The fitted bed sheet under the Resident had a yellow halo around the Resident which appeared to be dried urine with a strong odor. The Residents incontinence brief was obviously soaked with urine and wrinkled down at the waist with the heaviness of the liquid it contained. The Residents hair was matted to his head, greasy, dandruff lay in his bed and on his pillow, and body odor/sweat could be clearly smelled.
During the entire survey Resident #117 was never observed during the day out of bed, and asked the surveyors often for something to drink stating Please, Please bring me some water I'm so thirsty. The Residents lips were noted to be cracked and dry.
Resident #226 had no shoes, no coat, 2 pairs of pants, and 2 shirts (the Resident was wearing one of each). When asked about his clothing he stated I had more, but they have been stolen. The same number of clothing articles were found for Resident #117.
There was no soap nor paper towels in the Resident rooms for hand washing of staff or Residents.
Staff on the memory care unit were interviewed and asked why Resident's #226, and #117 were not clean, they stated well, they refuse a lot, and (name) Resident #226 doesn't want to go into the shower room, and (name) Resident #117 is hospice and doesn't like to be moved much. Staff were taken to the Residents' room and both Residents were asked if they would like a shower or bath, and Resident #226 said yes if I can use a different shower room that is clean. Resident #117 simply shook his head yes.
ADL (activities of daily living) care records were reviewed and revealed for Resident #226 during the time of survey no baths were documented as given for 12-11-24, and 12-12-24, and surveyors observed daily, every day, that the Resident was not bathed, and wore the same clothing until 12-19-24 (after the Resident was moved). The Resident was visited in his new room and was very happy.
ADL care records were reviewed for Resident #117 and revealed that the Resident was totally dependant on one staff member. The document indicated that a bath was given every morning, however, the Resident was observed every day during survey and found to be dirty and unkempt with flaking skin, dandruff, greasy hair, and in a soiled bed with soiled linens. At times the Resident was found wearing only an incontinence brief, and at other times wearing a white stained T-shirt wearing also an incontinent brief. The Resident was never seen out of bed during daytime hours for the entire survey.
On 12-12-24, and 12-13-24, and 12-18-24 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 the entire memory care unit was not clean and comfortable. Furthermore they were made aware that Residents were not being bathed and given hygiene timely, nor as often as needed, as this was the observation on days during the survey with both Residents being soiled and unkempt, in a dirty room with dirty linens and clothing.
On 12-19-24, prior to the survey exit the Director of Nursing informed surveyors that Resident #226 and his room mate had been moved back onto regular units last night (12-18-24).
At the time of survey exit on 12-19-24 the facility Administrator, and Director of Nursing stated they had nothing further to provide.
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 F0698
(Tag F0698)
Could have caused harm · This affected multiple residents
Based on a resident interview, staff interview, and clinical record review, the facility staff failed to have ongoing records of communication between the facility and the dialysis center for one (1) ...
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Based on a resident interview, staff interview, and clinical record review, the facility staff failed to have ongoing records of communication between the facility and the dialysis center for one (1) of 74 residents (Resident 13), in the survey sample.
The findings included:
Resident #13 was originally admitted to the facility 6/25/24. The current diagnoses included end stage renal disease requiring dialysis.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/2/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #13's cognitive abilities for daily decision making were intact
An interview was conducted with the Resident #13 on 12/10/24 at 3:55 PM. Resident #13 stated she receives dialysis services outside the facility on a Monday, Wednesday and Friday schedule. The resident stated she was waiting for the staff to add a low air loss mattress to her bed because she was experiencing back pain.
The resident stated the back pain started when the dialysis transport personnel dropped her on Friday 12/6/24, when they were transferring her from the dialysis chair to the stretcher for her return to the facility. The resident stated she reported the fall to the nurse when she arrived in the facility and the facility transferred her to the hospital for an evaluation of her back.
A review of the resident dialysis communication book revealed no communications notes from the dialysis center or the facility.
The person-centered care plan dated 6/27/24 had a problem which stated (name of the resident) needs hemodialysis related to renal failure. The goal read (name of the resident) will have no signs or symptoms of complications from dialysis through the review date, 1/1/25. The interventions failed to include ongoing communication, coordination and collaboration between the nursing home and the dialysis center.
An interview was conducted with the Unit 4 Manager on 12/13/24 at approximately 4:30 PM. The Unit 4 Manager stated there were no communication notes in the book therefore she would contact medical records to determine if they were there waiting to be uploaded in the medical record.
The medical records clerk stated she did not have any dialysis communication notes for Resident #13 therefore, the Unit 4 Manager telephoned the dialysis center to obtain the communication notes. The Unit 4 Manager stated on dialysis days they complete a dialysis note and send it with the resident to dialysis, but they were not consistently receiving the forms back from the dialysis center. She stated now that she was aware of the problem she would contact the dialysis center Manager to establish ongoing records of communication between the facility and the dialysis center.
On 12/19/24 at approximately 6:00 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, the Owner and three Corporate Nurse Consultants. They voiced no concerns regarding the above findings.
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and clinical record review the facility staff failed to ensure medications were acquired and ava...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and clinical record review the facility staff failed to ensure medications were acquired and available to meet the needs of one (1) of 74 residents in the survey sample, Resident #327.
The findings included:
For Resident # 327, the facility staff failed to ensure several medications were available for administration as ordered by the physician.
Resident # 327 was a [AGE] year old admitted to the facility on [DATE], with diagnoses that included but were not limited to: Asthma, emphysema, Pulmonary Fibrosis, Seizure disorder, Chronic anxiety and depression, Hypothyroidism and Gastroesophageal reflux disease, historyof Pulmonary Embolism, orthostatic hypotension and chronic hypoxic respiratory failure-on oxygen at 4 liters per minute via nasal cannula, Congestive Heart Failure. Cerebral Vascular Accident.
The most recent MDS (Minimum Data Set) assessment was coded as an admission assessment with an ARD (Assessment Reference Date) of 8/1/2023. The BIMS (brief interview for mental status) assessment was coded as 15 out of possible 15, indicating no cognitive impairment. The assessment also coded Resident # 327 as requiring assistance with activities of daily living; and continent of bowel and bladder.
Review of the clinical record was conducted on 12/10/2024 to 12/19/2024.
Review of the Progress Notes and August 2023 Medication Administration Record (MAR) revealed documentation of several medications being unavailable several times including but not limited to:
Effective Date: 08/01/2023 23:56 Type: eMar - Medication Administration Note
Note Text: Topiramate Tablet 100 MG (milligrams)
Give 1 tablet by mouth three times a day for Seizure three times per day
on order.
Review revealed that 4 doses of Topiramate were not available on: 8/9/2023 at 8 a.m.
8/14/2023 at 8 a.m.
8/19/2023 at midnight
8/19/2023 at 8 a.m.
Effective Date: 08/02/2023 21:36 Type: eMar - Medication Administration Note
Note Text : Adderall XR Capsule Extended Release 24 Hour 15 MG
Give 1 capsule by mouth two times a day for ADHD (Attention Deficient Hyperactivity Disorder) (scheduled at 9 a.m. and 9 p.m.)
On order
Review revealed that 3 doses of Adderall were not available on: 8/19/2023 at 9 a.m.
8/19/2023 at 9 p.m.
8/21/2023 at 9 a.m.
The medication, Adderrall, was not listed in the Cubex contents.
Note Text : Lidocaine HCl (PF) Injection Solution 1 %
Inject 3.5 ml intramuscularly one time a day for UTI for 2 Days
awaiting from rx (Pharmacy)
The medication, Lidocaine, was prescribed for 2 days. Review of the MAR revealed only one dose was given on 8/7/2023. There was no documentation of the second dose being given as ordered.
Note Text: Savella Oral Tablet 50 milligrams
Give 1 tablet by mouth two times a day for depression
not available- ordered 8/2/2023 at 9 am.
The medication, Savella, was not started until 8/4/2023 at 9 a.m.
The medication was not listed in the Cubex Stat box contents.
On 12/10/2024 at 3:05 p.m., an interview was conducted with LPN(Licensed Practical Nurse) # 3 who stated the medications come in a blister pack for each resident. The blister pack should have the medications for each scheduled dose. LPN # 3 stated if the medication was not available, the nurse was expected to check the Cubex (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 12/11/2024 at 10:20 a.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 Cubex 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.
On 12/11/2024 at 11:00 a.m., an interview was conducted with the Regional Nurse Consultant (Corporate # 1) who stated medications should be available for administration as ordered by the physician. Corporate # 1 stated the Pharmacy should have ensured the medication was available for administration. She also stated the nurses should have checked the Cubex (in house Stat box) for an available supply of the medication.
The Regional Nurse Consultant (Corporate # 1) explained that the Pharmacy would have sent a blister pack with the entire course of medication for the month. The nurses would have had access to the medications for each time of scheduled administration. She stated medications should be available for administration.
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.
No further information was provided.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
3. For Resident # 51 the facility staff failed to ensure drug regimen review was completed monthly.
On 12/16/24 during the clinical record review it was noted that Resident #51 did not have drug regim...
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3. For Resident # 51 the facility staff failed to ensure drug regimen review was completed monthly.
On 12/16/24 during the clinical record review it was noted that Resident #51 did not have drug regimen reviews in the clinical record.
On the morning of 12/16/24 an interview was conducted with the DON who stated that she was not sure of which Residents the pharmacist reviewed each month. She stated that she had a book with the reviews and any recommendations in her office. Resident #51's past years pharmacy reviews and recommendations were requested at that time.
On 12 /17/24 the DON submitted the pharmacy reviews for Resident #51 and the months of February, May, June, and November of 2024 were missing. When asked if there were any more, she stated that was all that she had.
On 12/17/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.
4. For Resident #33 the facility staff failed to ensure drug regimen review was completed monthly.
On 12/16/24 during the clinical record review it was noted that Resident #33 did not have drug regimen reviews in the clinical record.
On the morning of 12/16/24 an interview was conducted with the DON who stated that she was not sure of which Residents the pharmacist reviewed each month. She stated that she had a book with the reviews and any recommendations in her office. Resident #33's past years pharmacy reviews and recommendations were requested at that time.
On 12 /17/24 the DON submitted the pharmacy reviews for Resident #33 and the months of, August and September 2024 were missing. When asked if there were any more, she stated that was all that she had.
On 12/17/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.
5. For Resident # 78 the facility staff failed to ensure drug regimen review was completed monthly.
On 12/16/24 during the clinical record review it was noted that Resident #78 did not have drug regimen reviews in the clinical record.
On the morning of 12/16/24 an interview was conducted with the DON who stated that she was not sure of which Residents the pharmacist reviewed each month. She stated that she had a book with the reviews and any recommendations in her office. Resident #78's past years pharmacy reviews and recommendations were requested at that time.
On 12 /17/24 the DON submitted the pharmacy reviews for Resident #78 and the months of September and October of 2024 were missing. When asked if there were any more, she stated that was all that she had.
On 12/17/24 during the end of day meeting the Administrator was made aware of the findings and no further information was provided.
Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure pharmacy recommendations were obtained and acted upon for five Residents (Residents #117, #226, #51, #33 and #78), in the survey sample of 74 Residents.
The findings included:
1. For Resident #117, the pharmacist recommendations were either not obtained, or not acted upon, and none were in the clinical record in 2 of the preceding 3 months of survey (September, and October 2024).
Resident #117's clinical record was reviewed and for the last 3 months prior to survey (September through November), as December had not yet been completed, The Registered Pharmacist (RPH) Monthly Medication Regimen Reviews (MMR) were reviewed.
Resident #117 was receiving anticoagulants, blood pressure medication, psychotropic medication, anti seizure medication, diuretics, pain medication, heart medication, was on a fluid restriction, and had a history of kidney disease, congestive heart failure, bleeding, and dehydration.
On 12-16-24 the Director of Nursing (DON) was interviewed and asked when the MMR's were conducted and how they were conducted. She stated that the RPH reviewed a percentage of the Resident's medications every month. When asked what that percentage was, she stated I will have to check, I am not sure how many they do every month. She was asked if irregularities occurred how the staff would be made aware of that, and again she stated I'm not sure, I don't get that, I will have to find out.
On 12-16-24 the DON and Administrator returned with the Monthly Reviews and revealed that not all Residents were being reviewed monthly. The reviews also revealed that the physician had not been notified of those residents with recommendations for changes, which would have required a documented explanation by the physician of what their decision was in regard to the RPH recommendations for each resident listed. The DON and Corporate RN consultant stated that the recommendations had not been printed from the system where the RHP had documented them and so were not made available to the physician to act upon timely. They stated that the procedure had some cracks in it and that the DON would now be responsible to track this for 100% of the Residents monthly and that she would make sure the physician (MD) received these recommendations and acted upon them.
The MMR reviews were as follows;
September 2024 - Resident #117 - Not evaluated by the RPH.
October 2024 - Resident #117 - Recommendation for psychoactive medication Geodon. Not acted on by MD.
November 2024 - Resident #117 - Resident reviewed with no new recommendations.
The facility policy was reviewed and revealed that the MRR's would be completed at least monthly and placed in the Resident's clinical chart. They would be available in an easily retrievable format to nurses, physician's, and the care planning team after completion for review. The recommendations and findings will be documented and acted upon by the nursing care center and/or physician.
On 12-18-24 at 4:00 PM during a meeting with the Administrator and DON they were informed of the missing MRR evaluations, documentation, and MD responses to recommendations made by the RPH. They stated they had nothing further to provide.
2. For Resident #226, the pharmacist recommendations were not acted upon, and none were in the clinical record in 2 of the preceding 3 months of survey (September, and November 2024).
Resident #226 was receiving anticoagulants, blood pressure medication, muscle relaxants, opiate pain medication, dialysis medication, was on a renal dialysis diet, had a history of kidney disease, and was actively being treated with hemodialysis.
On 12-16-24 the Director of Nursing (DON) was interviewed and asked when the MMR's were conducted and how they were conducted. She stated that the RPH reviewed a percentage of the Resident's medications every month. When asked what that percentage was, she stated I will have to check, I am not sure how many they do every month. She was asked if irregularities occurred how the staff would be made aware of that, and again she stated I'm not sure, I don't get that, I will have to find out.
On 12-16-24 the DON and Administrator returned with the Monthly Reviews and revealed that not all Residents were being reviewed monthly. The reviews also revealed that the physician had not been notified of those residents with recommendations for changes, which would have required a documented explanation by the physician of what their decision was in regard to the RPH recommendations for each resident listed. The DON and Corporate RN consultant stated that the recommendations had not been printed from the system where the RHP had documented them and so were not made available to the physician to act upon timely. They stated that the procedure had some cracks in it and that the DON would now be responsible to track this for 100% of the Residents monthly and that she would make sure the physician (MD) received these recommendations and acted upon them.
The MMR reviews were as follows;
September 2024 - Resident #226 - Recommendation for Diabetes diagnosis with no treatment, and Baclofen muscle relaxant, Not acted on by MD.
October 2024 - Resident #226 - Resident reviewed with no new recommendations.
November 2024 - Resident #226 - Recommendation for Norco opiate for pain, Not acted on by MD.
The facility policy was reviewed and revealed that the MRR's would be completed at least monthly and placed in the Resident's clinical chart. They would be available in an easily retrievable format to nurses, physician's, and the care planning team after completion for review. The recommendations and findings will be documented and acted upon by the nursing care center and/or physician.
On 12-18-24 at 4:00 PM during a meeting with the Administrator and DON they were informed of the missing MRR evaluations, documentation, and MD responses to recommendations made by the RPH. They stated they had nothing further to provide.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review and facility documentation the facility staff failed to label with expir...
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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 label with expiration date and store medications appropriately for 3 Residents ( Resident #8, #74 and #103) and for the facility stock multi use vial medications, in a survey sample of 74 residents, and the facility failed to ensure that narcotic medications no longer in use by residents were properly locked away, accounted for and disposed of in a timely manner.
The findings included:
1. For Resident #8, the facility had failed to correctly label / store 2 bottles of Ativan (Lorazepam an anti-anxiety medication).
On [DATE] at approximately 3 p.m. while inspecting the medication room it was discovered that 2 bottles of liquid Ativan prescribed for Resident 8, had been opened and used however neither bottle had an open date on them. The bottles were open and available for use and clearly labeled to discard after 90 days.
LPN #3 was asked how would you know if the bottle was expired. LPN #3 stated you would not know because no one put an opened-on date on the bottle or the box. When asked if this medication is available for administration, she stated that it was.
When asked what the facility policy was for medications requiring disposal within a certain timeframe she stated, We are to label the bottle when we open it so that we know when it is time to dispose of it.
A review of the facility policy entitled Medication Administration revealed the following excerpt:
12. Identify the expiration date if expired notify the nurse manager.
2. For Resident #74 the facility staff failed to correctly store 2 bottles of liquid Ativan and one bottle of liquid Morphine (a narcotic pain medication).
On [DATE] at approximately 3 p.m. while inspecting the medication room it was discovered that a bottle of liquid Morphine 100 mg/ml prescribed for Resident #74, was opened without a date. There were 2 bottles of liquid Ativan (Lorazepam) prescribed to Resident #74 one bottle had no opened date, the second bottle had been opened on [DATE]. These medications clearly were labeled to be discarded after 90 days.
On [DATE] during the end of day meeting the Administrator was made aware of the findings and no further information was provided.
LPN #3 was asked how would you know if the bottle was expired. LPN #3 stated you would not know because no one put an opened-on date on the bottle or the box. When asked if this medication is available for administration, she stated that it was.
When asked what the facility policy was for medications requiring disposal within a certain timeframe she stated, We are to label the bottle when we open it so that we know when it is time to dispose of it.
A review of the facility policy entitled Medication Administration revealed the following excerpt:
12. Identify the expiration date if expired notify the nurse manager.
On [DATE] during the end of day meeting the Administrator was made aware of the findings and no further information was provided.
3. For Resident #103 the facility staff failed to correctly store a bottle of Augmentin 400 mg/5 ml (an antibiotic) prescribed for Resident #103.
On [DATE] at approximately 3 p.m. while inspecting the medication room it was discovered that a bottle of liquid Augmentin 400 mg/5ml prescribed for Resident #103 was open and available for use when it should have been completed on [DATE] and disposed of at that time. The label clearly stated to dispose of after 7 days.
LPN #3 was asked how to tell if the medication was expired LPN #3 pointed out the label that stated to discard after 7 days. When asked if this medication is available for administration, she stated that it was. When asked what the facility policy was for medications requiring disposal within a certain timeframe she stated, We are to label the bottle when we open it so that we know when it is time to dispose of it.
A review of the facility policy entitled Medication Administration revealed the following excerpt:
12. Identify the expiration date if expired notify the nurse manager.
On [DATE] during the end of day meeting the Administrator was made aware of the findings and no further information was provided.
4. The facility staff failed to correctly label / store 2 house stock multi use vials of Tubersol (Mantoux test solution for PPD).
On [DATE] at approximately 3 p.m. while inspecting the medication room it was discovered that 2 house stock vials of Tubersol were incorrectly labeled / stored, open and available for use.
When asked if this medication is available for administration, she stated that it was.
When asked what the facility policy was for medications requiring disposal within a certain timeframe she stated, We are to label the bottle when we open it so that we know when it is time to dispose of it. When asked how long a multi-use vial was good for and she stated 30 days. LPN #3 was asked how would you know if the bottle was expired. LPN #3 stated you would not know because no one put an opened-on date on the bottle or the box.
A review of the policy entitled Storage of Medication revealed the following excerpt:
6. d. Date label of any multiuse vial is first accessed (needle punctured), the vial should be dated and discarded within 28 days unless the manufacturers specify a different date (shorter or longer) date for that opened vial.
On [DATE] during the end of day meeting the Administrator was made aware of the findings and no further information was provided.
5. The facility staff failed to ensure that narcotic medications no longer in use by residents were properly locked away, accounted for and disposed of in a timely manner.
On the afternoon of [DATE] during an interview with the Unit Manager (LPN 2) Surveyors accompanied the LPN to her office to obtain some documents. The Unit Manager's door was unlocked, and surveyors and DON along with the Unit Manager walked in the office. The surveyors noticed that a large number of medications were left in an unlocked cart (open to view, no doors or enclosures on the cart, typically used for supply or mail distribution). The Unit Manager was asked what the medications were, and she stated that those were medications that needed to be destroyed or sent back to pharmacy. When asked if any of them were controlled substances she stated that they were not. The DON was asked what the proper procedure is for storage of narcotic medications, and she stated they should be behind 2 locks, usually the cart and the lock box or narcotic box on the cart. When asked if it was proper procedure to hold any medications in an unlocked office, she stated that it was not acceptable practice for any medications to be unsecured. The Surveyors looked at the overflowing bin of medications and saw Zolpidem (Ambien -a controlled substance used to aid in sleep) on the top of the bin. At that point the entire cart was taken to the conference room and with the DON and Administrator as witnesses, the contents were viewed.
The cart was found to have the following controlled substances:
1 bottle Dilaudid 1mg/ml - No count sheet - 30 ml bottle dispensed - 23 ml left (signed off destroyed after surveyors counted on [DATE]).
1 card of Oxycodone 5-325 mg - No count sheet 7 tablets (signed off destroyed after surveyors counted on [DATE]).
1 Card of Pregabalin 75 mg - No count sheet 34 tablets -(signed off destroyed after surveyors counted on [DATE]).
1 bottle of Morphine 100 ml/ 5 ml. - No count sheet 2 ml left in 30 ml bottle (signed off destroyed after surveyors counted on [DATE]).
1 bottle of Morphine 100 ml/ 5 ml. No count sheet 4 ml left in 30 ml bottle (signed off destroyed after surveyors counted on [DATE]).
1 bottle of Ativan 2mg /ml - Label altered to change the time from every 4 hours to every 8 hours and from PRN to routine. also, Narcotic sheet stated 24.75 ml, but 12.5 ml was in bottle (signed off destroyed after surveyors counted on [DATE]).
1 bottle of Ativan 2mg /ml - Narcotic count sheet shows 25 ml however 20 ml in bottle (signed off destroyed after surveyors counted on [DATE]).
1 bottle of Morphine 100 ml/ 5 ml - Narcotic count sheet shows 20 ml in bottle however only 2.0 ml in bottle (signed off destroyed after surveyors counted on [DATE]).
1 card of Hydrocodone 5/325 - Narcotic sheet says 50 tabs (Count correct signed off destroyed after surveyors counted on [DATE]).
1 Card of 30 Gabapentin 300 mg Narcotic sheet says 30 (Count correct signed off destroyed after surveyors counted on [DATE]).
1 Card hydrocodone 5/325 mg Narcotic sheet says 8 dispensed, 5 left -(Count correct signed off destroyed after surveyors counted on [DATE]).
Zolpidem (Ambien) Narcotic sheet says 30 dispensed- 13 remaining on card -(Count correct signed off destroyed after surveyors counted on [DATE]).
1 Card of 30 Gabapentin 300 mg Narcotic sheet says 10 dispensed 2 remaining on card -(Count correct signed off destroyed after surveyors counted on [DATE]).
Policy for Storage of Medications page 2 read:
6. Mechanism to minimize loss / diversion:
a. Maintain records for receipt and disposition of all controlled substances.
b. Records should provide sufficient detail for accurate reconciliation
c. All discrepancies that cannot be resolved must be reported immedicably as follows:
i. Notify the DON, charge nurse, or designee and pharmacy.
ii. Complete an incident report detailing the discrepancy, steps taken to resolve it and the names of all
licensed staff working when the discrepancy was noted.
iii. The DON, charge nurse, or designee must also report any loss of controlled substances where theft is
suspected to the appropriate authorities such as local law enforcement, Drug Enforcement Agency, State
Board of Nursing, State Board of Pharmacy and possible the State Licensure Board for Nursing Home
Administration.
On [DATE] during the end of day meeting the Administrator was made aware of the findings and no further information was provided.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility staff failed to ensure resources necessary to provide for the needs of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility staff failed to ensure resources necessary to provide for the needs of the residents who resided on the Memory unit were available.
The findings included:
On 12/10 through 12/13/24 observations were made from the conference room of the windows of residents who resided on the Memory Unit. Most windows were with broken window blinds which were unsightly and allowed residents and staff to be viewed. 12/12/24 and 12/13/24 observations were made of supplies (soap, paper towels, window coverings, damaged and missing tile or molding) to create a clean and homelike environment for all of the residents who resided on the unit.
On 12/12/24 at 11:21 AM observations were made of multiple resident room floors (62, 64, 65, 66, 68, 69 and 71). The floors were discolored, with spills, dirt/debris, and some had molding pulling away from the walls. Multiple rooms (62, 65,66, 68, and 71) were with no blinds or window coverings or severely damaged window blinds. Several resident occupied rooms which faced the activity room allowed persons in the activity room to directly see in the resident's room.
Also, on 12/12/24 residents who resided in rooms (62, 64, 65, 66, 68, 69 and 71) had no access to soap and towels at their sink. Strong odors of urine were prominent upon entering the unit, curtains in room [ROOM NUMBER] was observed hanging by zip ties instead of on a curtain rod. Severely warped sinks were observed in rooms (62, 64, and 65). In room [ROOM NUMBER] a receptacle box was pulling away from the wall at the head of the bed and the heating unit receptacle box was damaged.
An interview was conducted with the Administrator on 12/13/24 at approximately 11:40 AM. The Administrator stated the administrative staff performed facility rounds routinely and presented the findings to the administrative team during their meeting.
On 12/13/24 at approximately 2:50 P.M., a final interview was conducted with the Administrator, Director of Nursing, and three Corporate Nurse Consultants. The above information was conveyed to the present administrative staff, they all looked at each other but voiced no comments regarding the above findings.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0940
(Tag F0940)
Could have caused harm · This affected multiple residents
Based on staff interview and facility documentation the facility failed to maintain a training program for all new and existing staff based on the facility's assessment.
The findings included:
The fac...
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Based on staff interview and facility documentation the facility failed to maintain a training program for all new and existing staff based on the facility's assessment.
The findings included:
The facility failed to maintain a training program for all new and existing staff.
Review of the Staff Education, SNF Clinic and Healthcare Academy training transcripts revealed that not all facility staff had completed all the required training.
On 12/19/24 at approximately 6:30 PM, a final interview was conducted with the Administrator, Director of Nursing and the Staff Development Coordinator. They were made aware of the concerns.
No additional information was provided.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0941
(Tag F0941)
Could have caused harm · This affected multiple residents
Based on staff interview, and facility documentation, the facility failed to ensure that all direct care staff complete mandatory Effective Communication training.
The findings included:
The facility...
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Based on staff interview, and facility documentation, the facility failed to ensure that all direct care staff complete mandatory Effective Communication training.
The findings included:
The facility failed to ensure that all direct care staff complete mandatory Effective Communication training.
Review of the Staff Education, SNF Clinic and Healthcare Academy training transcripts revealed that not all direct care staff has documented completion of mandatory Effective Communication training.
On 12/18/2024 at approximately 2:40 p.m., an interview was conducted with the Staff Development Coordinator (SDC) who was asked about, direct care staff having completed mandatory Effective Communication training, she stated that training and education is recorded by SNF Clinic and Healthcare Academy, and that files are correct and up to date.
On 12/19/24 at approximately 6:30 PM, during the end of day meeting the Administrator, Director of Nursing and Staff Development Coordinator were made aware of the concerns.
No further information was provided.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0942
(Tag F0942)
Could have caused harm · This affected multiple residents
Based on staff interview, and facility documentation, the facility failed to ensure that all staff members are educated in the rights of the residents and responsibilities of the facility.
The findin...
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Based on staff interview, and facility documentation, the facility failed to ensure that all staff members are educated in the rights of the residents and responsibilities of the facility.
The findings included:
The facility failed to ensure that staff members are educated in the rights of the residents and responsibilities of the facility.
Review of the Staff Education, SNF Clinic and Healthcare Academy training transcripts, it was revealed that not all staff reviewed had completed the Resident Rights Training.
On 12/18/24 at approximately 2:40 p.m., an interview was conducted with the Staff Development Coordinator (SDC) who was asked about, staff Residents Rights mandatory training, she stated that training and education, is recorded by SNF Clinic and Healthcare Academy and that the files are correct and up to date.
On 12/19/24 at approximately 6:30 PM, during the end of day meeting the Administrator, Director of Nursing and Staff Development Coordinator were made aware of the concerns.
No further information was provided.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0944
(Tag F0944)
Could have caused harm · This affected multiple residents
Based on staff interview and facility documents the facility staff failed to ensure that all staff members were educated regarding the Quality Assurance and Performance Improvement
The findings includ...
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Based on staff interview and facility documents the facility staff failed to ensure that all staff members were educated regarding the Quality Assurance and Performance Improvement
The findings included:
Review of the Staff Education, SNF Clinic and Healthcare Academy training transcripts revealed that not all facility staff had completed all the required training for Quality Assurance and Performance Improvement.
On 12/19/24 at approximately 6:30 PM, a final interview was conducted with Administrator, Director of Nursing and the Staff Development Coordinator, they were made aware of the concerns.
No additional information was provided.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0946
(Tag F0946)
Could have caused harm · This affected multiple residents
Based on review of facility documents and staff interview the facility staff failed to ensure that all staff members were educated on Compliance and Ethics.
The findings included:
Review of the Staff...
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Based on review of facility documents and staff interview the facility staff failed to ensure that all staff members were educated on Compliance and Ethics.
The findings included:
Review of the Staff Education, SNF Clinic and Healthcare Academy training transcripts revealed that not all facility staff had completed all the required training for Compliance and Ethics.
On 12/19/24 at approximately 6:30 PM, a final interview was conducted with Administrator, Director of Nursing and the Staff Development Coordinator, they were made aware of the concerns.
No additional information was provided.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected multiple residents
Based on review of facility documents and staff interview the facility staff failed to ensure that all Certified Nurse's Aides (CNA) completed the mandatory twelve (12) hours of education each year.
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Based on review of facility documents and staff interview the facility staff failed to ensure that all Certified Nurse's Aides (CNA) completed the mandatory twelve (12) hours of education each year.
The findings included:
Review of the Staff Education, SNF Clinic and Healthcare Academy training transcripts revealed that not all CNAs had completed the mandatory twelve (12) hours of education each year which addressed each CNA's areas of weakness as determined in nurse aides' performance reviews the facility assessment and the special needs of residents as determined by the facility staff.
On 12/17/24 at 12:00 PM, an interview was conducted with the Staff Development Coordinator (SDC) regarding CNAs mandatory training. The SDC stated that training and education for most CNAs have been completed, but states that some of the transcripts were lost when the facility switched from Healthcare Academy to SNF Clinic for training transcripts, but that there was an ongoing plan for all CNAs to become compliant with mandatory training.
On 12/19/24 at approximately 6:30 PM, a final interview was conducted with Administrator, Director of Nursing and the Staff Development Coordinator, they were made aware of the concerns.
No additional information was provided.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0949
(Tag F0949)
Could have caused harm · This affected multiple residents
Based on staff interview, and facility documentation, the facility failed to ensure that all staff members had completed mandatory Behavioral Health Training.
The findings included:
The facility fail...
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Based on staff interview, and facility documentation, the facility failed to ensure that all staff members had completed mandatory Behavioral Health Training.
The findings included:
The facility failed to ensure that all staff members had completed the mandatory Behavioral Health Training.
Review of the Staff Education, SNF Clinic and Healthcare Academy training transcripts revealed that all staff had not completed the mandatory Behavioral Health Training.
On 12/18/24 at 2:40 p.m. an interview was conducted with the Staff Development Coordinator (SDC) who was asked about staff training regarding, the mandatory Behavioral Health Training. She stated that the training and education is recorded by SNF Clinic and Healthcare Academy and that the files are correct up to date.
On 12/19/24 at approximately 6:30 PM, during the end of day meeting the Administrator, Director of Nursing and Staff Development Coordinator were made aware of the concerns.
No further information was provided.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. On 12/13/24 at approximately 12:30 PM., an observation of Unit 3 was made on the Memory Care Unit. Fourteen residents were ob...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. On 12/13/24 at approximately 12:30 PM., an observation of Unit 3 was made on the Memory Care Unit. Fourteen residents were observed sitting, standing and or walking around in the dining room. Some residents were observed leaving from out of the dining room near a metal door plate that was separating in an outward position from the door approximately 1 inch. Staff were also observed coming and going from the dining area. On 12/19/24 at approximately 11:35 AM.,an observation was made on unit 3, to the dining room area. The metal door plate was still extending outward from the door leading into the dining room.
On 12/19/24 at approximately 1:07 PM., an observation was made on Unit 2, room [ROOM NUMBER]. Buckling ceiling tiles, a hole in the ceiling and a brown substance was noticed on the privacy curtain (32-A). Resident #88 was resting quietly in her bed. Her Brief Interview for Mental Status (BIMS) score was a 3 out of a possible 15. This indicated Resident #88 cognitive abilities for daily decision making were severely impaired. Resident #88 was not able to respond to questions asked concerning the condition of her room.
On 12/19/24 at 12:25 PM., an interview was conducted with the Maintenance Assistant/Other Staff Member (OSM) #11, concerning the ceiling tiles, and hole in the ceiling in room [ROOM NUMBER] on unit 2. OSM #11 said, The new ceiling tiles came in today. The privacy curtain was observed visible soiled with a brown substance.
On 12/19/24 at approximately 1:00 PM., an interview was conducted with the IP concerning the brown substance observed on the privacy curtain on unit 2, room [ROOM NUMBER]. The IP said that she had spoken to the Environmental Services Department (ESD) and said, It's an infection control issue.
On 12/19/24 at approximately 5:30 PM., an interview was conducted with the Administrator and with OSM #8 concerning the privacy curtain room, the ceiling tiles and the hole present in the ceiling in room [ROOM NUMBER].
On 12/19/24 at approximately 5:45 PM., OSM #8 informed surveyor that he was replacing the privacy curtain (32-A), and confirmed that it looked like Bowel Movement (BM) smeared on it.
On 12/19/24 at approximately 5:55 p.m., 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.7. For the facility, the facility staff failed to ensure clean comfortable and sanitary environment for Residents, staff and the public.
The following observations were made during the course of the survey:
Hallway bathroom on Unit 2 cove base pulled off wall since survey started on 12/10/24, not repaired.
Strong urine odor on hall Unit 1 noticed on the morning of 12-10-24, 12-16-24 and 12-17-24.
On 12/18/24 8:47 AM used glove noted outside of room [ROOM NUMBER] and linens in floor.
Soiled linens were observed on the floor in room [ROOM NUMBER].
Shower room Unit 1 - used pull ups, gloves and plastic cups on the floor, 1st shower stall floor was dirty and used washcloth left on railing.
Shower stall 2 - dirty washcloth on floor as well as one on handrail. Hoyer lift in middle of the room blocking the shower stalls chair scale had resident clothing and soiled brief laid across it.
On 12/18/24 10:00 AM - room [ROOM NUMBER] soiled linens observed on the floor.
On 12/18/24 at approximately 10:10 a.m. an interview conducted with LPN #2 (Unit Manager) who was asked if it was an acceptable practice to place soiled linens on the floor, she stated, It is not ok to have soiled linens on the floor and it is an infection control risk to leave soiled linens on the floor.
On 12/18/24 10:20 a.m. Shower room Unit 2 - toilet unflushed with urine and feces, bathroom smelled of urine, Cove base peeling off of the shower room walls, shower stall dirty and soiled linen in shower room floor.
The resident council minutes dated 8/14, 9/26 and 10/24/24 reflected complaints of needing more linens, (towels, sheets), as well as dirty bathrooms.
On 12/18/24 an interview was conducted with Other Employee #1 stated that they have had issues with linens being available due to 2 of the 3 dryers being broken and unavailable for use. When asked if this has impacted the staff she stated that they did not have enough clean linens to bathe the residents. They stated they had to cut towels to make wash cloths. Other Employee #1 stated that the facility would no longer allow them to use disposable wipes so they have to use the linens for incontinent care.
Review of the facility policy entitled Resident Environmental Quality revealed the following excerpts:
The facility should be designed, constructed, equipped and maintained to Provide a safe, functional, sanitary and comfortable environment for residents, staff and the public.
5. The facility must provide each resident with:
a. A separate bed of proper and height and size for the convenience of the resident
b. A clean comfortable mattress
c. Bedding appropriate to the weather and climate .
On 12/19/24 during the end of day debriefing meeting the Administrator was made aware of the findings and no further information was provided.
3. For Resident # 91 residing on Unit 1, the facility staff failed to ensure bugs/insect/gnats were not in sandwiches stored on top of the light fixture over the bed. There were no sheets on the mattress nor linens on the bed during the entire survey.
Resident # 91 was admitted to the facility on [DATE]. Diagnoses included but were not limited to: Cerebral Infarction, Hypertension, Anxiety Disorder, Hemiplegia and Vascular Dementia.
The most recent Minimum Data Set (MDS) was an Annual Assessment with an Assessment Reference Date (ARD) of 11/3/2024. Resident # 91's BIMS (Brief Interview for Mental Status) Score was a 14 out of 15, indicating no cognitive impairment. Resident # 91 required assistance with Activities of Daily Living.
Review of the clinical record was conducted on 12/10/2024-12/19/2024.
On 12/10/2024 during the initial tour of Unit 1, clutter was observed in Resident # 91's room. There were several items on the nightstand, on the window sill and clutter around the bed. There were 4 sandwiches wrapped individually in sandwich bags lying on top of the ledge of the light fixture above the bed. Numerous bugs/insects were observed swarming in one of the sandwich bags. There were dozens of bugs/insects in the sandwich bag. Closer observation of the room revealed there were bugs/insects flying in the room.
The Facility Administrator came into the room while the surveyor was inspecting the area. The Administrator picked up the four sandwiches and noticed the bugs/insects. The Administrator stated the insects they might have been black gnats. She stated that was unacceptable and that insects should not be in residents rooms. She stated she was going to take care of the problem. The Administrator took all four sandwiches to the soiled utility room at the end of the hall. The Administrator returned to Resident # 91's room and asked why he had so many sandwiched. Resident # 91 stated he was keeping them to eat later. The Administrator informed Resident # 91 that he could not keep several sandwiches at the bedside because they were attracting bugs/insects. The Administrator told Resident # 91 stated the Dietary Staff would provide sandwiches whenever he requested them.
On 12/10/2024 at 2:30 p.m., an interview was conducted with CNA (Certified Nursing Assistant)-1 who stated that Resident # 91 liked to keep snacks at the bedside and did not want staff members to remove them. CNA-1 stated bugs/insects should not be in residents rooms.
On 12/11/2024 at 9:15 a.m., black insects were noted in Resident # 91's room near the sink at the entrance to the room and on items on Resident # 91's side of the room. Resident # 91 was sitting on the side of the bed.
On 12/11/2024 at 9:45 a.m an interview was conducted with the Dietary Manager who stated the sandwiches were placed on each meal tray as requested by the resident. The Dietary Manager stated she was not aware that Resident # 91 was collecting the sandwiches and not eating them. The Dietary Manager stated she was not aware that bug/insects were in the sandwiches at the bedside.
On 12/11/2024 at 12:40 p.m. an interview was conducted with the DON (Director of Nursing) who stated bugs/insects should not be in residents rooms.
Review of the facility policy entitled Resident Environmental Quality, implemented 11/1/2020, revised 12/1/2022 revealed a policy statement which read The facility should be designed, constructed, equipped and maintained to Provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. The policy explanation and guidance included the following excerpts:
5. The facility must provide each resident with
a. A separate bed of proper and height and size for the convenience of the resident
b. A clean comfortable mattress
c. Bedding appropriate to the weather and climate .
During all of the days of the survey, there were observations of no sheet on the mattress at any time. Resident # 91 was observed lying in the bed with no sheet or bedding covering the mattress. The resident was lying on the uncovered vinyl mattress.
On 12/17/2024, at approximately 03:45 PM, Resident #91 was observed walking into his room. Bed observed unmade no sheets. Air condition unit set at 62 degrees. Resident states I don't want sheets on my bed its too hot. Everyone here knows not to put sheets on my bed and to keep my curtain drawn.
On 12/18/2024 during the end of day debriefing, the Administrator and Director of Nursing were informed of the findings of failure to provide a clean, comfortable, homelike environment. There was no documentation that the resident refused to allow the staff to provide bedding for the mattress
No further information was provided.
Upon walking up the sidewalk into the facility on [DATE] at approximately 11:15 AM, an observation was made of a large mat along the walkway leading to the front door entrance. Viewable at the corners of the mat were many broken and loose tiles in the sidewalk. Overhead under the awning were large pieces of plaster missing and hanging plaster about to fall.
As the Team was escorted to the conference room through the corridor of Unit 1, unpleasant lingering odors reeked to the end of the corridor and much debris and clutter was observed. Immediately upon getting seated in the conference room several windows had sections of missing blinds on Unit 3, observable from the conference room. Residents and staff were viewable through the broken blinds.
4. Resident #69 was originally admitted to the facility 1/2/2024. The current diagnoses included end stage renal disease requiring hemodialysis, and a history of strokes. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/23/2024 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #69's cognitive abilities for daily decision making were intact.
On 12/10/24 at approximately 2:39 PM an interview was conducted with Resident 69. Resident #69 stated he was dissatisfied with his room primarily because of episodes of water dripping from the ceiling onto his head and face. The resident pointed out many water-stained ceiling tiles. The resident further stated that the light over the sink has been extremely dim for months, and he had reported it to several staff but, no one would replace it. Resident #69 also stated that his room floor is not mopped consistently, and the sink is usually soiled, and the bathroom was not clean because of lack of general cleaning. Resident #69 adamantly stated he refuses to go to the shower room because it is not clean or homelike.
The resident also stated there are not always towels and washcloths for bathing and his soiled clothes were running over in his room because of problems in the laundry. He stated the environment saddens him and he would like to move but, he does not have a place to live outside the facility.
On 12/10/24 at 2:39 PM observations were made of the concerns the resident identified, it was validated that the bathroom did not have a freshness and there were multiple stained ceiling tiles overhead, as well as the light over the sink was barely projecting light. It was also identified that the floor lacked gloss and had a stickiness to it, the sink was with multiple items and lacked cleanliness. The trash can was without a liner and used gloves were observed on the floor next to it and soiled laundry was over in the corner beneath the television.
On 12/19/24 at approximately 4:45 PM the above information was shared with the Environmental Services Director and Maintenance. At approximately 5:00 PM four staff were observed in Resident #69's room, one was on a ladder working on the ceiling tiles, the dim light bulb had been removed from over the sink and a super bright light was in place.
On 12/19/24 at approximately 6:00 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, the Owner and three Corporate Nurse Consultants. They voiced no concerns regarding the above findings.
5. Resident #280 was originally admitted to the facility 12/3/24 after an acute care hospital stay. The resident's current diagnoses included a possible TIA, chronic pain fibromyalgia, and Raynaud's phenomena. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) 12/10/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 11 out of a possible 15. This indicated Resident #280's cognitive abilities for daily decision making were moderately impaired.
On 12/13/24 at approximately 12:55 PM an interview was conducted with Resident #280. The resident stated she was not satisfied with the cleanliness of the room. She stated the floors may appear clean, but she sees how black her socks are when she gets in the bed. The resident stated that she was in the room most of the time and she had not seen anyone clean the floors or the bathroom, but they had removed the trash daily.
Resident #280 also stated there was a dead bug in the floor near the door for two days before a nurse decided to sweep it up. Resident #280 stated her focus was to be discharged home very soon because nothing was going well in the facility.
On 12/19/24 at approximately 6:00 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, the Owner and three Corporate Nurse Consultants. They voiced no concerns regarding the above findings.
Based on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to maintain a safe, clean comfortable homelike environment for 4 of 4 nursing units to include the entire locked memory care unit and the direct care of five Residents (Resident #226, #117, #91, #69, and #280) in a survey sample of 74 Residents, resulting in a Substandard Quality of Care.
The findings included:
1. For Resident #226, the entire memory care unit was dirty, in disrepair, was not safe, not clean, nor homelike.
2. For Resident #117, the entire memory care unit was dirty, in disrepair, was not safe, not clean, nor homelike.
1. Resident #226 was admitted to the facility on [DATE] with diagnoses including: End stage renal disease with hemodialysis, history of stroke, anemia, chronic congestive heart failure, hypertension, and diabetes type 2. The Resident did not have a diagnosis of dementia and was his own responsible party and by facility agreement cognitively intact and able to make his own decisions. The Resident had a room mate, Resident #117.
2. Resident #117 was admitted to the facility on [DATE] with diagnoses including: Dementia without behavioral disturbance, hypertension, major recurrent depression. dysphagia, chronic kidney disease, cardiac disease, malignant cancer of nasal cavity, and congestive heart failure. The Resident had a room mate, Resident #226.
During an initial interview on 12-10-24, at 11:40 AM, Resident #226 was found to be alert and oriented to person, place, time, and situation. He stated that he had requested to stay in his current room after learning that the facility planned to move him rather than discharge him home.
During this interview, Resident #226 verbalized that he is a dialysis patient and that he received dialysis there in the facility. He further stated he hates the memory care unit because everyone is crazy in here, they wander into my room and take things, my room mate yells and cries all night for something to drink, I don't even get food every meal, the room is nasty and falling apart, and I can't even get a shower in here because the showers are so nasty dirty. He went on to say I like to walk around, it makes the time go faster, if I don't walk now I won't be able to leave, but locked in here I have no where to walk, I don't even have a TV to watch and I love TV, being in here will make you crazy with nothing to do.
The surveyor and Resident then immediately walked to the shower room for an initial observation and found it to be dirty, mildewed/moldy, foul smelling, had a strong odor of urine and feces, trash and debris littered the floor, used brown stained wet linens were on the floor, a white crusted substance was on the floor and walls, used soap and shampoo bottles were crusted on the shelves and hand rails in the shower, and the room was being used as a storage area as well for boxes of supplies and durable medical equipment. The Resident asked would you want to take a shower in here?
Immediately following the shower room observation the Resident's room was examined. 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, no curtains, a urine soaked bathroom, a pervasive smell of urine and feces in the room and on the entire unit.
The free standing broken armoire closets in the rooms were swollen and splitting, with rotten splinters and chunks of disintegrating wood and wood particles all over the Residents few items in the closet, and in the rooms.
The sink vinyl laminate countertop area was water damaged and swollen and separated revealing particle board disintegration with the sink partially separated from the wall in a downward unstable dropped position, and wood dust everywhere.
Under the sink a cabinet door was ajar as it would not close because of the downward sloping sink, and the inside compartment was an open hole with what appeared to be a black concrete floor. Inside was found mildew, mold, trash, a pair of urine stained white tennis shoes, and 2 shirts that were stuck together with an unknown substance, all thrown in onto the floor.
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 bed divider curtain had brown stains and smeared feces on it.
The PTAC (air conditioning wall unit) was not secured and had fallen forward into the room approximately 12 inches revealing light around it and cold air coming into the room from the outside of the building. The front cover of the unit was also missing and the sharp metal grill was exposed. The Resident's room mate's bed (#117) was pushed against the PTAC holding it in place so it would not completely fall out of the hole in the outside facing wall.
Resident #117 was in bed covered with only a bed sheet with no blanket and wore no clothing nor gown, and only an incontinence brief under the bed sheet. During the entire survey Resident #117 was never observed during the day out of bed, and asked the surveyors often for something to drink stating Please, Please bring me some water I'm so thirsty. The Residents lips were noted to be cracked and dry.
The Residents had no television, no clock, no telephone, no radio and the room had no personal items in it nor on the walls.
Resident #226 had no shoes, no coat, 2 pairs of pants, and 2 shirts (the Resident was wearing one of each). When asked about his clothing he stated I had more, but they have been stolen. The same number of clothing articles were found for Resident #117.
Each room on the unit was then inspected by all surveyors and found to be in the same condition as Resident #226's room. There were no televisions in any room, and no water to drink in any room.
There was also noted in the hallway the air conditioning main vent in the ceiling and air return on the wall were so dusty that they had the appearance of brown fur coating them. The walls were marked and smeared and had paint scraped off in places. There was no soap nor paper towels in the Resident rooms for hand washing of staff or Residents.
On 12-13-24 the Director of Maintenance and Director of Environmental Services (house keeping) were interviewed and agreed that staffing for the 2 departments had been tight. Environmental services had 13 total employees. That number was responsible for house keeping, laundry and floor machine technicians.
This number culminated in daily staffing dispersal of 3 staff in laundry, and 1 floor tech, which left 1 housekeeper on each of the 4 nursing units, and 1 housekeeper in common areas such as dining rooms on each unit, the main kitchen, activities, offices, therapy, bathrooms, conference rooms, the dialysis center, and main hallways/entrances. The added 4 staff positions would be trade outs for the other staff members days off during a seven day schedule.
With 123 resident rooms total each of the nursing units housed approximately 20 to 35 Resident rooms for one house keeper to clean each day in an 8 hour shift allowing for 16 minutes to clean each room.
Two of the 3 dryers in the laundry had been broken since June 2024, so linens and privacy curtains and resident personal laundry was not being washed and returned timely even though the staff was washing and drying around the clock. The only working dryer was being operated 24 hours per day. The dirty linen storage on the units was backed up as a result, and creating some of the pervasive urine and feces odors in the facility. Linens, bedding, and privacy curtains were not being changed as often as necessary due to the inability to have enough on hand to change them out more frequently.
The maintenance Director stated they were starting to get some priorities taken care of in the facility now as staffing had improved just recently, and he began painting the memory unit and new cabinets began to be installed on 12-13-24.
On 12-12-24, and 12-13-24 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 the entire memory care unit was not safe, clean and comfortable.
On 12-19-24, prior to the survey exit the Director of Nursing informed surveyors that Resident #226 and his room mate had been moved back onto regular units last night (12-18-24).
At the time of survey exit on 12-19-24 the facility Administrator, and Director of Nursing stated they had nothing further to provide.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The Activity Directors (AD) failed to conduct activity assessments for Resident #77 from 11/15/23 through 9/18/24 and after t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The Activity Directors (AD) failed to conduct activity assessments for Resident #77 from 11/15/23 through 9/18/24 and after the assessment was completed the resident's preferences were not incorporated in the person-centered care plan.
Resident #77 was originally admitted to the facility 11/3/23 and she was readmitted [DATE] after an acute care hospital stay. The current diagnoses included Epilepsy, ESRD requiring dialysis, depression, and behavior problems with hallucinations and fabricating stories.
The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/27/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #77's cognitive abilities for daily decision making were moderately impaired.
On 12/19/24 at 2:49 PM an interview was conducted with Resident #77. The resident stated she does not attend activities, and she did not remember a choir coming to her room to sing Christmas carols. The resident stated she would have enjoyed the singing because she loves music.
A review of the resident's activity assessments revealed assessments were conducted on 11/14/23 for her initial admission, 9/19/24 after return to the facility from a hospital stay and on 10/30/24 with the annual MDS assessment. This indicated activity assessment were only conducted for this resident upon admission/readmission and annually.
The 10/30/24 activity assessment revealed that it was very important to the resident to listen to music she likes, to be around animals such as pets, to keep up with the news and to participate in religious services or practices, yet the information was not incorporated in the person-centered care plan
A person-centered care plan was developed for resident #77 initially on 10/21/24 and the problem read, (name of resident) has no group activity involvement related to immobility and physical limitations. She enjoys reading and coloring in her room. The goal read, the resident will participate in 1:1 activities of choice such as talking and receiving new materials 2-3 times per week by review date 2/3/25. The interventions included establish and record the resident's prior level of activity involvement and interest by talking with the resident, caregivers, and family on admission and as necessary. The resident can color large print pictures. The resident's preferred activities are art and movies. The above-mentioned preferred activities were not documented on the 10/30/24 activity assessment.
On 12/19/24 at approximately 6:00 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, the Owner and three Corporate Nurse Consultants. They had no further comments and voiced no concerns regarding the above findings.
4. The Activity Directors (AD) failed to conduct activity assessments for Resident #105 from 12/27/23 through 12/19/24 and the preferences included on the activities assessment dated [DATE] were not incorporated in the person-centered care plan.
Resident #105 was originally admitted to the facility 10/27/23 and he was readmitted [DATE] after an acute care hospital stay. The current diagnoses included a major neurocognitive disorder with Lewy Bodies dementia.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/17/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 4 out of a possible 15. This indicated Resident #105's cognitive abilities for daily decision making were severely impaired.
The person-centered care plan was developed for resident #105 initially on 7/31/24 and the problem read, (name of resident) has little or no activity involvement related to cognitive deficits, chronic health conditions. The goal read, (name of resident) will express satisfaction with type of activities and level of activity involvement when asked through the review date 1/24/25. The interventions included explain to (name of the resident) the importance of social interaction, leisure activity time. Remind (name of the resident) that he may leave activities at any time and is not required to stay for entire activity.
The person-centered care plan also included activity interventions for behaviors; 11/1/23 Distract (name of the resident) from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. 7/31/24 Provide a program of activities that is of interest and accommodates the resident's status.
On 12/13/24 at 12:55 PM an interview was conducted with Licensed Practical Nurse (LPN) #8. LPN #8 stated Resident #105 does not communicate in English and prior to his decline could not focused, remain seated or concentrate long enough to participate in group activities.
On 12/19/24 at approximately 6:00 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, the Owner and three Corporate Nurse Consultants. They had no further comments and voiced no concerns regarding the above findings.
Based on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to maintain an activities program to meet the needs and preferences of each resident to include the entire locked memory care unit and for four individual Residents (Resident #226, #117, #77, and #105) in a survey sample of 74 Residents, resulting in a Substandard Quality of care.
The findings included:
1. For Resident #226, the entire memory care unit was without a television, or activities from the commencement of survey on 12-10-24 through 12-18-24, and some activity planning did occur on 12-19-24 just prior to exit.
2. For Resident #117, the entire memory care unit was without a television, or activities from the commencement of survey on 12-10-24 through 12-18-24, and some activity planning did occur on 12-19-24 just prior to exit.
1. Resident #226 was admitted to the facility on [DATE] with diagnoses including: End stage renal disease with hemodialysis, history of stroke, anemia, chronic congestive heart failure, hypertension, and diabetes type 2. The Resident did not have a diagnosis of dementia and was his own responsible party and by facility agreement cognitively intact and able to make his own decisions. The Resident had a room mate, Resident #117.
2. Resident #117 was admitted to the facility on [DATE] with diagnoses including: Dementia without behavioral disturbance, hypertension, major recurrent depression. dysphagia, chronic kidney disease, cardiac disease, malignant cancer of nasal cavity, and congestive heart failure. The Resident had a room mate, Resident #226.
During an initial interview on 12-10-24, at 11:40 AM, Resident #226 was found to be alert and oriented to person, place, time, and situation. He stated that he had requested to stay in his current room after learning that the facility planned to move him rather than discharge him home.
During this interview, Resident #226 verbalized that he is a dialysis patient and that he received dialysis there in the facility. He further stated he hates the memory care unit because everyone is crazy in here, they wander into my room and take things, my room mate yells and cries all night for something to drink, I don't even get food every meal, the room is nasty and falling apart, and I can't even get a shower in here because the showers are so nasty dirty. He went on to say I like to walk around, it makes the time go faster, if I don't walk now I won't be able to leave, but locked in here I have no where to walk, I don't even have a TV to watch and I love TV, being in here will make you crazy with nothing to do.
An observation the Resident's room was conducted. The Resident's room was shared with a second Resident (Resident #117). The room tour included but was not limited to the following being observed;
broken vinyl window blinds, no curtains, a urine soaked bathroom, a pervasive smell of urine and feces in the room and on the entire unit.
The free standing broken armoire closets in the rooms were swollen and splitting, with rotten splinters and chunks of disintegrating wood and wood particles all over the Residents few items in the closet, and in the rooms.
The sink vinyl laminate countertop area was water damaged and swollen and separated revealing particle board disintegration with the sink partially separated from the wall in a downward unstable dropped position, and wood dust everywhere.
Under the sink a cabinet door was ajar as it would not close because of the downward sloping sink, and the inside compartment was an open hole with what appeared to be a black concrete floor. Inside was found mildew, mold, trash, a pair of urine stained white tennis shoes, and 2 shirts that were stuck together with an unknown substance, all thrown in onto the floor.
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 bed divider curtain had brown stains and smeared feces on it.
The PTAC (air conditioning wall unit) was not secured and had fallen forward into the room approximately 12 inches revealing light around it and cold air coming into the room from the outside of the building. The front cover of the unit was also missing and the sharp metal grill was exposed. The Resident's room mate's bed (#117) was pushed against the PTAC holding it in place so it would not completely fall out of the hole in the outside facing wall.
Resident #117 was in bed covered with only a bed sheet with no blanket and wore no clothing nor gown, and only an incontinence brief under the bed sheet. During the entire survey Resident #117 was never observed during the day out of bed, and asked the surveyors often for something to drink stating Please, Please bring me some water I'm so thirsty. The Residents lips were noted to be cracked and dry.
The Residents had no television, no clock, no telephone, no radio and the room had no personal items in it nor on the walls.
Resident #226 had no shoes, no coat, 2 pairs of pants, and 2 shirts (the Resident was wearing one of each). When asked about his clothing he stated I had more, but they have been stolen. The same number of clothing articles were found for Resident #117.
Each room on the unit was then inspected by all surveyors and found to be in the same condition as Resident #226's and #117's room. There were no televisions in any room, and no water to drink in any room. There was no soap nor paper towels in the Resident rooms for hand washing of staff or Residents.
It is notable to mention that no activities were noted to be conducted during day shift in the secured unit from 12-10-24 until 12-18-24. The staff were asked why no activities were being conducted for the residents and they replied that we only have one activity person for the whole 150 bed facility.
Observations continued daily with multiple surveyors taking turns continuously and it was found that from 10:00 AM until 4:00 PM every day from 12-10-24 until 12-18-24 that no activities were noted to be conducted in the secured unit. The staff were asked why no activities were being conducted for the residents and they replied that we only have one activity person for the whole facility, and if we let them have TV's they will just pull them off the wall. When asked which Residents had done this none could attest that they had actually seen this in practice, it had simply been assumed.
Facility CNA (Certified nursing Assistant) and LPN (Licensed Practical Nurse) staff on the memory care unit and other units were interviewed, and stated the reason that Resident #226 had been placed on the memory unit was wandering and behaviors When asked what his behaviors were, they were only able to say he went outside and sat in his wheel chair one time after dialysis, and further stated he would wander up and down the halls and that will get you put in here for sure. The surveyor asked why he walked, and there was no response.
On 12-18-24, during a meeting with the Administrator, Director of Nursing, and Corporate clinical support consultant, the facility staff were made aware of the concerns that the entire memory care unit was not receiving any activity programming, and that the calendar of events document that had been received as requested from staff, had not been observed happening on the unit as was written on the calendar.
On 12-19-24, prior to the survey exit the Director of Nursing informed surveyors that Resident #226 and his room mate had been moved back onto regular units last night (12-18-24).
At the time of survey exit on 12-19-24 the facility Administrator, and Director of Nursing stated they had nothing further to provide.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0680
(Tag F0680)
Could have caused harm · This affected most or all residents
Based on staff interviews, clinical record reviews, and review of facility documents, the facility staff failed to ensure the activities program was directed by a qualified professional who could dire...
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Based on staff interviews, clinical record reviews, and review of facility documents, the facility staff failed to ensure the activities program was directed by a qualified professional who could direct the provision of activities to the residents which resulted in Substandard Quality of Care.
The findings included:
During a recertification survey conducted 12/10/24 through 12/13/24 and 12/16/24 through 12/19/24 residents were identified who could benefit from meaningful and individualized activity programs. A further review of the activities program revealed that the current Director of Activities (AD) had been employed at the facility since July 23, 2024, and her previous experience in a similar role was with an assisted living community, (assisted living facilities are not classified as health care settings).
An interview was conducted with the current AD on 12/12/24 at approximately 4:50 PM. The AD stated she had a special love for enrichment through various activities and it was her desire to become an Activities Director Certified not an Activities Professional. The facility's AD stated she was not completing the activity section of the comprehensive Minimum Data Set Assessment, but she was developing the care plan goals.
The facility's AD further stated she obtained a degree in gerontology and had worked greater than 700 hours in an activities program, therefore she had contacted a representative with the National Certification Council for Activity Professionals (NCCAP) about the Professional Equivalency Track for certification as an ADC. A review of the correspondence between the AD and the representative revealed the representative requested that the facility's AD proceed to upload specific documents for review.
The facility's AD stated NCCAP requirements were for her to complete and pass two test which cost $60.00 each, then she would be allowed to pay $80.00 to take the test for certification as an Activities Director.
On 12/13/24 at approximately 1:10 PM the Regional [NAME] President requested additional information and provided the surveyors with a copy of the state and federal regulations regarding the qualifications of an AD. She asked if she was reading the regulation correctly because the current AD had years of experience.
On 12/13/24 at approximately 12:45 PM, the Human Resource Director (HRD) stated the activity department had three employees, the Director and two assistants and neither was certified as an AD or AP. The HRD provided a summation of the facility's AD from 8/15/2023 to current. The findings revealed all the ADs between 8/15/2023 and 12/19/2024 were unqualified based upon the facility's job description below:
The facility's Activities Director job requirements dated December 2018 stated the Activities Director must meet at least one (1) of the following criteria: Degree and certification as a therapeutic recreation specialist; or Certified Activity Director by the National Certification Council for Activity Professionals; or two (2) years' experience in a social or recreational program within the past five (5) years, in which one (1) year was full time in a resident activities program in a health care setting; or prior completion of a state approved training course.
The Activities Director job requirements also stated that the individual must have one (1) to two (2) years management/supervisory experience, effective verbal and written English communication skills, excellent creative and communication skills and skill at working with individuals who have cognitive, physical or sensory disabilities.
The Activities Director job requirements further stated that the individual must have practical knowledge of how an Activity Department functions in a nursing facility. General knowledge of regulatory requirements for an activity program in a long-term care facility, outstanding interpersonal skills with a high level of energy and enthusiasm, experience in working with volunteers and the ability to organize and develop a volunteer program.
On 12/19/24 at approximately 6:00 P.M., a final interview was conducted with the Administrator, Director of Nursing, Assistant Director of Nursing, the Owner and three Corporate Nurse Consultants. They had no further comments and voiced no concerns regarding the above findings.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0839
(Tag F0839)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility failed to employ a full time professional necessary to carry out the provisions of a licensed or certified Social worker in a 220 bed facility impacting resident care to all residents including 1 Resident (Resident #226) in a survey sample of 74 Residents.
The findings included:
For Resident #226, who refused a transfer to the locked memory care unit (for Residents with dementia and behaviors), the facility staff failed to honor the Resident's request. The staff moved him against his will, and did not afford him the services of a Social worker to plan care and discharge, per his wishes. He was involuntarily secluded.
Resident #226 was admitted to the facility on [DATE] with diagnoses including: End stage renal disease with hemodialysis, history of stroke, anemia, chronic congestive heart failure, hypertension, and diabetes type 2. The Resident did not have a diagnosis of dementia and was his own responsible party and by facility agreement cognitively intact and able to make his own decisions.
On 9-26-24 at 4:42 PM the Resident was moved to the memory care locked unit and the Resident's son was notified according to the room change notification document in the clinical record, however, the document stated that the Resident's brother agreed to the room change even though these individuals were only emergency contacts and the Resident refused and was his own responsible party.
The reason given for the move, was elopement risk. The Resident had never eloped and on the one occasion that he went outside to sit in the sun after dialysis he did not leave, even though he could have walked away, he simply sat there until staff came to take him back to his room. When asked about this incident the Resident stated there is no reason that I can't sit outside for awhile and get some fresh air. I am not a prisoner.
During an initial interview on 12-10-24, at 11:40 AM, Resident #226 was found to be alert and oriented to person, place, time, and situation. He stated that he had requested to stay in his current room after learning that the facility planned to move him rather than discharge him home.
Resident #226 stated he was told his son and grandson were not able or willing to care for him in the home that the three of them had formerly shared. The Resident insisted on planning a discharge back to the community, or an assisted Living Facility as soon as possible, however, he stated no one listened, no one came to talk to me about it, and nothing ever happened even though I kept telling them.
During this interview, Resident #226 verbalized that he is a dialysis patient and that he received dialysis there in the facility.
He further stated he hates the memory care unit because everyone is crazy in here, they wander into my room and take things, my room mate yells and crys all night for something to drink, I don't even get food every meal, the room is nasty and falling apart, and I can't even get a shower in here because the showers are so nasty dirty. He went on to say I like to walk around, it makes the time go faster, if I don't walk now I won't be able to leave, but locked in here I have no where to walk, I don't even have a TV to watch and I love TV, being in here will make you crazy with nothing to do.
The Residents had no television, no clock, no telephone, no radio and the room had no personal items in it nor on the walls.
Resident #226 had no shoes, no coat, 2 pairs of pants, and 2 shirts (the Resident was wearing one of each). When asked about his clothing he stated I had more, but they have been stolen.
It is notable to mention that no activities were noted to be conducted in the secured unit from 12-10-24 until 12-18-24. The staff were asked why no activities were being conducted for the residents and they replied that we only have one activity person for the whole facility.
Facility CNA (Certified nursing Assistant) and LPN (Licensed Practical Nurse) staff on the memory care unit and other units were interviewed, and stated the reason that Resident #226 had been placed on the memory unit was wandering and behaviors When asked what his behaviors were, they were only able to say he went outside and sat in his wheel chair one time after dialysis, and further stated he would wander up and down the halls and that will get you put in here for sure. The surveyor asked why he walked, and there was no response.
The Social worker was interviewed on 12-10-24 and revealed that she had just been hired on 11-19-24. The former Social worker resigned on 6-28-24, and there had been no social worker in the facility from 6-28-24 until 11-19-24. She stated she would be putting in a progress note for Resident #226 on this same day, and she stated that she didn't really know much about him.
On 12-11-24 the social work note was reviewed and revealed a progress note that documented the Resident as long term care during a care planning meeting, and nothing about discharge planning or his desire to be discharged .
On 12-12-24 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 not sufficient for the role.
The Director of Nursing and Administrator were asked for a policy or procedural guidance for moving a Resident onto the memory care locked unit. Both stated that they did not have one, and could not describe a pathway to the decision for moving a resident into the secure unit.
On 12-11-24, through 12-19-24 a clinical record review was conducted. There was no evidence in the clinical record that the physician had been called and notified of the Resident's move, nor was a request made for assessment and told that the Resident wished to discharge.
On 12-5-24 a PHQ-9 (the only one during his stay) evaluation for depression was conducted and gave a score of 3 which equaled minimal or not at all suffering from depression. The Resident was not ordered to have any psychoactive medications, nor did he have any diagnoses to support the use of them.
On 12-12-24, during a meeting with the Administrator, Director of Nursing, and Corporate clinical support consultant, the facility staff were made aware of the lack of Social Work services for 5.5 months which continued through survey, and that the Resident had requested to stay in his room, and to be planned for discharge. The discharge request was ignored. Further they were notified that no Social Worker was providing care during the Resident's stay which compounded the incident further, which culminated in the withholding of a resident's rights, and involuntary seclusion.
On 12-19-24, prior to the survey exit the Director of Nursing informed surveyors that Resident #226 and his room mate had been moved back onto regular units last night (12-18-24).
At the time of survey exit on 12-19-24 the facility Administrator, and Director of Nursing stated they had nothing further to provide.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility failed to maintain a qualified Social Worker in a 220 bed facility resulting in a Substandard Level of Care impacting resident care to all residents including 1 Resident (Resident #226) in a survey sample of 74 Residents.
The findings included:
For Resident #226, who refused a transfer to the locked memory care unit (for Residents with dementia and behaviors), the facility staff failed to honor the Resident's request. The staff moved him against his will, and did not afford him the services of a Social worker to plan care and discharge, per his wishes.
Resident #226 was admitted to the facility on [DATE] with diagnoses including: End stage renal disease with hemodialysis, history of stroke, anemia, chronic congestive heart failure, hypertension, and diabetes type 2. The Resident did not have a diagnosis of dementia and was his own responsible party and by facility agreement cognitively intact and able to make his own decisions.
On 9-26-24 at 4:42 PM the Resident was moved to the memory care locked unit and the Resident's son was notified according to the room change notification document in the clinical record, however, the document stated that the Resident's brother agreed to the room change even though these individuals were emergency contacts and the Resident refused and was his own responsible party.
The reason given for the move, was elopement risk. The Resident had never eloped and on the one occasion that he went outside to sit in the sun after dialysis he did not leave, even though he could have walked away, he simply sat there until staff came to take him back to his room. When asked about this incident the Resident stated there is no reason that I can't sit outside for awhile and get some fresh air. I am not a prisoner.
During an initial interview on 12-10-24, at 11:40 AM, Resident #226 was found to be alert and oriented to person, place, time, and situation. He stated that he had requested to stay in his current room after learning that the facility planned to move him rather than discharge him home.
Resident #226 stated he was told his son and grandson were not able or willing to care for him in the home that the three of them had formerly shared. The Resident insisted on planning a discharge back to the community, or an assisted Living Facility as soon as possible, however, he stated no one listened, no one came to talk to me about it, and nothing ever happened even though I kept telling them.
During this interview, Resident #226 verbalized that he is a dialysis patient and that he received dialysis there in the facility.
He further stated he hates the memory care unit because everyone is crazy in here, they wander into my room and take things, my room mate yells and crys all night for something to drink, I don't even get food every meal, the room is nasty and falling apart, and I can't even get a shower in here because the showers are so nasty dirty. He went on to say I like to walk around, it makes the time go faster, if I don't walk now I won't be able to leave, but locked in here I have no where to walk, I don't even have a TV to watch and I love TV, being in here will make you crazy with nothing to do.
The Residents had no television, no clock, no telephone, no radio and the room had no personal items in it nor on the walls.
Resident #226 had no shoes, no coat, 2 pairs of pants, and 2 shirts (the Resident was wearing one of each). When asked about his clothing he stated I had more, but they have been stolen.
It is notable to mention that no activities were noted to be conducted in the secured unit from 12-10-24 until 12-18-24. The staff were asked why no activities were being conducted for the residents and they replied that we only have one activity person for the whole facility.
Facility CNA (Certified nursing Assistant) and LPN (Licensed Practical Nurse) staff on the memory care unit and other units were interviewed, and stated the reason that Resident #226 had been placed on the memory unit was wandering and behaviors When asked what his behaviors were, they were only able to say he went outside and sat in his wheel chair one time after dialysis, and further stated he would wander up and down the halls and that will get you put in here for sure. The surveyor asked why he walked, and there was no response.
The Social worker was interviewed on 12-10-24 and revealed that she had just been hired on 11-19-24. The former Social worker resigned on 6-28-24, and there had been no social worker in the facility from 6-28-24 until 11-19-24. She stated she would be putting in a progress note for Resident #226 on this same day, and she stated that she didn't really know much about him.
On 12-11-24 the social work note was reviewed and revealed a progress note that documented the Resident as long term care during a care planning meeting, and nothing about discharge planning or his desire to be discharged .
On 12-12-24 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 not sufficient for the role.
The Director of Nursing and Administrator were asked for a policy or procedural guidance for moving a Resident onto the memory care locked unit. Both stated that they did not have one, and could not describe a pathway to the decision for moving a resident into the secure unit.
On 12-11-24, through 12-19-24 a clinical record review was conducted. There was no evidence in the clinical record that the physician had been called and notified of the Resident's move, nor was a request made for assessment and told that the Resident wished to discharge.
On 12-5-24 a PHQ-9 (the only one during his stay) evaluation for depression was conducted and gave a score of 3 which equaled minimal or not at all suffering from depression. The Resident was not ordered to have any psychoactive medications, nor did he have any diagnoses to support the use of them.
On 12-12-24, during a meeting with the Administrator, Director of Nursing, and Corporate clinical support consultant, the facility staff were made aware of the lack of Social Work services for 5.5 months which continued through survey, and that the Resident had requested to stay in his room, and to be planned for discharge. The discharge request was ignored. Further they were notified that no Social Worker was providing care during the Resident's stay which compounded the incident further, which culminated in the withholding of a resident's rights, and involuntary seclusion.
On 12-19-24, prior to the survey exit the Director of Nursing informed surveyors that Resident #226 and his room mate had been moved back onto regular units last night (12-18-24).
At the time of survey exit on 12-19-24 the facility Administrator, and Director of Nursing stated they had nothing further to provide.
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
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. The facility staff failed to ensure her hands were washed with soap and dried with paper towels before providing Activity of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. The facility staff failed to ensure her hands were washed with soap and dried with paper towels before providing Activity of Daily Living (ADL) care for a dependent care Resident.
Resident #87 was originally admitted to the facility 03/06/23 and readmitted [DATE] after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included; Difficulty in walking, not elsewhere classified.
The Minimum Data Set (MDS) assessment with discharge assessment reference date (ARD) of 10/20/24 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for short term memory problems as well as severely impaired for daily decision making.
In sectionGG(Functional Abilities Goals) the resident was coded as dependent oral hygiene, toileting hygiene, showering/bathing, personal hygiene, requiring set-up eating.
The care plan dated 9/20/24 read that Resident #87 has an ADL self-care performance deficit r/t Activity Intolerance, Aggressive Behavior, Confusion, Dementia, Impaired balance and Stroke. The goal was resident will maintain current level of function in ADLs through the review date 10/29/2024. The interventions are the following: Resident requires limited to extensive assistance by 1 staff with bathing/showering and Provide sponge bath when a full bath or shower cannot be tolerated.
On 12/19/24 at approximately 11:00 AM., a Full bed bath observation was conducted on Resident #87 with Certified Nursing Assistant (CNA) #14 was observed washing her hands with water and with dripping wet hands she placed them inside of her gloves and began to provide a full bed bath to Resident #87. License Practical Nurse (LPN) #8 was also present. An observation was made of the resident's room, no soap dispenser or paper towels were seen.
On 12/19/24 at approximately 11:40 AM., an interview was conducted with CNA #14 concerning Resident #87. CNA #14 said that she was not able to use soap because the rooms don't have soap or paper towels in them. CNA #14 also said that she needs soap and paper towels to wash her hands and the resident hands.
About Handwashing: Many diseases and conditions are spread by not washing hands with soap and clean, running water. If soap and water are not readily available, use a hand sanitizer with at least 60% alcohol to clean your hands. Follow these five steps every time. Wet your hands with clean, running water (warm or cold), turn off the tap, and apply soap. Lather your hands by rubbing them together with the soap. Lather the backs of your hands, between your fingers, and under your nails. Scrub your hands for at least 20 seconds. Rinse your hands well under clean, running water. Dry your hands using a clean towel or an air dryer. https://www.cdc.gov/clean-hands/about/index.html
On 12/19/24 at approximately 5:55 p.m., 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.
3. The facility's staff failed to have soap and towels available for use in Resident #105's room.
Resident #105 was originally admitted to the facility 10/27/23 and he was readmitted [DATE] after an acute care hospital stay. The current diagnoses included a major neurocognitive disorder with Lewy Bodies dementia.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/17/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 4 out of a possible 15. This indicated Resident #105's cognitive abilities for daily decision making were severely impaired.
A review of Resident #105's person-centered care plan dated 1024/24 failed to reveal an intervention not to have soap or a towel at the sink for use.
On 12/11/24 at approximately 12:10 PM Resident #105 was observed in his room as the lunch meal was being served. At the sink it was identified there was no means of washing the resident's or staff's hands for there was no soap or towels for use. The room across the hall was also observed without soap or towels for use. The staff did not perform hand hygiene for Resident #105 before serving the lunch meal.
On 12/13/24 at 12:45 PM, an observation was also made of Resident #105 prior to serving of the lunch meal and after the meal. Again, there were no soap or towels available to be used and the resident had no hand hygiene before or after lunch.
On 12/13/24 at 12:55 PM an interview was conducted with Licensed Practical Nurse (LPN) #8. LPN #8 stated Resident #105 does not communicate in English and is unable to wash his own hands therefore the staff provides hygienic services to the resident.
On 12/13/24 at approximately 2:50 P.M., a final interview was conducted with the Administrator, Director of Nursing, and three Corporate Nurse Consultants. The above information was conveyed to the administrative staff, they all looked at each other but voiced no comments/concerns regarding the above findings.
Based on Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility staff failed to implement an infection prevention and control program to include environmental concerns for 4 of 4 nursing units to include the entire locked memory care unit and the direct care of four Residents (Resident #226, #117, #105, and #87) in a survey sample of 74 Residents.
The findings included:
1. For Resident #226, the entire memory care unit was dirty, in disrepair, had bodily fluids on surfaces, and there were no paper towels nor soap to wash staff hands in any resident room.
2. For Resident #117, the entire memory care unit was dirty, in disrepair, had bodily fluids on surfaces, and there were no paper towels nor soap to wash staff hands in any resident room.
1. Resident #226 was admitted to the facility on [DATE] with diagnoses including: End stage renal disease with hemodialysis, history of stroke, anemia, chronic congestive heart failure, hypertension, and diabetes type 2. The Resident did not have a diagnosis of dementia and was his own responsible party and by facility agreement cognitively intact and able to make his own decisions. The Resident had a room mate, Resident #117.
2. Resident #117 was admitted to the facility on [DATE] with diagnoses including: Dementia without behavioral disturbance, hypertension, major recurrent depression. dysphagia, chronic kidney disease, cardiac disease, malignant cancer of nasal cavity, and congestive heart failure. The Resident had a room mate, Resident #226.
During an initial interview on 12-10-24, at 11:40 AM, Resident #226 was found to be alert and oriented to person, place, time, and situation. He stated that he had requested to stay in his current room after learning that the facility planned to move him rather than discharge him home.
During this interview, Resident #226 verbalized that he is a dialysis patient and that he received dialysis there in the facility. He further stated he hates the memory care unit because everyone is crazy in here, they wander into my room and take things, my room mate yells and cries all night for something to drink, I don't even get food every meal, the room is nasty and falling apart, and I can't even get a shower in here because the showers are so nasty dirty. He went on to say I like to walk around, it makes the time go faster, if I don't walk now I won't be able to leave, but locked in here I have no where to walk, I don't even have a TV to watch and I love TV, being in here will make you crazy with nothing to do.
The surveyor and Resident then immediately walked to the shower room for an initial observation and found it to be dirty, mildewed/moldy, foul smelling, had a strong odor of urine and feces, trash and debris littered the floor, used brown stained wet linens were on the floor, a white crusted substance was on the floor and walls, used soap and shampoo bottles were crusted on the shelves and hand rails in the shower, and the room was being used as a storage area as well for boxes of supplies and durable medical equipment. The Resident asked would you want to take a shower in here?
Immediately following the shower room observation the Resident's room was examined. 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, no curtains, a urine soaked bathroom, a pervasive smell of urine and feces in the room and on the entire unit.
The free standing broken armoire closets in the rooms were swollen and splitting, with rotten splinters and chunks of disintegrating wood and wood particles all over the Residents few items in the closet, and in the rooms.
The sink vinyl laminate countertop area was water damaged and swollen and separated revealing particle board disintegration with the sink partially separated from the wall in a downward unstable dropped position, and wood dust everywhere.
Under the sink a cabinet door was ajar as it would not close because of the downward sloping sink, and the inside compartment was an open hole with what appeared to be a black concrete floor. Inside was found mildew, mold, trash, a pair of urine stained white tennis shoes, and 2 shirts that were stuck together with an unknown substance, all thrown in onto the floor.
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 bed divider curtain had brown stains and smeared feces on it.
The PTAC (air conditioning wall unit) was not secured and had fallen forward into the room approximately 12 inches revealing light around it and cold air coming into the room from the outside of the building. The front cover of the unit was also missing and the sharp metal grill was exposed. The Resident's room mate's bed (#117) was pushed against the PTAC holding it in place so it would not completely fall out of the hole in the outside facing wall.
The Residents had no television, no clock, no telephone, no radio and the room had no personal items in it nor on the walls.
Resident #226 had no shoes, no coat, 2 pairs of pants, and 2 shirts (the Resident was wearing one of each). When asked about his clothing he stated I had more, but they have been stolen.
Each room on the unit was then inspected by all surveyors and found to be in the same condition as Resident #226's room. There were no televisions in any room, and no water to drink in any room.
There was also noted in the hallway the air conditioning main vent in the ceiling and air return on the wall were so dusty that they had the appearance of brown fur coating them. The walls were marked and smeared and had paint scraped off in places. There was no soap nor paper towels in the Resident rooms for hand washing of staff or Residents.
On 12-13-24 the Director of Maintenance and Director of Environmental Services (house keeping) were interviewed and agreed that staffing for the 2 departments had been tight. Environmental services had 13 total employees. That number was responsible for house keeping, laundry and floor machine technicians.
This number culminated in daily staffing dispersal of 3 staff in laundry, and 1 floor tech, which left 1 housekeeper on each of the 4 nursing units, and 1 housekeeper in common areas such as dining rooms on each unit, the main kitchen, activities, offices, therapy, bathrooms, conference rooms, the dialysis center, and main hallways/entrances. The added 4 staff positions would be trade outs for the other staff members days off during a seven day schedule.
With 123 resident rooms total each of the nursing units housed approximately 20 to 35 Resident rooms for one house keeper to clean each day in an 8 hour shift allowing for 16 minutes to clean each room.
Two of the 3 dryers in the laundry had been broken since June 2024, so linens and privacy curtains and resident personal laundry was not being washed and returned timely even though the staff was washing and drying around the clock. The only working dryer was being operated 24 hours per day. The dirty linen storage on the units was backed up as a result, and creating some of the pervasive urine and feces odors in the facility. Linens, bedding, and privacy curtains were not being changed as often as necessary due to the inability to have enough on hand to change them out more frequently.
The maintenance Director stated they were starting to get some priorities taken care of in the facility now as staffing had improved just recently, and he began painting the memory unit and new cabinets began to be installed on 12-13-24.
On 12-12-24, and 12-13-24 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 the entire memory care unit was not safe, clean and comfortable.
On 12-19-24, prior to the survey exit the Director of Nursing informed surveyors that Resident #226 and his room mate had been moved back onto regular units last night (12-18-24).
At the time of survey exit on 12-19-24 the facility Administrator, and Director of Nursing stated they had nothing further to provide.
Apr 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
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 develop and implement a base...
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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 develop and implement a baseline care plan that includes the instructions needed to provide immediate and effective and person-centered care of the resident, for 1 Resident (#1) in a survey sample of 5 Residents.
The findings included:
For Resident #1, the facility failed to address the issue of wandering and food seeking for a Resident who is a high aspiration risk with a g-tube and NPO (Nothing by Mouth) order.
On 4/11/24 a review of the clinical record revealed that Resident #1 was admitted to the facility on [DATE] with diagnoses that included but were not limited to unspecified fracture of left femur, gastrostomy tube placement, Type 2 diabetes, anemia (unspecified), unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, dysphagia high aspiration risk, hypotension with history of falls.
A review of the baseline care plan revealed that on Page 3 Section G 8 of the Baseline care plan V2-V4 the question read:
Is the Resident an elopement risk? NO
A review of the Gates Wandering Assessment revealed that on 2/16/24 at 4:56 PM Resident #1 scored 13 -HIGH RISK WANDERING. [Please note score of 11 or above is High Risk to Wander]
Page 2 Section G read:
COMPLETE 72 HOURS POST ADMISISON
The resident:
0. Has not wandered
1. Has wandered within the home without leaving grounds
5. Has wandered aimlessly within the home or off the grounds.
This section was left blank and was not answered 72 hrs. after admission.
A review of the clinical record revealed the following progress notes withing 24 hours of admission:
2/17/2024 12:00 AM - AHR Nursing Progress Note Text: Client sitting up in wheelchair. Attempting to pull foley catheter out. States he has to go to bathroom. Staff explains that urine is contained and going to bag. Will continue to monitor.
2/17/2024 01:31 AHR Nursing Progress Note Text: Client is up ambulating towards Dialysis Den. Gait unsteady. Foley Cath tubing pulled apart and urine is on floor. Catheter is still intact and taken to nurses station. Will continue to monitor.
2/17/2024 02:46 AHR Nursing Progress Note Text: Client is going to other patient rooms stating he needs to use the bathroom. Somewhat combative when redirected. Using profanity to deter nursing staff.
2/17/2024 06:40 AHR Nursing Progress Note Text: Client is sitting in wheelchair in nurses station at this time. Staff has been with client 1:1 on a rotation basis. Client is quiet and denies any complaints of pain or discomfort. Will continue to monitor.
2/17/2024 04:05 AHR Nursing Progress Note Text: Client continues to scream for help and propels self in wheelchair. He ambulated to door and set off alarm as he opens it. will continue to monitor and observe client.
On 4/11/24 at approximately 1:30 PM an interview was conducted with Employee D (a unit manager) who stated that it is the expectation that the nurses complete all aspects of the wandering / elopement risk assessments to include the 72 hour and 1 month follow up sections. When asked the importance of this as it pertains to a new admission, she stated that if a person is admitted to a facility, we don't necessarily know their behaviors and 72 hours gives us time to observe them and see if they are indeed an elopement risk. She stated that someone who is not wandering when they were acutely ill in the hospital may begin to wander when they come into a nursing home setting. She stated that the wandering and elopement risk assessment is an important tool to let staff know that this Resident may need a wander guard or may need closer supervision. When asked if this should be included in the care plan, she stated that it should. When asked if a new resident starts wandering would be considered a change that needed to be noted in the baseline care plan, she stated that it should.
A review of the care plan policy revealed the following:
Page 2 Policy explanation and compliance guidelines:
6. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the president's personal and cultural preferences in developing goals of care.
On 4/12/24 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
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, clinical record review, and facility documentation, the facility staff failed to provide nutrition in a for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, clinical record review, and facility documentation, the facility staff failed to provide nutrition in a form designed to meet the individual needs of the Resident, for 1 Resident (#1) in a survey sample of 5 Residents.
The findings included:
The facility staff failed to implement NPO (Nothing by Mouth) orders for Resident #1. The resident was given a regular meal tray which he consumed, resulting in being sent out via rescue squad on 2/22/24 to the hospital. The resident was admitted with respiratory failure related to aspiration of food.
On 4/11/24 a review of the clinical record revealed that Resident #1 was admitted to the facility on [DATE] with diagnoses that included but were not limited to unspecified fracture of left femur, gastrostomy tube placement, Type 2 diabetes, anemia (unspecified), unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, dysphagia high aspiration risk, hypotension with history of falls. The Resident has no BIMS (Brief Interview of Mental Status) score on record however there is a statement in the discharge summary that the Resident was evaluated for competency at the hospital on 2/22/24 and found incompetent.
A review of the clinical record revealed that the admission orders were confusing, unclear, and not specific about the resident's tube feeding and NPO status. A review of the orders revealed that his medication orders were originally put into the system as give by mouth on admission, however, most were changed to via g-tube before administration. The following excerpts are from physician orders:
If necessary, all meds may be opened or crushed and mixed with applesauce, pudding, etc., except those that cannot be crushed (entered 2/16/24).
NPO -Nothing by Mouth diet, Nothing by Mouth texture Diet (entered 2/16/2024).
Enteral Feed Order: four times a day for Enteral Nutrition Administer (300 Milliliters) every day at (0800 / 12:00 / 17:00 / 21:00) Flush G-Tube with (30ml) of water Prior and Post Administration. -Start Date_02/16/2024. This order did not specify the type of tube-feeding formula.
On 4/11/23 a review of the clinical record revealed the following note from the last day the Resident was at the facility (2/22/24).
2/22/2024 - 5:06 AM Electronic Health Record (EHR) Progress Note -Note Text: Resident observed with Altered Mental Status (AMS), lethargic not as active, urine is cloudy, dark brown. BP 97.6, 101, 16, 89/62. Sent to [hospital name redacted] via 911. [Resident Representative name redacted] notified. [initials redacted] with on-call MD.
A review of the entire clinical record including nurses' notes, progress notes for all disciplines, and physician notes revealed no mention of an incident involving the Resident receiving a tray from dietary.
On 4/12/24 at 2:05 PM, an interview was held with the Administrator, the DON, and the ADON. The DON was asked about the incident that happened on 2/22/24 regarding Resident #1 being sent out to the hospital. When asked about the resident being sent out, she stated that the Resident was assessed to have altered mental status, so he was sent to the hospital for evaluation. When asked how they came to know about the Resident getting a regular meal tray, she stated, Well when his brother came to the facility the next day, after he passed (2/23/24), that's when I started the investigation. She stated that she had no idea there was a problem until his family member told her that he had died from respiratory failure due to aspiration. She said she started looking into the situation and held a QAPI meeting that day. The Facility submitted the Past Non-Compliance Corrective Action Plan with a start date of 2/23/24 and an AOC date of 4/2/24. Upon interviewing staff, she was told that on 2/21/24 Resident #1 was given a food tray and was eating the food, when staff tried to get the tray from the Resident he refused and said, It's mine. The staff did not report this to the MD/RP nor was this documented in the clinical record. The only documentation of this event existed in the PNC Corrective Action Plan.
During the above interview, when asked if she was sure Resident #1 was given the tray by dietary, she stated, Well we really don't know, there was no ticket on it, so we cannot say for sure if he took it from the cart, another Resident's room, or if he was given the tray. She stated that no one observed him taking a tray on that day, the staff denied giving the resident a tray and the resident kept repeating It's mine so, they believed that he was given the tray. She stated they tweaked the electronic health record system so it would flow smoother. She stated before in the field that said Diet staff would put NPO and in the field that says Texture they would click NPO, but for some reason when it would go to dietary it would default to regular. She stated that they worked with IT so now the nurses will put NPO in the field that says Diet and they put Tube feeding in the field that says Texture, and this new process seemed to have fixed the problem. They also stated they were using dietary slip carbon copies to be sure the nurses were putting in the physical slip as well.
The following excerpt is from the facility documentation of their Corrective Action Plan that was initiated on 2/23/24:
Facility Name: [redacted] Date Started: 2/23/24 Date Completed: 4/2/24.
Problem Statement: Meal tray prepared and delivered to resident with order of NPO.
Goal: All resident diet orders will be followed.
Baseline Data: [area left blank]
Root Causes: Diet order correct sequence input into [electronic health record system name redacted] to pull over correctly to assisted dining solutions ticket system.
Meal cart doors not closed when not in use.
Dietary slip not provided to dietary department by nursing.
Medication orders without correct route.
On 4/12/24 at approximately 2:30 PM an interview was conducted with LPN C (the admitting nurse) who was asked about Resident #1's admission, and she stated that the normal process was to get the orders and verify them with the physician and then put them into the electronic health record so that pharmacy can get started on filling the medications. When asked how the verification process worked, she stated that if the physician or NP is in the building, they would give them the discharge summary meds and get them to approve it if not she calls them and reads the discharge orders, and the physician will say yes or no and tell her if anything is to change. When asked if this is what happened in Resident #1's case she stated that it was. When asked if she noticed that he had a g-tube and tube feeding NPO orders she stated, I did.
During the above interview with LPN C, when asked why the Resident would have g-tube and medication orders by mouth, she stated that originally the admission orders (2/16/24) were put in as they were exactly ordered at the hospital and later on, that day, they realized the error and corrected it. When asked about inputting dietary orders she stated that in the area that said Diet she entered NPO and in the area that said texture she entered NPO. She stated, This process has changed now because for some reason it was not pulling over to the dietary ticket system. It was not pulling the orders correctly from the electronic health record into the system for the dietary dept. When asked about filling out a dietary slip for Resident #1, she stated she thought she filled out the dietary slip at the time, but the kitchen said they did not receive it. She stated, Now we have carbon copies for us and the original for the kitchen.
On 4/15/24 at approximately 2:00 PM an interview was conducted with the Dietary Manager who stated that she remembered the incident involving Resident #1. She stated that she recalled having it in her system that he was NPO, but she could not provide the evidence due to his discharge status, and these meal tray tickets are not kept in the system. She stated that her system could not pull up meal tray tickets once a resident had been discharged . She stated that if the resident was NPO no ticket or tray should have been issued. The Dietary Manager said that the dietary staff denied making or delivering a tray to Resident #1. She said a new system that was put into place would ensure residents who are NPO would not receive a regular tray.
The Survey team verified that the facility implemented the corrective actions they had outlined in their plan dated 2/23/24. The survey team interviewed staff on duty about the correct way to enter diet, NPO, and tube feeding orders into the system. All nursing staff interviewed were knowledgeable on how to correctly input the orders and knowledgeable about why there were changes made to the old way of putting orders into the system. The dietary staff were interviewed, and all staff interviewed understood the importance of following the meal ticket system regarding diet/consistency/NPO status. The nursing staff was interviewed regarding the education received on ensuring orders are correct, questioning any unclear orders, or contradictory orders, and reporting behaviors. All nursing staff interviewed were knowledgeable on the importance of correct physician orders, the importance of clarification of ambiguous or contradictory orders such as crush meds or give by mouth for Residents with NPO status, and the importance of notification of Physician and Resident Representative of changes in behavior. The facility provided and the survey team reviewed credible evidence of Audits and all staff training that began on 2/23/24 and continued until the plan was complete and all staff was educated before working.
Based on the facility corrective action plan with an Allegation of Compliance (AOC) date of 4/2/24 to the current survey, there were no other issues related to accurate meal trays delivered to residents with NPO order, thus Past Non-Compliance was attributed to this deficient practice.
On 4/12/24 during the end-of-day meeting, the Administrator was made aware of the findings, and no further information was provided.
Nov 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record review, and facility documentation review, the facility staff failed to consistently ...
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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 consistently assess, track, monitor, and treat a stage II pressure ulcer timely for 1 of 5 residents (Resident #5) in the survey sample.
The findings included:
Resident #5 was admitted to the nursing facility on [DATE]. Resident #5 was discharged to home on [DATE], she expired at the hospital on [DATE]. Diagnosis for Resident #5 included but was not limited to Multiple Myeloma (cancer), End Stage Renal Disease (ESRD) required dialysis in house 5 x week, and protein-calorie malnutrition.
The most recent Minimum Data Set (MDS - an assessment protocol) an admission Assessment (14-day) with an Assessment Reference Date (ARD) of [DATE] coded Resident #5's Brief Interview for Mental Status (BIMS) scored a 00 indicating short- and long-term memory problems and severe cognitive impairment - never/rarely made decisions. Resident #5 was coded as having total dependence on one with bathing, extensive assistance of one with bed mobility, transfer, dressing, toilet use, and personal hygiene, and supervision with one assistance with eating for Activities of Daily Living (ADL). Under section H - (Bladder and Bowel) was coded for always incontinent of bowel and frequent incontinent of bladder. Section G0400 - Functional Limitation in Range of Motion (ROM) coded Resident #5 with no impairment to her upper or lower extremities. Under section M- skin condition was coded as not being at risk for pressure ulcers or having pressure ulcers at the time of admission.
Resident #5's person-centered care plan revised on [DATE] identified the resident has the potential for pressure ulcer development related to incontinence of bowel and bladder. The goal set for the resident by the staff was to maintain intact skin, free of redness, blisters, or discoloration by/through review date [DATE]. Some of the interventions/approaches the staff would use to accomplish this goal were to assist with repositioning and or turning at frequent intervals to provide pressure relief, educate family/caregivers as to causes of skin breakdown including transfer/positioning requirements, importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, provide incontinence care after each incontinence episode, or per established toileting plan, teach resident and family the importance of changing positions for prevention of pressure ulcers and encourage small frequent position changes.
The Braden Scale for Prediction of Pressure Sores completed on [DATE] scored an 11 indicating a high risk for developing pressure ulcer. It revealed the resident responded to verbal commands but could not always communicate discomfort or the need to be turned and had some sensory impairment which limited the ability to feel pain or discomfort in 1 or 2 extremities. The skin was often moist, but not always moist requiring linen to be changed at least once a shift, due to confinement to bed. The resident was very limited with mobility; and made occasional slight changes in body or extremity position but was unable to make frequent or significant changes independently. Poor nutrition and never eats a complete meal. Moves freely or requires minimum assistance. During a move skin probably slides to some extent against sheets, chairs, restraints, or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down.
A review of Resident #5's admission Skin assessment dated [DATE] indicated a pressure ulcer to the sacrum. The ulcer was not staged. On [DATE], the facility's wound nurse, License Practical Nurse (LPN) #1 assessed the sacral pressure as a stage II.
A review of Resident #5's clinical record indicated no weekly nursing assessments for tracking or monitoring of the resident's sacral pressure ulcer from admission on [DATE] until discharge to the community on [DATE].
An interview was conducted with LPN #1 on [DATE] at 11:35 AM. The LPN stated she assessed and staged Resident #5's sacral pressure ulcer on [DATE]. She said the ulcer was a Stage II, but she forgot to document her assessment or start a treatment. On [DATE], the LPN stated she spoke with the wound Nurse Practitioner (NP) in the hallway. The wound NP was given a description of Resident #5's sacral pressure and she classified the wound as a stage II. A new order was given by the wound NP to start Hydrogel daily. On [DATE], the sacral wound was assessed and observed with increased drainage but without odor. The sacral wound had advanced to Stage III, but the LPL stated forgot to document the assessment. She stated the wound NP was notified of a change in Resident #5's sacral wound with a new order to apply Calcium Alginate daily and as needed.
A review of Resident #5's clinical record revealed the following wound care orders:
-Sacrum - cleanse with wound cleanser, apply hydrogel, and cover with border gauze every day on the 7a-3p shift for wound care (stage II pressure ulcer) starting on [DATE].
-Sacrum - cleanse with wound cleanser, apply calcium alginate, and cover with border foam once a day on the 7a-3p shift for wound care starting on [DATE].
The Director of Nursing (DON) and Assistant Director of Nursing were interviewed on [DATE] at 1:16 PM. The DON stated according to Resident #5's admission assessment on [DATE], the resident was admitted with a Stage II sacral pressure ulcer. The DON stated a treatment should have been started on the day of admission. She stated Resident #5's sacral pressure should have been assessed and monitored weekly to see if the wound had worsened, improved, or healed. She stated according to Resident #5's clinical record, the sacral pressure ulcer did not receive a wound treatment from [DATE] until [DATE]. She stated the pressure never had routine tracking assessments completed during her stay.
A final meeting was held with the Administrator, Director of Nursing, Assistant Director of Nursing, and Unit Managers on [DATE] at 1:30 PM., who were informed of the above findings. No further information was provided prior to exit.
The facility's policy titled Pressure Ulcer Prevention and Management revised on [DATE] indicates the facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries.
Policy Explanation Compliance Guidelines:
2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce, or remove underlying risk factors, monitoring the impact of the interventions; and modifying the interventions as appropriate.
3. Assessment of Pressure Injury Risk.
c. Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after newly identified pressure injury. Findings will be documented in the medical record.
d. Assessments of pressure injuries will be performed by a licensed nurse and documented on the Weekly Skin Review in Point Click Care (PCC) and detailed on the Pressure and Non-pressure Wound Log. The staging of pressure injuries will be clearly identified to ensure correct coding on the MDS.
5. Monitoring
a. RN Unit Manager, or designee, will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing, and compliance at least weekly, and document a summary of findings in the medical record.
Definitions:
Pressure Injury - Stage 2 (Partial-thickness skin loss with exposed dermis)
Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel.
Pressure Injury - Stage 3 (Full-thickness skin loss)
Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed. (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages).
Sept 2021
28 deficiencies
2 IJ (2 facility-wide)
CRITICAL
(L)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Infection Control
(Tag F0880)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9. The facility staff failed to ensure infections control measures were consistently implemented to prevent the development and/...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9. The facility staff failed to ensure infections control measures were consistently implemented to prevent the development and/or transmission of a communicable disease (COVID-19), and other infectious diseases by not wearing the required N95 masks or improperly wearing the required facial coverings.
A. On 09/20/21 at approximately 7:05 p.m., upon facility entrance Dietary Staff member #3 was observed sitting in a chair in the dining room with no facial covering on. Sitting less than four feet near him was dietary staff member #4 with no facial covering. They appeared to be playing a video game. The surveyor was screened at the entrance then entered into the dining area where the two facility staff were seen. She asked Dietary staff member #4 where was his mask. He stated, that he didn't think he needed to wear his mask because he wasn't around residents.
B. On 9/21/21 at approximately 10:10 AM. FSD/OSM (Food Service Director/Other Staff Member) #5 was seen wearing his N95 mask with his nose exposed on several occasions during the kitchen inspection.
C. On 9/21/21 at approximately 12:00 PM, District Dietary Manager (OSM) #6 was interviewed concerning wearing his surgical mask in the kitchen. He stated, N95 Masks are required only inside COVID-19 restricted areas. The dietary staff don't enter those areas.
D. On 9/23/21 at approximately, 10:30 AM Dietary staff (OSM) #18 was interviewed concerning her surgical mask. She stated, I have a N95 mask that I wear in the hallway. Some people wear this one (Surgical Mask) and some wear the other one (N95). I don't know anything about getting FIT tested. I know that nursing was tested. I got the N95 a month ago. When Unit 1 was shut done everybody had one.
E. On 9/26/21 at 10:50 AM Dietary Aide (OSM) #21 Observed sitting in the dining room with no mask on. She immediately put it on when she saw the said surveyor. The Administrator also witnessed her without a mask on and putting it back on immediately. He said that he had educated her about the importance of wearing a mask at all times while here. He said she told him that she didn't think she needed a mask on because no one was in the dining area but her.
Throughout the survey many of the above staff members were observed not wearing a facial covering or not wearing their facial covering properly.
On 09/30/21 at approximately 6:20 p.m., the above findings were shared with the Administrator, and Corporate Staff Members. An opportunity was offered to the facility's staff to present additional information but no additional information was provided.10. The facility staff failed to ensure 3 outside Independent (Name) construction workers and 1 child who were unvaccinated were screened for signs and symptoms of Covid-19 and followed appropriate source control of facemask's when they entered the facility on 9/28/21 through a back door where the building was being refurbished, to prevent the spread of Covid-19.
On 9/28/21 at 10:45 a.m. a walk-through was conducted on Unit 4. Unit 4 was empty due to a facility refurbishment in progress. During the walk-through 3 construction workers and 1 child was observed on Unit 4. In the dining room two of the construction workers and the child were observed painting. The third construction worker was down the short hall installing ceiling tiles. All 4 individuals were observed without facemasks.
On 9/28/21 at 10:50 a.m., at the nurses station on the short hall a clipboard with Covid-19 sign in/out logs was found and reviewed for 9/28/21 screening entries. There were no entries for 9/28/21 on the Covid-19 screening logs and there was no thermometer with the logs either.
On 9/28/21 at 10:55 a.m., Construction worker #10 who was on the short hall was asked if he had completed the Covid-19 screening log when he entered the facility today. Construction worker #10 stated, No English. Construction worker #10 opened his phone, and was able to speak using a Spanish to English translator application. Construction worker #10 stated, No, didn't sign in yesterday or today, no ink. Construction worker #10 was asked if he had been vaccinated for Covid-19. Construction worker #10 stated, No vaccine.
On 9/28/21 at 11:05 a.m., Construction worker #11 and Construction worker #9 who were painting in the Unit 4 dining room with the child were asked if they had completed the Covid-19 screening log when they entered the facility today. Construction worker #9 stated, We forgot to sign in yesterday and today. We just came back yesterday, we haven't been in the building for 30 days. Construction worker #9 was asked if the 3 of them were vaccinated and if anyone in the facility had informed them that the building was experiencing a Covid -19 outbreak and that facemask's were required. Construction worker #9 stated, No one is vaccinated. We have masks but no one from the facility told us to wear the masks or anything about the covid.
On 9/28/21 at approximately 4:30 p.m., the Administrator, the Regional Director of Clinical Services and the Regional Director of Operations were made aware of the above observations. The Regional Director of Operations stated, All construction was supposed to be stopped at the end of August when the outbreak started. There should not be anyone back there at all.
On 9/29/21 at approximately 3:30 p.m., the Regional Director of Clinical Services stated, We have place signage at the side construction entrance of the facility indicating to vendors that the facility is in a Covid-19 outbreak status and visitation is restricted as of 7/28/21. Signage in Spanish was also placed on the construction door prohibiting entrance until further notice. The construction supervisor was notified a second time that all construction must stop and workers are not authorized to be in the building until further notice. Also the Administrator will walk the construction unit twice daily to assure workers do not enter.
The facility policy titled Novel Coronavirus Prevention and Response dated 3/2020 was reviewed and is documented in part, as follows:
Policy: The facility will respond promptly upon suspicion of illness associated with a novel coronavirus in efforts to identify, treat, and prevent the spread of the virus.
Policy Explanation and Compliance Guidelines:
5. Interventions to prevent the introduction of respiratory germs into the facility:
a. Post signs or posters at the entrance instructing visitors about wearing a cloth face covering or facemask. Restrict visitors in accordance with local, state, and national directives.
f. Assess visitors and healthcare personnel, regardless of vaccination status, for symptoms of Covid-19. This can include, but not limited to:
i. Individual screening on arrival at the facility.
ii. Implementation of an electronic monitoring system in which, prior to arrival at the facility, people report absence of fever and symptoms of Covid-19, absence of a diagnosis of Covid-19 infection in the prior 10 days, and confirmation they have not been exposed to others with Covid-19 infection during the prior 14 days.
On 9/30/21 at 6:42 p.m., a pre-exit debriefing was conducted with the Administrator, the acting Director of Nursing, the Regional Director of Clinical Services and the Regional Director of Operations, where the above information was shared. Prior to exit no further information was shared.
The following Immediate Jeopardy Abatement Plan for F-tag 880 signed by the Administrator on 09/30/21 was provided to the survey team:
1. Corrective Actions
A. The facility placed signage at the front entry door, dietary entrance door and, the side construction entrance indicating to staff, residents, visitors, and vendors that the facility is in a COVID-19 outbreak status and visitation is restricted on 9/28/2021. The signage (also in Spanish) for the construction door prohibits entrance until further notice. The construction supervisor was notified on 9/23/2021 and 9/27/2021 that all construction must stop, and workers are not authorized to be in the building until further notice. The Nursing Home Administrator/designee will walk the construction unit twice daily to assure workers do not enter.
B. The facility staff were provided additional and appropriate PPE for isolation units with enhanced droplet precautions on 9/24/2021. The Regional Director of Clinical Services (RDCS) made rounds and verified PPE was available and that staff were wearing PPE appropriately on 9/29/2021. Surgical masks are required when in the facility. Sign posted at doorway. Signage was posted throughout the facility for donning and doffing procedures, hand hygiene, and masking requirements on 9/25-9/26/2021. Education was provided to unit staff regarding PPE requirements beginning 9/24/2021 and will continue until all covid unit staff are being educated. Education will be completed by 10/1/2021.
C. Facility COVID-19 surveillance plan was updated 9/29/21 to accurately reflect the status of residents, staff, vendors, and contractors of the facility which includes vaccination status. Ongoing updates will be provided by the Infection Preventionist as vendors and contractors arrive. Vendors and contractors will be questioned prior to entrance regarding vaccination and testing status. Any person not able to provide proof of this information will be rapid tested upon entrance by the Infection Preventionist or assigned team member. Staff assigned to monitor the front entrance will be educated on the requirements to clarify covid vaccine and/or testing status.
D. Rooms 50-59 are designated as the quarantine unit. Residents have been moved to accommodate this change. Room changes are completed as of 9/30/2021 to create a 10 bed unit for quarantine. The Director of Nursing observed Unit 1 & 5 set up to assure it was in accordance with CDC and VDH Guidelines on 9/27/2021. Enhanced droplet precaution signs were placed on each resident room door and doors were closed on 9/27/2021. Clean and soiled areas were reestablished to separate and identify the two areas more clearly. All covid positive residents were re-established to separate and identify the two areas more clearly. All covid positive residents on Unit 5 have been resolved. Precautions for these residents have been discontinued on 9/27/2021. Dementia residents with a covid positive status will isolate in place. They will be provided increased supervision that will ensure transmission-based precautions are maintained in their current setting to decrease episodes of increased behaviors.
The survey team validated the plan of removal through observations, interviews and review of facility documents and the Immediate Jeopardy was removed on 9/30/21 at 4:25 p.m. The deficient practice was decreased to an F (potential for more than minimal consequence).
Based on observations, resident interviews and staff interviews on all four resident living areas, and review of facility documentation, the facility's staff failed to follow Centers for Disease Control and Prevention (CDC) guidance to establish an infection control program to ensure SARS-CoV-2 infection control measures/practices were in place during a major SARS-CoV-2 outbreak and to prevent further transmission, severe infections, hospitalizations and deaths which constituted immediate jeopardy at F880 (L) in the following specific areas:
The facility failed to provide accurate documentation of their COVID-19 surveillance and data analysis including line listings of infections and vaccination status of resident and HCP; which was necessary for early detection to enable a response to a SARS-CoV-2 outbreak and to report SARS-CoV-2 infections information to Public Health Authorities.
The facility failed to post visual signs at the entrance and/or in strategic places with instructions about current Infection Prevention Control recommendations related to SARS-CoV-2.
The facility failed to adhere to the CDC recommended screening process to identify anyone entering the facility who was positive for SARS-CoV-2 or with symptoms of COVID-19.
The facility failed to quarantine residents with suspected or confirmed SARS-CoV-2 infection including new admissions and re-admissions during an outbreak for 6 residents (Resident #21, #73, #90, #53, #16, and #65) of 42 residents in the survey sample.
The facility staff failed to ensure facemasks were well-fitting and worn to cover the nose and mouth, and ensure that HCP caring for SARS-CoV-2 positive residents are using full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator).
On 9/23/21 at 8:37 p.m., the facility Administrator, Director of Nursing and three Corporate Consultants were informed that the above non-compliance constituted Immediate Jeopardy at F-880; Infection Prevention and Control Program secondary to an outbreak of SARS-CoV-2 infections within the facility at a scope and severity level 4 widespread (L) which constituted Substandard Quality of Care.
The survey team validated the plan of removal through observations, interviews and review of facility documents and the Immediate Jeopardy was removed on 9/30/21 at 4:25 p.m. The deficient practice was decreased to an F (potential for more than minimal consequence).
The facility's final cumulative of data provided on 9/30/21 disclosed from 8/28/21 through 9/30/21; there were fifty-three SARS-CoV-2 positive residents, nineteen were hospitalized , one remained in the hospital and nine died. The cumulative of SARS-CoV-2 positive staff was six, one staff was hospitalized and died, four staff returned to work and no staff was still in quarantine. The facility stated they felt this was accurate but was unable to attest it was one hundred percent accurate.
The findings included:
1A. The facility staff failed to provide accurate documentation of their COVID-19 surveillance and data analysis including line listings of infections and vaccination status of resident and HCP; which was necessary for early detection to enable a response to a SARS-CoV-2 outbreak.
Multiple times on 9/21/21 interviews were attempted with the Infection Preventionist (IP) to review the line listing of SARS-CoV-2 cases in the facility including residents and staff. Each time the IP would leave for she desired to review the documents on her computer. Even after bringing in the computer to review the line listing she was unable to definitely provide the requested numbers. She stated the cases are not adding up correctly. The IP stated the outbreak began 8/28/21 when an alert and oriented resident (Resident #90) tested positive after a Rapid test. She was not certain of the symptoms the resident presented with prior to the test but she stated the resident was symptomatic and a PCR test was performed as a result of the positive Rapid test. The PCR test results were also positive.
Another interview was attempted with the IP on 9/22/21 at approximately 10:10 a.m., to obtain a cumulative of SARS-CoV-2 cases since the beginning of the pandemic was requested as well as the number of cases in-house on 9/20/21, when the survey team entered the facility. The IP stated she thought there were 36 in-house cases on 9/20/21 but the numbers still weren't adding up therefore; she needed to review the line listing to get an official count. The IP was also asked to provide the number of hospitalized residents/staff, number of deceased residents/staff, and the number/name of residents/staff who were vaccinated.
On 9/22/21 at approximately 3:15 p.m., the IP stated she believed there were 19 SARS-CoV-2 cases in the facility when the survey team arrived on 9/20/21 but she still wasn't sure of the cumulative since the pandemic began. At approximately 4:15 p.m., the Regional Clinical Reimbursement Consultant (RCRC) stated the IP wasn't able to assist further with the SARS-CoV-2 statistics because she would be rendering direct care therefore; she would be calculating the numbers.
On 9/24/21 at approximately 11:20 a.m., the RCRC provided the following numbers as an accurate cumulative of the facility SARS-CoV-2 cases and the disposition of the affected residents/staff. The cumulative of Residents who tested positive for SARS-CoV-2 was forty-eight. Seven of the forty-eight resident died including one in the facility, seventeen of the cumulative residents were admitted to the hospital, three of the cumulative residents remained in the hospital and thirty-six of the cumulative residents were quarantined in the facility. The cumulative of staff who tested positive for SARS-CoV-2 was eight, one staff died, one staff was hospitalized , no staff remained in the hospital, one staff remained quarantined and six staff had returned to work.
On 9/30/21 at approximately 3:15 p.m., the facility stated they had made additional changes to the cumulative number of residents and staff to account for all affected since the outbreak beginning 8/28/21. The cumulative of SARS-CoV-2 positive residents was fifty-three, nineteen were hospitalized , one remained in the hospital and nine died. Six new resident cases were identified 9/27/21 - 9/29/21. The cumulative of SARS-CoV-2 positive staff was six, one staff was hospitalized and died, four staff returned to work and no staff were still in quarantine.
Three pages of emails were provided to the survey team along with documentation of the cumulative data and line listings. An email dated 9/7/21 at 6:02 a.m., stated; we have eight more staff and two staff members who tested positive for SARS-CoV-2. At 7:47 a.m., an email read; another one just tested positive. Its nine now. Another email dated 9/8/21 read; we have two more residents who tested positive for COVID today. An email dated 9/9/21 read; we have two COVID positive residents who expired at the hospital. We also have some new residents who tested positive. I will send an updated line listing later this evening. Another email dated 9/9/21 at 6:04 p.m. read; Attached is a copy of the COVID-19 line list. It seems like 75% of my September positives are residents who are vaccinated. On 9/13/20 an email read A COVID positive staff death at (name of the facility). Have you done the Occupational Safety and Health Administration investigation to determine work relatedness? We need to document thoroughly.
B. The facility staff failed to report SARS-CoV-2 infections information to Public Health Authorities.
The three pages of email chains above revealed the facility staff had a situation too overwhelming for then to manage, yet they failed to notify the health department promptly of the first positive case of SARS-CoV-2, each suspected or confirmed SARS-CoV-2 infection and of additional cases, including residents with severe respiratory infection resulting in hospitalization or death, three residents or HCP with acute illness compatible with COVID-19 with onset within a 72-hour period.An interview was conducted with the Infection Preventionist on 9/24/21 at approximately 3:20 p.m. The Infection Preventionist stated she had not contacted the local Health Department and/or the Epidemiologist in reference to the facility's outbreak or to ask for assistance in managing their rapid increasing number of SARS-CoV-2 positive cases. The Infection Preventionist further stated approximately one week ago the Local Health Department came in on their own to conduct a site visit and offer assistance.
2. The facility failure to post visual signs at the entrance and/or in strategic places with instructions about current Infection Prevention Control recommendations related to SARS-CoV-2.
On 9/20/21 at approximately 7:05 p.m., upon arriving to the facility the only signage at the visitor's entrance read face mask required at all times. This signage was located to the sides of the door and at a low position. There was no entrance door signage with clear information/alerts to visitors. Review of other visitor entrances (kitchen, construction unit and the laundry door connecting with Unit 1) also disclosed no signage.
CDC had recommended that long term care facilities developed a written COVID-19 plan which included; Facilities should encourage visitors to be aware of signs and symptoms of acute respiratory illness consistent with COVID-19 and not enter the facility if they have such signs and symptoms. Visual alerts, such as signs and posters, should be placed at facility entrances and other strategic areas instructing visitors not to enter as a visitor if they have fever or respiratory symptoms. Signage should include signs and symptoms of COVID-19 and who to notify if visitors/staff/vendors have symptoms. (https://www.cdc.gov/coronavirus/2019-ncov/hcp/non-us-settings/hcf-visitors.html).
3. The facility staff further failed to adhere to the CDC recommended screening process to identify anyone entering the facility who was positive for SARS-CoV-2 or with symptoms of COVID-19.
On 9/20/21 at approximately 7:05 p.m., after ringing the doorbell the survey team was allowed to enter the first set of doors where visitors and staff were screened. The staff member stated screening was a self-performed task but assisted us to obtain our temperatures.
After multiple days of reviewing the screening logs the team was unable to account for many on duty staff therefore a review of the screening logs for 9/12/21 - 9/13/21 were reviewed with the staffing coordinator on 9/23/21. The review of 9/12/21 confirmed eleven direct care staff were not signed in as screened. The review of 9/13/21 confirmed there were seven direct care staff who did not sign in as screened. On 9/12/21 - 9/13/21 many support staff wasn't verified. Another screening review was conducted of the facility's personnel on duty 9/20/21. The review disclosed seven direct care staff and eleven support staff had not signed in as screened. Many of the facility Healthcare Personnel (HCP) were foregoing the screening process by entering and exiting the facility through various doors. The outcome of foregoing the screening resulted in a breach in the infection prevention and control (IPC) protocol as evidenced by continuous newly diagnosed residents with SARS-CoV-2 infections, some resulting in hospitalizations and/or death. After this was brought to the facility staff attention on 9/23/21, staff was assigned to carryout screening.
According to the April 27, 2021, Centers for Medicare and Medicaid Services (CMS) Memo QSO20-39-NH, Guidance for Infection Control and Prevention of COVID-19, nursing homes should follow the Core Principles of COVID-19 Infection Prevention. One of the Core Principles read; Screening of all who enter the facility for signs and symptoms of COVID-19 (e.g., temperature checks, questions about and observations of signs or symptoms), and denial of entry of those with signs or symptoms or those who have had close contact with someone with COVID-19 infection in the prior 14 days (regardless of the visitor's vaccination status). HCP should not work while acutely ill, even if SARS-CoV-2 testing is negative, in order to minimize the risk of transmission of other infectious pathogens, including respiratory pathogens such as influenza. All visitors should sign in and out on a visitor's log.
4. The facility staff failed to manage residents with suspected or confirmed SARS-CoV-2 infection including new admissions and re-admissions during an outbreak, and to manage staffing of HCP who worked a COVID positive unit and immediately afterward worked a Well unit.
A. On 9/28/21 at approximately 4:00 p.m., a review of resident readmissions/admission was conducted with the DON. The DON stated Resident #21 was readmitted to the facility from the hospital 9/1/21 with a diagnosis of sepsis related to a urinary tract infection and the resident tested negative for SARS-CoV-2 prior to leaving the hospital. The DON stated they elected not to quarantine Resident #21 an unvaccinated resident, after an eight day hospital stay because of the negative SARS-CoV-2 test and for resident safety related to impaired cognition, gait problems and behaviors. Resident #21 was re-admitted to the Memory Unit. The DON further stated they didn't have a quarantine unit for residents who resided on the Memory Unit.
B. On 9/23/21 at approximately 8:30 a.m., Resident #73 was observed sitting in a wheelchair in his doorway.
Resident #73 was originally admitted to the facility 8/24/21 and had never been discharged from the facility. The current diagnoses included; diabetes and high blood pressure.
The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/31/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #73's cognitive abilities for daily decision making were intact.
The resident stated he was moving off the COVID-19 positive unit that day. Resident #73 stated he was vaccinated and had never tested positive for SARS-CoV-2. The resident further stated he was admitted to the room in August and he was told 9/22/21 that he no longer needed to quarantine and he would be moved. Review of the resident's clinical record revealed he was admitted to the facility 8/24/21. Resident #73 a fully vaccinated had resided on a COVID-19 positive unit from 8/28/21 - 9/22/21.
On 9/28/21 at approximately 4:00 p.m., a review of Resident #73's admission was conducted with the Director of Nursing (DON). The DON stated Resident #73 was admitted to the room on the Admitting Unit prior to the outbreak of SARS-CoV-2 cases and he remained there to complete his period of quarantine.
On day one of the survey, the survey team made observations to determine how the facility was managing admissions/re-admission of residents. Designated rooms for quarantine were not identified for residents returning to the facility after hospitalization or for pending and newly confirmed positive resident within the facility. On 9/29/21 at approximately 1:55 p.m., the survey team addressed this concern with the facility's team including five corporate consultants. Corporate Consultant #4 stated there was a designated quarantine unit and ask what happened to it. The Administrator stated the positive cases resulted in them outgrowing the COVID-19 positive unit therefore; they didn't have quarantine rooms and new admissions would not be accepted because of the vast number of SARS-CoV-2 positive cases.
An email dated 8/28/21 in reference to the first positive resident case of SARS-CoV-2 read; do you have a COVID unit set up? What will you do if the PCR is positive? Please let us know the results when you know them.
The facility COVID-19 Action Plan dated 7/30/21, read there would be three units set-up for the resident population in accordance with CDC Guidelines. The Units were described as a Well/Cool Unit, a Quarantine/Warm Unit for new admission and readmissions and an Isolation/Hot Unit for COVID-19 positive residents. The facility only had one general well unit, one well memory unit, one COVID-19 positive memory unit and one full COVID-19 positive unit. Facilities should create a plan for managing new admissions and readmissions. In general, all new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission. Exceptions include residents within 3 months of a SARS-CoV-2 infection and fully vaccinated residents. (https://www.vdh.virginia.gov/content/uploads/sites/182/2020/10/VDH-COVID-19-Guidance-for-Nursing-Homes.pdf)
C. Resident #90 was originally admitted to the facility 5/14/19 and readmitted [DATE] after an acute care hospital stay, returning to the facility 9/9/21. The current diagnoses included; SARS-CoV-2 infection and Multiple Sclerosis.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/16/21 coded the resident as not completing the Brief Interview for Mental Status (BIMS). The staff interview was coded for intact long and short term memory as well as modified independence with daily decision making.
A physician's progress note dated 9/3/21 at 10:15 a.m., read; Evaluation following positive COVID-19 test. Resident #90 is seen today for follow-up after a positive COVID-19 test. The resident is currently symptomatic with low grade fevers, positive for Shortness of Breath/Cough, Oxygen saturation at 85% on Room Air. Chest X-Ray shows a Left Lower Lobe pneumonia. Facility unable to obtain the monoclonal antibody infusion from Maryland. Advised nursing to send to Emergency Department for infusion. Resident was subsequently admitted for COVID-19 pneumonia. The resident was readmitted to the facility 9/9/21.
Upon entering Resident # 90's room on 9/23/21 at approximately 9:45 a.m., a sheet was observed on the floor and on top of the sheet were elimination saturated towels, a gown and used gloves. Resident #90; a SARS-CoV-2 infected resident; was in bed uncovered and without clothing. The resident stated he no longer felt sick and presented without shortness of breath, cough, diaphoresis or fatigue. Shortly afterwards the wound care Nurse Practitioner and LPN #3 entered the resident's room to assess the resident's impaired skin. After the wound care Nurse Practitioner completed her assessment she stepped on the sheet and soiled linen, proceeded out the room and off the unit with the same dirty shoe protectors on.
D. Observation of multiple resident room on the COVID-19 positive unit revealed no trash bags in the trash cans in most rooms, the hallway was with dried brownish spill areas, paper, used gloves and other debris. There were no clean gowns on the unit to be utilized by the staff, the clean linen cart cover was up exposing all the linen and stacks of what appeared to be clean linen was observed in chairs and sitting on top of furniture in rooms in approximately five rooms.
An interview was conducted with the DON on the COVID-19 positive unit on 9/23/21 at approximately 10:05 a.m. The DON stated she didn't agree with the manner the staff allowed Resident #90 to handle his soiled linen but it was the practice. The DON also stated she would have Environmental Services to come immediately to clean the unit and add liners to the trash cans. As the DON walked the hallway she instructed staff to cover the clean linen and remove linen from resident rooms.
E. Review of staff scheduling revealed on 9/24/21, LPN #7 worked a COVID-19 positive Unit from 11:00 - 7:30 a.m., afterwards working from 7:30 a.m. - 3:30 p.m., on a Well Unit. An interview was conducted with LPN #7 on 9/26/21 at approximately 10:25 a.m. LPN #7 stated she knew it appeared she hadn't been home but she works sixteen hours most days on the same unit and is off for eight hours. LPN #7 didn't say anything about working a positive unit before working a negative unit.
The facility COVID-19 Action Plan update 7/30/21 read; Staff have been assigned to work only on COVID or quarantined or non-affected units/wings/rooms. Staff assignments are documented and time reconciled daily.
An interview was conducted with the DON on 9/28/21 at approximately 4:45 p.m. The DON stated staff are scheduled to remain on the COVID positive unit if they worked the COVID positive unit their first shift and they are working a double shift. She further stated if a staff worked the Well unit the first shift they may work the COVID positive unit the second shift.
An interview was conducted with the Medical Director on 9/28/21 at 11:20 a.m. The Medical Director stated the facility staff informed him of the Immediate Jeopardy status on 9/24/21 and they conducted a Quality Assurance meeting 9/26/21 to discuss the SARS-CoV-2 status and means to improve infection control practices in the facility. The Medical Director stated he was aware of the outbreak but he wasn't aware of the cumulative data since the outbreak occurred. He assured us he was notified of cases as they occur but not as cumulative data. The Medical Director stated SARS-CoV-2 infections can be deadly and following CDC guidelines we[TRUNCATED]
CRITICAL
(L)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0886
(Tag F0886)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The facility staff failed to ensure that 3 Independent Contracted Construction Workers and 1 child who were observed on Unit ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. The facility staff failed to ensure that 3 Independent Contracted Construction Workers and 1 child who were observed on Unit 4 on [DATE] working, who admitted to working in the building on [DATE] and 30 days prior were tested for Covid-19 based on the facility's testing frequency to coincide with the level of community transmission (HIGH/RED) twice a week.
On [DATE] at 10:45 a.m. a walk-through was conducted on Unit 4. Unit 4 was empty due to a facility refurbishment in progress. During the walk-through 3 construction workers and 1 child was observed on Unit 4. In the dining room two of the construction workers and the child were observed painting. The third construction worker was down the short hall installing ceiling tiles. All 4 individuals were observed without facemasks.
On [DATE] at 10:55 a.m., Construction Worker #10 who was on the short hall was asked if he had ever been tested for Covid-19 by anyone at the facility. Construction Worker #10 stated, No English. Construction Worker #10 opened his phone, and was able to speak using a Spanish to English translator application. Construction Worker #10 stated, No tested, no vaccine.
On [DATE] at 11:05 a.m., Construction Worker #11 and Construction Worker #9 who were painting in the Unit 4 dining room with the child were asked if they had completed the Covid-19 screening log when they entered the facility today. Construction Worker #9 stated, We forgot to sign in yesterday and today. We just came back yesterday, we haven't been in the building for 30 days. Construction Worker #9 was asked if the 3 of them were vaccinated and if anyone in the facility had informed them that the building was experiencing a Covid -19 outbreak and that facemask's were required. Construction Worker #9 stated, No one is vaccinated. We have masks but no one from the facility told us to wear the masks or anything about the covid. Construction Worker #9 was asked if anyone in the facility had ever tested them for Covid-10. Construction Worker #9 stated, No, we have not been tested.
On [DATE] at approximately 1:30 p.m., the Infection Preventionist was asked if she has any documentation to show that the 3 construction workers or the 1 child had been tested when they were in the facility 30 days ago or any results that they had been tested on [DATE] or [DATE] prior to working. The Infection Preventionist was unable to provide the information that was requested.
On [DATE] at approximately 4:30 p.m., the Administrator, the Regional Director of Clinical Services and the Regional Director of Operations were made aware of the above observations. The Regional Director of Operations stated, All construction was supposed to be stopped at the end of August when the outbreak started. There should not be anyone back there at all.
On [DATE] at approximately 3:30 p.m., the Regional Director of Clinical Services stated, We have place signage at the side construction entrance of the facility indicating to vendors that the facility is in a Covid-19 outbreak status and visitation is restricted as of [DATE]. Signage in Spanish was also placed on the construction door prohibiting entrance until further notice. The construction supervisor was notified a second time that all construction must stop and workers are not authorized to be in the building until further notice. Also the Administrator will walk the construction unit twice daily to assure workers do not enter. The Regional Director of Operations stated, Beginning [DATE] all staff including contracted employees and vendors reporting to work will be required to submit to routine testing per community transmission rates, provide proof of recent testing (within 3 days), provide proof of vaccination status, or get tested on their scheduled shift.
The facility policy titled Novel Coronavirus Prevention and Response dated 3/2020 was reviewed and is documented in part, as follows:
Policy: The facility will respond promptly upon suspicion of illness associated with a novel coronavirus in efforts to identify, treat, and prevent the spread of the virus.
Policy Explanation and Compliance Guidelines:
4. Considerations/priorities for testing.
c. Testing for COVID-19 will occur for staff or residents with signs and symptoms of COVID-19, outbreaks within the facility and routinely following the frequency guidance according to the facility's level of community transmission.
On [DATE] at 6:42 p.m., a pre-exit debriefing was conducted with the Administrator, the acting Director of Nursing, the Regional Director of Clinical Services and the Regional Director of Operations, where the above information was shared. Prior to exit no further information was shared.
An Immediate Jeopardy Abatement Plan for F-tag 886 signed by the Administrator on [DATE] was provided to the survey team.
1. The facility performed staff testing of scheduled employees and agency staff [DATE]-[DATE]. It was discovered that two unvaccinated dietary staff members did not follow policy for testing and screening and worked on [DATE]. Both employees had received education on [DATE] and one employee received an additional test reminder on [DATE] by the regional director of dining services. Both employees were subsequently tested on [DATE] with negative results. Reeducation on policy for testing and screening was provided to dietary staff members on [DATE]. All staff including contracted employees and vendors reporting to work as of [DATE] will be required to submit to routine testing per community transmission rates, provide proof of recent testing (within 3 days), provide proof of vaccination status, or get tested on their scheduled shift. Per CMS guidelines, vaccinated staff members will not be required to submit to routine testing.
2. There was a cumulative total of 53 resident who have tested positive for Covid-19. 9 residents died, 1 died while still at the facility. 19 residents were hospitalized . 1 resident remains hospitalized . 6 staff tested positive for Covid-19. 1 staff member was hospitalized and passed. 4 staff have returned to work, none are on quarantine. Residents on this list who remain in the facility will continue to be monitored and treated under current COVID protocols until their cases have resolved. The center conducted facility wide rapid testing of negative residents [DATE] -[DATE] and six new resident cases were identified. All six residents currently reside on the COVID unit. All residents of the facility have the potential to be affected by the this practice.
3. Staff education was provided on [DATE] to employees in the following departments; nursing, environmental services, dietary, maintenance, and administrative staff. Staff education included CMS guidelines regarding frequency of testing for unvaccinated employees based on level of community transmission. Beginning [DATE] no employees will be allowed to return to work until the training has been completed. Training will be provided by the SDC in person or by phone. Staffing coordinator will ensure proof of vaccination status or a recent negative test (within three days) for all agency employees prior to scheduling them to work. Unvaccinated agency staff who have not had a recent test must be tested on their scheduled shift in order to be able to work. Scheduled staff testing will be held Monday and Thursday, however a nurse will be assigned to conduct testing seven days a week for all staff in order to remain in compliance with the testing guidelines. The frequency of scheduled staff will be adjusted to reflect current community transmission rates.
4. Beginning [DATE] staff testing and results for unvaccinated employees will be tracked on COVID testing log. Infection preventionist will provide a weekly updated vaccinated staff list to Administrator or designee who will audit testing log 3 x per week for 8 weeks to ensure all unvaccinated facility staff and unvaccinated contracted staff are in compliance with routine testing according to community transmission rates. Any identified concerns will be immediately corrected. Additional education and disciplinary actions will be taken as appropriate. Results of audits will be summarized and submitted by the Nursing Home Administrator to the QAPI committee for oversight and additional recommendations to this plan. The next QAPI meeting is scheduled for [DATE] and will continue monthly x 6 months to assure ongoing compliance.
5. Medical Director was notified on [DATE] of the Immediate Jeopardy status of the facility and actions taken to abate. The facility conducted an AdHoc QAPI meeting on [DATE] reviewing and approving the Allegation of Compliance and corrective actions.
Facility alleges compliance as of [DATE], signed by the Administrator.
The survey team validated the plan of removal through observations, interviews and review of facility documents and the Immediate Jeopardy was removed on [DATE] at 4:25 p.m. The deficient practice was decreased to an F (Potential for more than minimal consequence).
Based on observations, resident interviews, staff interviews and review of facility documentation, the facility's staff failed to adhere to the following Centers for Disease Control and Prevention (CDC) guidance to have an established and effective COVID-19 testing program in place during a major SARS-CoV-2 outbreak and to prevent further transmission, severe infections, hospitalizations and deaths which constituted Immediate Jeapardy at a scope and severity level of 4 widespread (L):
The facility failed to ascertain the vaccination status of all Healthcare Personnel (HCP) to determine who was unvaccinated and required expanded screening testing and the facility failed to conduct unvaccinated HCP testing for SARS-CoV-2 infection based on the level of community transmission (high/Red). The facility was broad based testing two times a week.
The facility failed to have documentation that the required testing of the results of unvaccinated HCP including contractors, agencies and vendors was completed and corresponded to the facility's testing frequency.
On [DATE] at 8:37 p.m., the facility Administrator, Director of Nursing and three Corporate Consultants were informed of the above Immediate Jeopardy concerns at F-886; COVID-19 Testing; during an outbreak of SARS-CoV-2 infections within the facility which was cited at a scope and severity level of 4 widespread (L) which constituted Substandard Quality of Care.
The survey team validated the plan of removal through observations, interviews and review of facility documents and the Immediate Jeopardy was removed on [DATE] at 4:25 p.m. The deficient practice was decreased to an F (potential for more than minimum consequence).
During this non-compliance the facility was subject to a major SARS-CoV-2 outbreak with increased transmission of COVID-19, hospitalizations and death. The following cumulative data was provided by the facility on [DATE]. From [DATE] to [DATE], there were fifty-three SARS-CoV-2 positive residents, nineteen were hospitalized , one remained in the hospital and nine died. The cumulative of SARS-CoV-2 positive staff was six, one staff was hospitalized and died, four staff returned to work and no staff was still in quarantine. The facility stated they felt this was accurate but was unable to attest it was one hundred percent accurate.
The findings included:
1. The facility failed to ascertain the vaccination status of all Healthcare Personnel (HCP) to determine who was unvaccinated and required expanded screening testing and the facility failed to conduct unvaccinated HCP testing for SARS-CoV-2 infection based on the level of community transmission.
Interviews with many of the HCP revealed based on CDC guidelines they met the requirements to be tested (they were unvaccinated) but were not tested based on the level of community transmission for they lacked knowledge related to the testing requirements.
On [DATE], the level of community transmission was reviewed for the facility's city's level data. The level was HIGH and the community had been at that level during our review period of [DATE] - [DATE]. The guidance stated when the level of community transmission is HIGH unvaccinated staff must be tested two times each week.
Many of the facility HCP interviewed [DATE] - [DATE] stated they were unvaccinated and had not tested two times per week from [DATE] - [DATE] for various reasons (specifics for each individual).
An interview was conducted with Certified Nursing Assistant (CNA) #4 on [DATE] at 2:27 p.m., CNA #4 stated she was unvaccinated, had never tested positive for SARS-CoV-2 and she usually tested approximately one time each week.
An interview was conducted with Physical Therapist Assistant (PTA) #4 on [DATE] at 2:33 p.m., PTA #2 stated she was unvaccinated, had never tested positive for SARS-CoV-2 and she had not recently tested but she only worked at the facility as needed.
An interview was conducted with Certified Nursing Assistant (CNA) #6 on [DATE] at 10:00 a.m., CNA #6 stated she was unvaccinated, had never tested positive for SARS-CoV-2 and she usually test approximately one time each week. CNA #6 stated she thinks she was lasted tested [DATE] by the IP.
An interview was conducted with Dietary staff #15 on [DATE] at approximately 12:20 p.m., Dietary staff #15 stated she was unvaccinated, had never tested positive for SARS-CoV-2 and was last tested approximately one week ago because the facility administration doesn't want them walking through the building to get tested.
An interview was conducted with LPN #11 on [DATE] at 10:04 a.m., LPN #11 stated she was unvaccinated, had never tested positive for SARS-CoV-2 and she usually tested on e to two time each week and she was lasted [DATE] at a CVS pharmacy and prior to that [DATE] but no one at the facility had ever asked her to provide documentation of testing.
An interview was conducted with Certified Nursing Assistant (CNA) #13 on [DATE] at 10:19 a.m., CNA #13 stated she was unvaccinated, had tested positive for SARS-CoV-2 February 2021 and she tested [DATE] and prior to that she hadn't tested for over a week.
An interview was conducted with LPN #10 on [DATE] at 10:27 a.m., LPN #10 stated she was unvaccinated, had never tested positive for SARS-CoV-2 and she was last tested approximately [DATE] and hadn't tested since then.
An interview was conducted with Certified Nursing Assistant (CNA) #8 on [DATE] at 10:30 a.m., CNA #8 stated she was unvaccinated, had never tested positive for SARS-CoV-2 and she was tested [DATE] when she arrived for her shift but prior to that she hadn't been tested since approximately [DATE].
An interview was conducted with Dietary staff #20 on [DATE] at approximately 10:55 a.m. The Dietary staff #20 stated she was unvaccinated, had tested positive for SARS-CoV-2, [DATE] and was last tested approximately six weeks ago for another.
Dietary staff #20 stated the facility had never asked about the vaccination or requested testing status.
An interview was conducted with Dietary staff #19 on [DATE] at approximately 11:05 a.m. The Dietary staff #19 stated she was unvaccinated, had never tested positive for SARS-CoV-2 and was last tested approximately two weeks ago for another entity. Dietary staff #19 stated the facility had never asked about her vaccination or requested testing status.
2. The facility failed to have documentation that the required testing of the results of unvaccinated HCP was completed and corresponded to the facility's testing frequency.
On [DATE] at approximately 10:25 a.m., HCP testing was observed and the documentation of the testing was reviewed. A review of those listed as tested revealed the HCP name/signature only, no documentation of their test results.
An interview was conducted with the Infection Preventionist (IP) on [DATE] at approximately 3:20 p.m., the Infection Preventionist stated testing for HCP was two times weekly (Tuesday and Thursday) based on the level of community transmission and that an undocumented test result indicated the result was negative. The tested HCP results for [DATE] remained undocumented throughout the survey.
During an interview with the IP on [DATE] at approximately 3:20 p.m., the IP stated all staff testing isn't documented because the licensed nurses who performs the testing often test direct care HCP during their shift and solely provide the HCP with the result. The IP had no documentation indicating which HCP should have been tested, if they had been tested based on the level of community transmission from [DATE] - [DATE], or documentation the testing was completed along with the results. The IP stated she never followed-up with the licensed nurses to gleam information of HCP testing and results except if a staff member tested positive.
An interview was conducted with Licensed Practical Nurse (LPN) #3 on [DATE] at 12:04 p.m., LPN #3 stated the Rapid test (The BinaxNOW COVID-19 Ag Card) are used for staff testing and if there is a positive result it is followed-up with a polymerase chain reaction (PCR) test. LPN #3 also stated that the current practice for staff testing is to delegate it to licensed nurses on various shifts and only the Director of Nursing and IP knows where the results are documented for the prior system of documentation was discontinued for the computerized line listing method.
On [DATE] at approximately 6:30 p.m., the above information was reviewed with the Administrator, Interim Director of Nursing, and Regional Director of Operations, Regional Reimbursement Consultant and the Regional Director of Clinical Services. The Regional Director of Operations stated beginning [DATE] staff testing and results of unvaccinated employees will be tracked on COVID testing logs. The IP will provide a weekly updated vaccination list to the Administrator/designee who will audit testing three times each week for eight weeks to ensure all unvaccinated staff are in compliance with routine testing according to the level of community transmission
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to notify the resident representative of a significant weight loss for Resident #22 in the survey s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to notify the resident representative of a significant weight loss for Resident #22 in the survey sample.
Resident #22 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Diagnosis for Resident #22 included but not limited Unspecified Dementia with Behavioral Disturbance and Major Depressive Disorder.
The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 07/17/21 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS).
In section G(Physical functioning) the resident was coded as extensive assistance of one person with bed mobility, dressing and locomotion on and off the unit. Requiring extensive assistance of two persons transfers. Requiring supervision set-up help with eating and requiring totals dependence of one person with toileting, personal hygiene and bathing.
The Care Plan dated 5/23/21 reads: FOCUS: The resident has nutritional problems or potential nutritional problems r/t Diet restrictions, mechanically altered diet, weight loss. Goals: The resident will tolerate diet and have no significant gain/loss through review date. Interventions: Observe/report to MD (Medical Doctor) PRN (as needed) s/sx (signs and symptoms) of malnutrition: Emaciation, muscle wasting, significant weight loss: 3lbs in 1 week, greater than 5% in 1 month, greater than 7.5% in 3 months, greater than 10% in 6 months.
MAR (Medication Administration Record) reads: weekly weights one time a day every Wed -Start Date 10/14/2020 at 9:00 AM.
MAR (11/2020). Weights not recorded.
MAR (12/2020) Weights not recorded.
The following weights were recorded in the clinical record under weights. 10/7/2020 152.8 1bs.
11/15/20 135 lbs.
12/03/20 135.2 lbs.
12/8/21 135.2 lbs.
The above recorded weights were not consistent with the ordered weekly weights).
A review of resident's weight from October 7, 2020 (152.8 lbs) to November 15, 2020 (135.0 lbs.) Resident has lost 17.8 lbs.
According to the complainant the resident had a significant amount of weight loss. The weekly ordered weights were not consistent from 10/07/20-11/15/20 Resident lost 17.8 lbs.
A review of clinical progress notes show no documentation proving the POA (Power of Attorney) or family member were notified of the 17.8 lbs. weight loss.
Review of progress note dated on 11/20/2020 at 9:43 AM from NP (Nurse Practitioner) reads: CC: Weight loss. This is an [AGE] year old who is residing on Memory Unit for LTC (Long Term Care). She was seen recently due to report of abnormal weight loss and poor appetite. Her weight is down to 135# this month, 152.8 # in October. She is seen today to follow up on lab results.
A review of progress notes dated 11/18/2020 13:09 (1:09 PM). Progress Notes reads: CC: Weight loss. She is seen today due to report of abnormal weight loss. Her weight is down to 135# this month, 152.8 # in October. Staff report poor intake, about 25% at meals. No report of diarrhea or GI symptoms. She is a poor historian due to dementia. She says she is alright and denies pain or difficulty breathing. She is c/o feeling cold. Weight loss: possible etiologies-thyroid dysfunction, progressing dementia, or depression. Start Eldertonic 15 ml BID. Monitor weight. Weight warning trigger: 11/16/2020 15:31 Nutrition Note Text: WEIGHT WARNING: 135 lbs.
A review of Progress notes dated 11/15/2020 read: RD (Registered Dietician) weight review; resident displays significant weight loss; Re-weigh to verify weight; weekly weights x 1 mo, RD to f/u PRN; RDN.
A review of the clinical record dated 11/24/2020 at approximately 9:27 AM reveal that Resident's daughter spoke to staff about concerns about her mother's/resident's condition days after she was noted to have significant weight loss.
On 9/23/21 at approximately 2:00 PM an interview was conducted with the District Dietary Manager/OSM (Other Staff Member) #6. He stated, A lot of it has to do with her decline with dementia. Her weight has been stable through 6 months. They had a staff member not putting down the proper weights. We found out that she wasn't weighing the resident. Nursing should notify the family of weight loss issues. Quarterly nutrition report completed.
On 9/23/21 at approximately 12:10 PM an interview was conducted with resident's daughter. She stated, We received no calls about her weight loss or her not being able to walk. I spoke to the DON (Director of Nursing) and explained the weight concern she stated they would call me every Monday with weights.
On 9/23/21 at approximately 12:00 PM a telephone interview was conducted with the Registered Dietician/OSM #2 concerning Resident # 22. She stated, The weights aren't consistent especially since COVID19. I brought it up a few times with the dietary managers. They had gotten better since the new DON came. Mostly from staff shortage. In my note she stabilized (weight) and was at a relative stable weight. I recommended fortified foods because sometimes her po (by mouth) intake is poor. She's now on weekly weights. She was on Remeron for a while for her appetite. House shakes 3 times a day. I also recommended they give her calorie dense snacks. Usually the DON's would call the family members.
On 9/23/21 at approximately 2:00 PM an interview was conducted with the District Dietary Manager/OSM (Other Staff Member) #6. He stated, A lot of it has to do with her decline with dementia. Her weight has been stable through 6 months. They had a staff member not putting down the proper weights. We found out that she wasn ' t weighing the resident. Nursing should notify the family of weight loss issues. Quarterly nutrition report completed.
On 9/23/21 at approximately 12:10 PM an interview was conducted with resident ' s daughter. She stated, We received no calls about her weight loss or her not being able to walk. I spoke to the DON (Director of Nursing) and explained the weight concern she stated they would call me every Monday with weights.
On 9/23/21 at approximately 12:00 PM a telephone interview was conducted with the Registered Dietician/OSM #2 concerning Resident # 22. She stated, The weights aren't consistent especially since COVID19. I brought it up a few times with the dietary managers. They had gotten better since the new DON came. Mostly from staff shortage. In my note she stabilized (weight) and was at a relative stable weight. I recommended fortified foods because sometimes her po (by mouth) intake is poor. She's now on weekly weights. She was on Remeron for a while for her appetite. House shakes 3 times a day. I also recommended they give her calorie dense snacks. Usually the DON's would call the family members.
On 09/30/21 at approximately 6:20 p.m., the above findings were shared with the Administrator, and Corporate Staff Members. An opportunity was offered to the facility's staff to present additional information but no additional information was provided.
This is a complaint deficiency
Based on staff interview, clinical record review and facility document review, the facility staff failed to notify the physician and/or responsible party of missed COVID-19 vaccination for Resident #24 and failed to notify the resident's representative of weight loss for Resident #22 in a survey sample of 42 residents.
The findings included:
1. Resident #24 was originally admitted to the nursing facility on 07/15/21. Diagnosis included but not limited to Chronic Obstructive Pulmonary Disease (COPD). The most recent Minimum Data Set (MDS - an assessment protocol) an annual assessment with an Assessment Reference Date (ARD) of 09/14/21 coded Resident #24 with a 14 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment.
The MDS coded Resident #24 total dependence of two with transfer and total dependence of one with dressing, bathing and personal hygiene and extensive assistance of two with bed mobility and toilet use and supervision with limited assistance of one with eating for Activities of Daily Living (ADL) care.
Resident #24's comprehensive care plan with a revision date of 08/10/20 document resident at risk for alteration in psychosocial well-being related to restrictions on visitation due to COVID-19. The goal set for the resident by the staff the resident will not experience any adverse effects. Some of the intervention/approaches to manage goal include but not limited resident is on droplet isolation precautions related to dialysis, encourage alternative communication with visitors and provide opportunities for expression of feelings related to situational stressors.
Review of Resident #24's clinical record revealed a COVID-19 vaccination consent form signed and dated by the resident's representative (RR) on 12/18/20. The document was also signed and dated by Registered Nurse (RN) #1 on 01/21/21.
Review of Resident #24's clinical record did not reveal evidence that the COVID-19 vaccination was either offered or declined.
On 09/29/21 at approximately 10:30 a.m., a phone interview was conducted with the Administrator, Regional Director of Clinical Services, RN #1 and Infection Preventionist/Staff Development Coordinator. RN #1 said Resident #24 refused the COVID-19 vaccination but it's wasn't documented in the nurses note or clinical record. RN #1 stated, I should have written a nurse's note of the refusal and the clinical record should have been updated under vaccination to include Resident #24 refused the COVID-19 vaccination.
An interview was conducted with the Administrator on 09/30/21 at approximately 2:27 p.m., who stated, If Resident #24 refused the COVID-19 vaccination when offered, the nurse should have attempted again, and if the resident still refused, the refusal should have been documented in the nurse's note or someone where in his clinical record. The Administrator said the physician and the resident's (RR) should have been notified Resident #24 did not receive the COVID-19 vaccination.
The Administrator, Interim Director of Nursing, Chief Operating Officer, Regional Director of Operations and Regional Director of Clinical Services was informed of the findings during the exit meeting on 09/30/21 at approximately 7:40 p.m. The facility did not have any further questions or present any further information about the findings.
The facility's policy titled: Charting and Documentation - revision date 07/2017.
Policy statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.
Policy Interpretation and Implementation read in part:
7. Documentation of procedures and treatments will include care-specific details, including:
e. Whether the resident refused the procedure/treatment.
f. Notification of family, physician or other staff, if indicated; and the signature and titles of the individual documenting.
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 clinical record review, staff interview and facility documentation, the facility staff failed to ensure Medicare Beneficiary Notices in accordance with applicable Federal regulations, were is...
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Based on clinical record review, staff interview and facility documentation, the facility staff failed to ensure Medicare Beneficiary Notices in accordance with applicable Federal regulations, were issued to 2 of 2 residents (Resident #5 and Resident #80) in the survey sample.
The findings included:
1. The facility staff failed to issue an Advanced Beneficiary Notice (ABN) letter to Resident #5 who was discharged from skilled services with Medicare days remaining. Resident #5 was admitted to the nursing facility on 07/16/20. Diagnosis for Resident #5 included but not limited to Muscle Weakness. Resident #5's Minimum Data Set (MDS) a Medicare/5 day assessment with an Assessment Reference Date (ARD) date of 09/06/21 coded Resident #5 a 13 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicated no cognitive impairment.
Review of the SNF Beneficiary Notification provided by the facility was noted that Resident #5 was not issued the SNF ABN (Skilled Nursing Facility-Advanced Beneficiary Notice). The resident had received a NOMNC (Notice of Medicare Provider Non-Coverage).
Resident #5 started Medicare Part A stay on 08/31/21 and the last covered day was on 09/17/21. Resident #5 was discharged from Medicare Part A services when benefit days were not exhausted. Resident #5 had only used 21 days of his Medicare Part A services with 79 days remaining. Resident #5 should have been issued a SNF ABN and an NOMNC.
A phone interview was conducted with the Social Worker (SW) on 09/23/21 at approximately 9:00 a.m. The SW said only the NOMNC was issued when Resident #5 was discharged from Medicare A services that ended on 09/20/21. She said I should have issued an ABN letter along with the NOMNC letter.
2. Resident #80 was admitted to the nursing facility on 12/07/17. Diagnosis for Resident #80 included but not limited to Lack of Coordination. Resident #80's Minimum Data Set (MDS) a quarterly assessment with an Assessment Reference Date (ARD) date of 09/01/21 coded Resident #14 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicated no cognitive impairment.
Review of the SNF Beneficiary Notification was noted that Resident #80 was not issued the SNF ABN (Skilled Nursing Facility-Advanced Beneficiary Notice.) The resident had received a NOMNC (Notice of Medicare Provider Non-Coverage).
Resident #80 started a Medicare Part A stay on 09/07/21, and the last covered day of this stay was 09/20/21. Resident #80 was discharged from Medicare Part A services when benefit days were not exhausted. Resident #80 only used 77 days of her Medicare Part A services with 23 days remaining. Resident #80 should have been issued a SNF ABN and an NOMNC. The resident was only issued an NOMNC.
A phone interview was conducted with the Social Worker (SW) on 09/23/21 at approximately 9:00 a.m. The SW said only the NOMNC was issued when Resident #5 was discharged from Medicare A services ended on 09/17/21. She said I should have issued an ABN letter along with the NOMNC letter.
The Administrator, Interim Director of Nursing, Chief Operating Officer, Regional Director of Operations and Regional Director of Clinical Services was informed of the above findings during the exit meeting on 09/30/21 at approximately 7:40 p.m. The facility did not have any further questions or present any further information about the findings.
The facility's policy titled: Advance Beneficiary Notices, revision date: 11/01/20.
Policy: It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage.
Policy Explanation and Compliances Guidelines included but not limited to:
1. The Business Office Manager (BOM) is the contact person for information regarding Medicare eligibility, coverage, and applying for benefits.
5. The current CMS-approved revision of the forms shall be used at all time of issuance to the beneficiary (resident or resident representative). Contents of the form shall comply with related instructions and regulations regarding the use of the form.
A. For Part A times and services, the facility shall us the Skilled Nursing facility Advance Beneficiary Notice (SNF ABN). Form CMS-10055.
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 interviews, clinical record review, the facility's staff failed to ensure person...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interviews, clinical record review, the facility's staff failed to ensure personal privacy of a resident's physical body during personal care for 1 of 42 residents (Resident #90), in the survey sample.
The findings included:
Resident #90 was originally admitted to the facility 5/14/19 and readmitted [DATE] after an acute care hospital stay, returning to the facility 9/9/21. The current diagnoses included; SARS-CoV-2 infection and Multiple Sclerosis.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/16/21 coded the resident as not completing the Brief Interview for Mental Status (BIMS). The staff interview was coded for intact long and short term memory as well as modified independence with daily decision making. In section G (Physical functioning) the resident was coded as requiring total care of one person with bathing, extensive assistance of one person with bed mobility, transfers, dressing, toileting, and personal hygiene, limited assistance of one person with transfers, and supervision after set-up with eating.
Upon entering Resident # 90's room on 9/23/21 at approximately 9:45 a.m., a sheet was observed on the floor and on top of the sheet were elimination saturated towels, a gown and used gloves. Resident #90; a SARS-CoV-2 infected resident; was in bed uncovered and without clothing. The resident stated he no longer felt sick and presented without shortness of breathe, cough, diaphoresis or fatigue. Resident #90 stated CNA #5 was obtaining towels for him to use for incontinence wear, afterwards she would dress him. The resident stated use of towels was his method of staying dry for it takes the staff too long to provide assistance when he rings the call bell. The resident's window was opened and he was viewable as staff passed by the window. The resident stated when he gets up he closes the blinds but he hadn't been up for a few days and no one had closed the blinds on his behalf.
An interview was conducted with CNA #5 on 9/23/21 at approximately 9:53 a.m. CNA #5 stated she forgot to close the window prior to beginning care for the resident was in a private room. She also stated she should have covered the resident before she stepped out to get towels, it was an oversight.
An interview was conducted with the DON on the COVID-19 positive unit on 9/23/21 at approximately 10:05 a.m. The DON stated her expectation of the CNA is to close doors, privacy curtains and window coverings before personal care is started and that no more of the resident's body be exposed than the area care is being rendered.
On 9/30/21 at approximately 6:30 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultants. An opportunity was offered to the facility's staff to present additional information or comment but no additional information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility documentation review, and in the course of a complaint investigation, the facili...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility documentation review, and in the course of a complaint investigation, the facility staff failed to provide reasonable care for the protection of residents' property from loss for 2 of 42 residents (Resident #7 and #22) in the survey sample.
The findings included:
1. Resident #7 was originally admitted to the facility on [DATE]. Diagnoses for Resident #7 included but not limited to COVID-19 and Cognitive Communication Deficit.
The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/18/21 coded Resident #7 as not having the ability to complete the Brief Interview for Mental Status (BIMS).
A review of the complaint/grievance report dated 2/06/20 filed by POA (Power of Attorney) Reads: Resident is missing significant amount of personal items: Clothes, burgundy/beige comforter, white watch and a gold bracelet. Sister sews name on garments. Resolution reads items returned on 2/21/20.
A review of complaint document/grievance dated 1/01/21 filed by POA reads: Other residents clothing found in the laundry bin when sister picks up residents laundry. Resident is missing her gold chain. Findings of Investigation: Gold chain was not able to be located. Residents on unit 5 are in and out of each other's rooms/closets. Plan to resolve complaint: Speak with CNAs on Unit 5 about consolidating resident's clothing only for sister to retrieve every week. Results of action taken: Will continue to look for gold chain. Advised sister of facility policy on missing items. Resolution: Ongoing: Hopes that gold chain will turn up soon.
Received document on 9/27/21(dated 9/24/21) from Social Worker (OSM/Other Staff Member) #8 concerning misplaced items. The document reads: Laundry/Housekeeping recovered burgundy/beige comforter (Initials in the corner) and other items. (Five pairs of pants, four shirts and two bras). Signed laundry personnel. [NAME] watch and gold bracelet was not found. The writer (OSM#8) spoke to POA on 9/25/21 to inform her of items found. POA very thankful for call and information via this writer.
During the initial tour on 9/21/21 at approximately 2:25 PM Resident #7 was observed Resting in bed. An interview was attempted with Resident #7 but due to her cognitive communication deficit an interview was not successful.
On 9/23/21 an interview was conducted at 8:25 AM with CNA (Certified Nursing Assistant) #10 concerning Resident #7. She stated, Her sister did her laundry at first but wasn't coming frequently enough so the resident would run out of clean laundry so we started washing it here. I don't know anything about the resident having a gold chain or remember seeing her wearing a watch.
On 9/23/21 at approximately 10:30 a.m., an interview was conducted with the Laundry Supervisor. He stated they had a staff member out of work therefore the laundry services were backed-up but it was their intention to get the three large bins of resident personal belongings sorted, folded or hung and returned to the residents very soon. The Laundry Supervisor stated no resident will be without needed personal items affecting their care as a result of the back-up
On 9/23/21 at approximately 1:00 PM a phone call was made to Resident #7's sister concerning her lost belongings. She stated, The jewelry is at our own risk. She had a gold chain, gold bracelet and a watch when she first came in. It was hard getting things from her. The facility told me I shouldn't leave valuable things here. She lost glasses and they said they would refer her. She's lost wigs. The former Social Worker said they don't replace items. The Laundry wasn't available to me for pick up. Due to resident's incontinence the clothes were sent to laundry. She's lost many clothes and a comforter set that she liked.
On 9/24/21 at approximately 12:20 p.m., the Laundry Supervisor stated he recruited assistance of a previous laundry employee and they managed to get all resident personal laundry sorted and returned to the rightful owners.
On 9/28/21 at 3:45 PM an interview was conducted with Social Worker (OSM/Other Staff Member) #8 concerning Resident #7. She stated, I didn't locate the resident's watch or bracelet. From the policy we don't reimburse for such items. I didn't see an inventory list in her chart. We informed the POA (Power of Attorney). I will see if we have a policy.
2. For Resident #22, the facility staff failed to replace a lost hearing aid and assist a hearing impaired resident's hearing aid and dentures needed to hear and eat foods. Per physicians order
Resident #22 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Diagnosis for Resident #22 included but not limited Unspecified Dementia with Behavioral Disturbance and Major Depressive Disorder.
The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 07/17/21 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS).
In section G(Physical functioning) the resident was coded as extensive assistance of one person with bed mobility, dressing and locomotion on and off the unit. Requiring extensive assistance of two persons transfers. Requiring supervision set-up help with eating and requiring totals dependence of one person with toileting, personal hygiene and bathing.
Reveiwed complaint/grievance report dated 3/23/21 filed by son and communicated to Social Services. Concern: During last recent in person visits on 3/19/21 and 3/20/21 resident had no dentures or hearing aid. Family requested resident to have daily. Findings: Hearing aids were being kept on medication cart when not in use. Dentures and hearing aids have been missing for an unknown amount of time. Plan: Facility to acquire contract with senior well that offers dental and audiology services for residents. Resolution: Follow-up needed. Remarks: Missing items are a continious issue for this family and son is weery about replacement dentures.
A review of the MAR (Medication Administration Record) reveal the following:
9/10/2021: Remove Dentures ( top & bottom) at bedtime & lock in nurse cart at bedtime. No dentures in the nursing cart.
9/9/2021: Place bilateral hearing aids in resident ears every morning. one time a day for hearing impaired. due to behavior of taking them out and putting them in random places only one remains.
7/8/2020: Medication Administration Note Note Text: Place bilateral hearing aids in resident ears every morning. one time a day for hearing impaired.
12/4/2020: Remove Dentures ( top & bottom) at bedtime & lock in nurse cart at bedtime Only top denture collected from resident. No bottom denture.
A review of progress notes read:
On 11/27/2020 at 11:47 AM Nursing Progress Note: CNA placed residents upper and lower dentures in her mouth this shift. Resident removed her bottom dentures/misplaced them. Hearing aids are in place. Resident met with family this shift through window visit. No concerns noted at this time. Will inform oncoming staff of misplaced bottom dentures.
11/24/2020 at 9:27 AM Progress Note: This Lpn (Licensed Practical Nurse) spoke with daughter, her concerns was resident didn't have dentures, hearing aids, hair and nail cut. Also not knowing her mother is w/c bound and incontinent. I reeducated her on resident condition and that we will make sure on her mother is will groom on a daily basis.
11/21/2020 at 10:53 AM-Medication Administration Note: Place bilateral hearing aids in resident ears every morning.
On 9/22/21 at approximately 10:25 AM., Surveyor observed Resident without dentures and hearing aides as she was sitting at the table in the activities room. No dentures intact. No hearing aide intact. Her CNA stated, She will take out her own dentures.
On 9/22/21 at approximately 7:10 PM- an interview was conducted with LPN (Licensed Practical Nurse) #6 concerning Resident #22's dentures. She stated, I haven't seen her dentures in her mouth in a couple of weeks.
On 9/23/21 at approximately 8:25 AM an interview was conducted with CNA (Certified Nursing Assistant) #10 concerning Resident #22. He stated, Her dentures should be taken out at night and soaked. They should be left on the sink. Her hearing aid should be locked in the medication cart before she goes to bed.
On 9/23/21 at approximately 9:35 AM an interview was conducted with CNA (Certified Nursing Assistant) #1 concerning Resident #22. She stated, She doesn't have any dentures. When she did she would take them out.
On 9/23/21 Resident observed in Activity room at 9:40 AM. No dentures intact.
On 9/23/21 at approximately 12:44 PM an interview was conducted with Resident #22's son concerning her dentures and weight loss. He stated, I never saw her pull them out (her dentures) nor the hearing aids. Not wearing the dentures makes her face sunken in. Constant lack of not shaving her.(Whiskers on her face). The dietician would talk about her weight loss at the quarterly meetings.
Received Investigation document dated on 9/24/21 on 9/27/21 from Social Worker (OSM/Other Staff Member) #8. It reads as follows: During investigation one hearing aid is in place. No dentures found. Appointment was scheduled October 7, 2021 @10:00 AM with Affordable Dentures. Resident's son was called and informed of upcoming appointment. Reached out to ENT (Ear, Nose and Throat) on 9/24/21 office was closed. Will follow up on Monday September 27, 2021 to schedule an appointment.
On 09/30/21 at approximately 6:20 p.m., the above findings were shared with the Administrator, and Corporate Staff Members. An opportunity was offered to the facility's staff to present additional information but no additional information was provided.
This is a complaint deficiency
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 resident record review, staff interviews and facility document reviews, the facility staff failed to notify the Office ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review, staff interviews and facility document reviews, the facility staff failed to notify the Office of the State Long-Term Care Ombudsman in writing of discharges for two residents (Resident #22, #21) in the sample of 42 residents.
The findings included:
1. The facility staff failed to notify the Office of the State Long-Term Care Ombudsman of Resident #22's transfer to the local hospital on [DATE]. Resident #22 was originally admitted to the facility on [DATE] and was re-admitted on [DATE]. Diagnosis for Resident #22 include but not limited to Unspecified Intracapsular Fracture of the Left Femur, Sequela.
The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 07/17/21 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS).
On 7/10/20, according to the facility's documentation, a change in condition was reported concerning resident's skin color. An X-ray was ordered and showed an acute left hip fracture. Resident was picked up via transportation services and taken to the local ER (Emergency Room).
On 7/14/20, according to the facility's documentation, Resident returned from the hospital. Resident has a Honeycomb dressing at the left hip over incision to repair fracture.
On 9/29/21 at approximately 3:00 PM an interview was conducted with ASM (Administrative Staff Member) #7. She stated, We don't have a record of an Ombudsman notification being sent.
On 09/30/21 at approximately 6:20 p.m., the above findings were shared with the Administrator, and Corporate Staff Members. An opportunity was offered to the facility's staff to present additional information but no additional information was provided.2. The facility staff failed to ensure the local State Long-Term Care Ombudsman was notified that Resident #21 was discharged to the hospital on 4/26/21 and 8/22/21.
Resident #21 was admitted on [DATE] with diagnoses to include but not limited to Dementia, Paranoid Schizophrenia, Psychosis and Difficulty Swallowing.
Resident #21's most recent Minimum Data Set (MDS) was a quarterly with an Assessment Reference Date (ARD) of 9/7/21. Resident #21's Brief Interview for Mental Status (BIMS) was coded as a 00, indicating severe cognitive impairment and the inability to perform daily decision making.
Resident #21's Clinical Census was reviewed and revealed the resident was discharged on 4/26/21 and 8/22/21.
Resident #21's Nursing Progress Notes were reviewed and are documented in part, as follows:
4/26/2021 21:32 (9:39 p.m.), Nursing Progress Note: Called the hospital for an update and the ER(emergency room) Nurse stated pt(patient) was intubated and being admitted for AMS(altered mental status), Seizures, and Renal Failure. MD(medical doctor)/NP(nurse practitioner) and ADON made aware.
8/22/2021 06:25 a.m. Nursing Progress Note: Call placed to ED(emergency department) for admitting diagnosis. Informed there was no admitting diagnosis only that resident was admitted to the ICU(intensive care unit) for further treatment.
On 9/22/21 at 11:00 a.m., the facility Social Worker was asked for documentation to show that the local State Long-Term Care Ombudsman was notified that Resident #21 was discharged to the hospital on 4/26/21 and 8/22/21.
On 9/22/21 at 1:00 P.M. an interview was conducted with the facility Social Worker regarding documentation that the State Long-Term Care Ombudsman was notified by the facility that Resident #21 was discharged to the hospital on 4/26/21 and 8/22/21. The Social Worker stated, I was not here in April and can not find any documentation that the ombudsman was notified of that discharge. Also I can not find documentation that I notified the ombudsman of the 8/22/21 discharge. I should have sent that at the beginning of September.
On 9/22/21 at 2:00 p.m., an interview was conducted with the Regional Director of Clinical Services regarding when and who should notify the State Long-Term Care Ombudsman of discharges. The Regional Director of Clinical Services stated, The Social Worker should notify the ombudsman at least monthly of all discharges.
The facility policy titled Transfer and Discharges dated 11/1/20 was reviewed and is documented in part, as follows:
7. Emergency Transfer/Discharges: k. Social Services Director, or designee, shall provide notice of transfer to a representative of the State Long-Term Care Ombudsman via monthly list.
On 9/30/21 at 6:42 p.m., a pre-exit debriefing was conducted with the Administrator, the acting Director of Nursing, the Regional Director of Clinical Services and the Regional Director of Operations, where the above information was shared. Prior to exit no further information was shared.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Transfer
(Tag F0626)
Could have caused harm · This affected 1 resident
Based on a closed record review, staff interviews, and a complaint investigation, the facility staff failed to re-admit one resident Resident # 92 in the survey sample of 42 residents after they were ...
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Based on a closed record review, staff interviews, and a complaint investigation, the facility staff failed to re-admit one resident Resident # 92 in the survey sample of 42 residents after they were hospitalized .
The findings included:
Resident #92 had an original admission date of 08/19/15. Diagnoses included schizophrenia, anxiety, traumatic brain injury, benign prostatic hyperplasia, dementia, mood disorder, seizures, hypertension,muscle weakness, dysphagia.
This resident was assessed on a quarterly Minimum Data Set (MDS) in the area of Cognitive Patterns as 15 on the BIMS assessment. This resident was assessed as requiring one person physical assist in the area of Activities of Daily Living (ADL's) in the area of transfer, dressing, personal hygiene and toileting.
A Care plan dated 01/15/20 indicated: Focus- No plans to discharge. Goal- Participate in care decisions for long term stay. Interventions- Monitor for signs and symptoms of anxiety, distress, withdrawal or depression relating to not return to previous home environment.
A Nursing Note dated 02:35 on 08/10/20 indicated: Resident became combative around 0145 threatening roommate waving walking cane in his roommates face. Turning up his radio loud, treating other residents and staff members. Resident went to another unit and called 911. Officers came to the facility. Resident stated he wanted to go to jail and continued to open lobby door. Police officer called medical transport and resident was sent to ER. RP and NP were notified.
A Social Service note dated 13:39 on 08/10/20 indicated: IDT met to discuss resident's possible re-admission to facility and decided that a 30 day notice would be the safest option for the facility. Hospital notes indicate that resident is still exhibiting dangerous behaviors and psych concerns still persist even after medication adjustment. Resident made some alarming threats and put both himself and others in danger. 30 day notice was sent to the hospital, and two agency's.
During an interview on 09/22/21 at 11:10 a.m. with the administrator he was asked why Resident #92 was not permitted to return to the facility? The Administrator stated, Resident #92 was a danger to himself and other residents. The Administrator stated, Resident #92 had attempted to set fire to the curtains in his room. When asked for documentation of Resident #92 attempting to set fire to the curtains, the administrator stated he did not have any documentation to support the allegation.
During an interview on 9/22/21 at 11:29 a.m. with the complainant, she stated, Resident #92 had appealed the facility's ruling and the facility still refused to re admit him.
A review of Department of Medical Assistance Services Appeal Decision dated February 5, 2021 indicated the following: Issue - Nursing Home Discharge- Endangerment of Staff and Residents - Appeal filed August 14, 2020 Hearing Date December 16, 2020. The Notice of Discharge stated a reason for discharge that was not supported by the evidence in the record, and it did not provide the required 30 days of notice for transfer or discharge.
The Notice of Discharge states that discharge was for the health and safety of the residents and staff. That is not one of the permissible basis for discharge provided in the applicable regulation. Code of Federal Regulations, 42 CFR 483.15 (c) 1 (C) and (D). The transfer or discharge must documented in the resident's medical record by a physician and must include the basis for the discharge. 42 CFR 483.15 (c) (2).
The Nursing Facility Representatives did not provide any evidence or testimony to show that the Appellant's attending physician or Nursing Facility's medical director had evaluated the Appellant and determined that discharge was necessary based on the reason for discharge stated in the Notice of Discharge. There was no signed medical records to establish whether the requirement for such documentation had been met. There was no evidence provided to show that the Appellant's attending physician or the Nursing Facility's medical director had evaluated the Appellant for his potential discharge, notated the Appellant's medical records, drafted medical orders for potential discharge. Accordingly, the Hearing Officer finds that the Nursing Facility's proposed discharge of the Appellant was not in compliance with the applicable law and policy requiring a physician's approval.
The Nursing Facility failed to follow applicable law and policy for an involuntary discharge/transfer from the Nursing Facility. The Nursing Facility did not provide evidence to show a valid reason for involuntary discharge/transfer, did not provide adequate notice of discharge, did not provide evidence that the Appellant's physician or Nursing Facility's medical director had made a notation in the Appellant's record approving the discharge, and did not conduct a formal discharge planning meeting with the Appellant.
Therefore, the Nursing Facility's proposal to involuntarily transfer/discharge the Appellant on August 10, 2020 was not in compliance with the applicable law and regulations.
Complaint deficiency
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 clinical record review, facility document review and staff interviews the facility staff failed to initiate a Level II ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility document review and staff interviews the facility staff failed to initiate a Level II Preadmission Screening and Annual Resident Review (PASARR) after a positive Level I PASARR screening was completed for 2 of 42 residents in the survey sample, Resident #21 and Resident #71.
The findings included:
1. The facility staff failed to initiate a Level II PASARR for Resident #21 after a positive Level I PASARR screening was completed on 4/19/2017
Resident #21 was originally admitted to the facility on [DATE] with diagnoses to include but not limited to Dementia, Paranoid Schizophrenia, and Psychosis.
Resident #21's most recent Minimum Data Set (MDS) was a Quarterly with an Assessment Reference Date (ARD) of 9/7/21. Resident #21's Brief Interview for Mental Status (BIMS) was coded as a 00, indicating severe cognitive impairment and the inability to perform daily decision making.
Resident #21's last comprehensive MDS was a Significant Change with an ARD of 5/21/21. Under Section A1500 Preadmission Screening and Resident Review (PASRR): Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? Resident #21 was coded as No.
Resident #21's Level I PASARR screening completed on 4/19/2017 was reviewed and is documented in part, as follows:
2. Does this individual have a current serious mental illness? YES.
a. Is this major mental disorder diagnosable under DSM-IV (Diagnostic and Statistical Manual of Mental Disorders); (e.g., schizophrenia, mood, paranoid, panic, or other serious anxiety disorder; personality disorder; other psychotic disorder; or mental disorder that may lead to chronic disability)? YES.
b. Has the disorder resulted in functional limitations in major activities within the past 3-6 months, particularly with regard to interpersonal functioning; concentration, persistence, or pace: and adaptation to change? YES.
c. Does the treatment history indicate that the individual has experienced psychiatric treatment more intensive than outpatient care more than once in the past 2 years or the individual has experienced within the last 2 years an episode of significant disruption to the normal living situation due to the mental disorder? YES.
5. Recommendation: a; refer for secondary assessment. (NF(nursing facility) Placement =(equals) Level II refer to ASCEND.
*Ascend: Company that provides onsite, independent PASARR level II mental health and intellectual/development evaluations. (https://www.dmas.virginia.gov/media/1294/virginia-pasrr-training).
Resident #21's Progress Notes were reviewed and are documented in part, as follows:
9/22/2021 17:15 (5:15 p.m.), Social Service Progress Note: Documentation for PASARR update faxed to Name at Ascend this date. SS (Social Services) will assist as needed.
9/24/2021 14:02 (2:14 p.m.), Social Service Progress Note: Call rec'd (received) from VA(virginia) PASARR assessment screener requesting a Sunday at 10:00 a.m. visit for Name (Resident #21). Unit manager and Nurse on duty today made aware of tentative visit for resident Sunday. Contact information also provided in writing to nurse on duty this date.
On 9/24/21 at 2:55 p.m., an interview was conducted with the facility Social Worker regarding Resident #21's Level I PASARR completed on 4/19/2017 and if a Level II PASARR was indicated. The Social Worker stated, Name (Resident #21) re-admitted to the facility on [DATE]. I completed a Level I PASARR on 6/4/21 that indicated no Level II PASARR was required. However, during a re-audit of the resident's chart on 7/31/21 I found the PASARR dated 4/19/17 indicating a Level II. I did another Level I PASARR on 7/21/21 which also indicated a Level II needed to be completed. Name (Resident #21's) medical records were faxed to Ascend on 9/23/21. The Social Worker was asked why Ascend was just being notified on 9/23/21 when she found the Level I PASARR dated 4/19/17 on 7/21/21 indicating a Level II PASARR was needed. The Social Worker stated, I just got busy with other things that needed my attention and hadn't gotten back to working on it.
On 9/30/2021 at 1:10 p.m., during an interview the Social Worker was asked what was the importance of the PASARR screening. The Social Worker stated, The PASARR ensures that individuals are provided with the disability services that they need, including rehabilitative and specialized services. The goal of the PASARR is to optimize each individual placement success, treatment and ultimately, the individual's quality of life.
The facility policy titled Resident Assessment-Coordination with PASARR Program was reviewed and is documented in part, as follows:
Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs.
Policy Explanation and Compliance Guidelines:
1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening.
a. PASARR Level I-initial pre-screening that is completed prior to admission.
ii. Positive Level I Screen-necessitates a PASARR Level II evaluation prior to admission.
b. PASARR Level II- a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has mental disorder, intellectual disabilities, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs.
6. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status, and referring to the appropriate authority.
On 9/30/21 at 6:42 p.m., a pre-exit debriefing was conducted with the Administrator, the acting Director of Nursing, the Regional Director of Clinical Services and the Regional Director of Operations, where the above information was shared. Prior to exit no further information was shared.
2. The facility staff failed to initiate a Level II PASARR for Resident #71 after a positive Level I PASARR screening was completed on 7/16/2021
Resident #71 was admitted to the facility on [DATE] with diagnoses to included but not limited to Dementia, Bipolar Disorder, Anxiety Disorder and Dementia.
Resident #71's most recent Minimum Data Set (MDS) was a Quarterly with an Assessment Reference Date (ARD) of 8/27/21. Resident #71's Brief Interview for Mental Status (BIMS) was coded as a 01, indicating severe cognitive impairment and the inability to perform daily decision making.
Resident #71's Level I PASARR screening completed on 7/16/2021 by the current Social Worker was reviewed and is documented in part, as follows:
2. Does this individual have a current serious mental illness? YES.
a. Is this major mental disorder diagnosable under DSM-IV (Diagnostic and Statistical Manual of Mental Disorders); (e.g., schizophrenia, mood, paranoid, panic, or other serious anxiety disorder; personality disorder; other psychotic disorder; or mental disorder that may lead to chronic disability)? YES.
b. Has the disorder resulted in functional limitations in major activities within the past 3-6 months, particularly with regard to interpersonal functioning; concentration, persistence, or pace: and adaptation to change? YES.
c. Does the treatment history indicate that the individual has experienced psychiatric treatment more intensive than outpatient care more than once in the past 2 years or the individual has experienced within the last 2 years an episode of significant disruption to the normal living situation due to the mental disorder? NO.
5. Recommendation: a; refer for Level II evaluation (NF Placement = Level II refer to ASCEND.
Resident #71's Social Service Progress Notes were reviewed for any entries regarding a Level I PASARR, a Level II PASARR, or any notification to Ascend. No entries were identified in Resident #71's clinical record.
On 9/24/21 at 2:55 p.m., an interview was conducted with the facility Social Worker regarding Resident #71's Level I PASARR completed on 7/16/2021 and if a Level II PASARR was indicated. The Social Worker stated, Name (Resident #71's) chart was audited on 7/16/21 and I discovered there was no Level I PASARR uploaded in the clinical record. I completed a Level I PASARR on 7/16/21 that indicated a Level II PASARR was required. During a re-audit of the Name (Resident #71's) chart on 7/23/21 I noted that the medical records had not been sent to Ascend. Name (Resident #71's) medical records were faxed to Ascend on 9/23/21. The Social Worker was asked why Ascend was just being notified on 9/23/21 when the Level I PASARR she completed on 7/16/21 indicated that a Level II PASARR was needed. The Social Worker stated, I just got busy with other things that needed my attention and hadn't gotten back to working on it.
On 9/30/2021 at 1:10 p.m., during an interview the Social Worker was asked what was the importance of the PASARR screening. The Social Worker stated, The PASARR ensures that individuals are provided with the disability services that they need, including rehabilitative and specialized services. The goal of the PASARR is to optimize each individual placement success, treatment and ultimately, the individual's quality of life.
On 9/30/21 at 6:42 p.m., a pre-exit debriefing was conducted with the Administrator, the acting Director of Nursing, the Regional Director of Clinical Services and the Regional Director of Operations, where the above information was shared. Prior to exit no further information was shared.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility documentation review, and in the course of a complaint investigation, the facili...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility documentation review, and in the course of a complaint investigation, the facility staff failed to monitor daily weights per physician's orders for 1 of 42 residents (Resident #22) in the survey sample.
The findings included;
Resident #22 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Diagnosis for Resident #22 included but not limited Unspecified Dementia with Behavioral Disturbance and Major Depressive Disorder.
The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 07/17/21 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS).
In section G(Physical functioning) the resident was coded as extensive assistance of one person with bed mobility, dressing and locomotion on and off the unit. Requiring extensive assistance of two persons transfers. Requiring supervision set-up help with eating and requiring totals dependence of one person with toileting, personal hygiene and bathing.
The Care Plan dated 5/23/21 reads: FOCUS: The resident has nutritional problems or potential nutritional problems r/t Diet restrictions, mechanically altered diet, weight loss. Goals: The resident will tolerate diet and have no significant gain/loss through review date. Interventions: Observe/report to MD (Medical Doctor) PRN (as needed) s/sx (signs and symptoms) of malnutrition: Emaciation, muscle wasting, significant weight loss: 3lbs in 1 week, greater than 5% in 1 month, greater than 7.5% in 3 months, greater than 10% in 6 months.
MAR (Medication Administration Record) reads: weekly weights one time a day every Wed -Start Date 10/14/2020 at 9:00 AM.
MAR (11/2020). Weights not recorded.
MAR (12/2020) Weights not recorded.
The following weights were recorded in the clinical record under weights. 10/7/2020 152.8 1bs.
11/15/20 135 lbs.
12/03/20 135.2 lbs.
12/8/21 135.2 lbs.
The above recorded weights were not consistent with the ordered weekly weights.
A review of resident's weight from October 7, 2020 (152.8 lbs) to November 15, 2020 (135.0 lbs.) Resident has lost 17.8 lbs.
According to the complainant the resident had a significant amount of weight loss. The weekly ordered weights were not consistent from 10/07/20-11/15/20 Resident lost 17.8 lbs.
A review of clinical progress notes show no documentation proving the POA (Power of Attorney) or family member were notified of the 17.8 lbs. weight loss.
Review of progress note dated on 11/20/2020 at 9:43 AM from NP (Nurse Practitioner) reads: CC: Weight loss. This is an [AGE] year old who is residing on Memory Unit for LTC (Long Term Care). She was seen recently due to report of abnormal weight loss and poor appetite. Her weight is down to 135# this month, 152.8 # in October. She is seen today to follow up on lab results.
A review of progress notes dated 11/18/2020 13:09 (1:09 PM). Progress Notes reads: CC: Weight loss. She is seen today due to report of abnormal weight loss. Her weight is down to 135# this month, 152.8 # in October. Staff report poor intake, about 25% at meals. No report of diarrhea or GI symptoms. She is a poor historian due to dementia. She says she is alright and denies pain or difficulty breathing. She is c/o feeling cold. Weight loss: possible etiologies-thyroid dysfunction, progressing dementia, or depression. Start Eldertonic 15 ml BID. Monitor weight. Weight warning trigger: 11/16/2020 15:31 Nutrition Note Text: WEIGHT WARNING: 135 lbs.
A review of Progress notes dated 11/15/2020 read: RD (Registered Dietician) weight review; resident displays significant weight loss; Re-weigh to verify weight; weekly weights x 1 mo, RD to f/u PRN; RDN.
A review of the clinical record dated 11/24/2020 at approximately 9:27 AM reveal that Resident's daughter spoke to staff about concerns about her mother's/resident's condition days after she was noted to have significant weight loss.
On 9/23/21 at approximately 2:00 PM an interview was conducted with the District Dietary Manager/OSM (Other Staff Member) #6. He stated, A lot of it has to do with her decline with dementia. Her weight has been stable through 6 months. They had a staff member not putting down the proper weights. We found out that she wasn't weighing the resident. Nursing should notify the family of weight loss issues. Quarterly nutrition report completed.
On 9/23/21 at approximately 12:10 PM an interview was conducted with resident's daughter. She stated, We received no calls about her weight loss or her not being able to walk. I spoke to the DON (Director of Nursing) and explained the weight concern she stated they would call me every Monday with weights.
On 9/23/21 at approximately 12:00 PM a telephone interview was conducted with the Registered Dietician/OSM #2 concerning Resident # 22. She stated, The weights aren't consistent especially since COVID19. I brought it up a few times with the dietary managers. They had gotten better since the new DON came. Mostly from staff shortage. In my note she stabilized (weight) and was at a relative stable weight. I recommended fortified foods because sometimes her po (by mouth) intake is poor. She's now on weekly weights. She was on Remeron for a while for her appetite. House shakes 3 times a day. I also recommended they give her calorie dense snacks. Usually the DON's would call the family members.
On 09/30/21 at approximately 6:20 p.m., the above findings were shared with the Administrator, and Corporate Staff Members. An opportunity was offered to the facility's staff to present additional information but no additional information was provided.
This is a complaint deficiency
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, staff interview, facility documentation review, and in the course of a complaint investigation, the facili...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility documentation review, and in the course of a complaint investigation, the facility staff failed to maintain assistive devices to include hearing aids and dentures for 1 of 42 residents (Resident #22) in the survey sample.
Resident #22 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Diagnosis for Resident #22 included but not limited Unspecified Dementia with Behavioral Disturbance and Major Depressive Disorder.
The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 07/17/21 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS).
In section G(Physical functioning) the resident was coded as extensive assistance of one person with bed mobility, dressing and locomotion on and off the unit. Requiring extensive assistance of two persons transfers. Requiring supervision set-up help with eating and requiring totals dependence of one person with toileting, personal hygiene and bathing.
The careplan dated 01/09/20 Reads: ADL (Activity of Daily Living) self-care performance deficit relating to dementia. Goals: The resident will maintain current level of function through the review date. Interventions: Honor resident's preference for rising, going to bed, bathing/showering. The resident is totally dependent on staff for bathing needs.
Physician Order Summary dated 1/09/20 reads: Place bilateral hearing aids in resident ears every morning.
Physician's Order Summary Dated 1/08/20 reads: Remove Dentures (top & bottom) at bedtime & lock in nurse cart.
MAR (Medication Administration Record) reads: Place bilateral hearing aids in resident ears every morning. One time a day for hearing impaired -Start Date 01/09/2020 0900 (9:00 AM.)
A review of the MAR for November 2020 reads: Place bilateral hearing aids in resident ears every morning. One time a day for hearing impaired.
A review of the MAR for September show that staff placement of the hearing aids were completed. The date in question 11/23/21 when family visited was also checked off as completed.
MAR for November 2020 reads: Performed Oral & Denture (top & bottom
denture) care every morning.
A review of the September 2021 MAR reveal that staff checked off Yes for placement of hearing aids on the following dates: 9/05/21 and 9/06/21.
MAR reads: Performed Oral & Denture (top & bottom denture) care every morning in the morning -Start Date 01/09/2020 0800 (8:00 AM).
A review of the September 2021 MAR reveal that staff performed oral and denture care every day except on 9/25/21.
A review of the MAR notes reveal the following:
9/25/2021 23:24 (11:24 PM) Medication Administration Note: Remove bilateral hearing aid out of resident in ear at bedtime & lock in nursing cart at bedtime for hearing impaired. N/A (Not Applicable).
9/25/2021 10:32 AM Medication Administration Note: Performed Oral & Denture (top & bottom denture)care every morning. Unable to locate dentures.
9/24/2021 22:29 (10:29 AM) Medication Administration Note: Remove Dentures (top & bottom) at bedtime & lock in nurse cart at bedtime No denture in resident's mouth.
9/24/2021 22:27 (10:27 PM) Medication Administration Note: Remove bilateral hearing aid out of resident in ear at bedtime & lock in nursing cart at bedtime for hearing impaired one hearing in the narcotic box.
9/24/2021 9:51 AM-Medication Administration Note: Place bilateral hearing aids in resident ears every morning. one time a day for hearing impaired not available.
9/10/2021 10:24 PMMedication Administration Note Text: Remove Dentures (top & bottom) at bedtime & lock in nurse cart at bedtime. No dentures in the nursing cart.
9/9/2021 10:02 AM Medication Administration Note: Place bilateral hearing aids in resident ears every morning. one time a day for hearing impaired. due to behavior of taking them out and putting them in random places only one remains.
12/4/2020 11:31 PM -Medication Administration Note Text: Remove Dentures (top & bottom) at bedtime & lock in nurse cart at bedtime. Only top denture collected from resident. No bottom denture.
A review of the Complaint/Grievance Report dated 3/23/21 reads: During the last recent in person visits on 3/19/21 and 3/20/21 resident had no dentures or hearing aid. Family requested resident to have daily. Family upset. No management to assist with concerns. Investigations: Hearing aides were being kept on medication cart when not in use. Dentures and hearing aids have both been missing for an unknown amount of time.
Reviewed complaint/grievance report dated 3/23/21 filed by son and communicated to Social Services. Concern: During last recent in person visits on 3/19/21 and 3/20/21 resident had no dentures or hearing aid. Family requested resident to have daily. Findings: Hearing aids were being kept on medication cart when not in use. Dentures and hearing aids have been missing for an unknown amount of time. Plan: Facility to acquire contract with senior well that offers dental and audiology services for residents. Resolution: Follow-up needed. Remarks: Missing items are a continuous issue for this family and son is weary about replacement dentures.
A review of progress notes read:
11/27/2020 11:47 Nursing Progress Note: CNA placed residents upper and lower dentures in her mouth this shift. Resident removed her bottom dentures/misplaced them. Hearing aids are in place. Resident met with family this shift through window visit. No concerns noted at this time. Will inform oncoming staff of misplaced bottom dentures.
11/24/2020 09:27 Progress Note: This LPN (Licensed Practical Nurse) spoke with daughter, her concerns was resident didn't have dentures, hearing aids, hair and nail cut. Also not knowing her mother is w/c (wheel chair) bound and incontinent. I re-educated her on resident condition and that we will make sure on her mother is will groom on a daily basis.
On 09/21/21 at approximately 2:12 PM Resident #22 was observed sitting in her wheel chair in the activity room. Well groomed, hair combed, finger nails trimmed and clean, clothing clean and without body odor. CNA #1 was asked if Resident was wearing her dentures at the moment. She stated, She's not wearing her dentures.
On 9/22/21 at approximately 10:25 AM., Resident #22 was observed sitting at the table in the activities room engaged in activity. No dentures were intact. No hearing aids was intact. Resident was well groomed, wearing clean clothing, hair combed, finger nails clean. No body odor was present.
On 9/22/21 at approximately 10:30 AM an interview was conducted with CNA #1 concerning Resident #22. She stated, She will take out her dentures.
On 9/22/21 at approximately 7:10 PM- an interview was conducted with LPN (Licensed Practical Nurse) #6 concerning Resident #22's dentures. She stated, I haven't seen her dentures in her mouth in a couple of weeks. A medication cart audit was conducted by LPN #6. No dentures were found. She was able to locate 1 hearing aide.
On 9/23/21 at approximately 8:25 AM an interview was conducted with CNA (Certified Nursing Assistant) #10 concerning Resident #22. He stated, Her dentures should be taken out at night and soaked. They should be left on the sink. Her hearing aid should be locked in the medication cart before she goes to bed.
On 9/23/21 at approximately 9:35 AM an interview was conducted with CNA (Certified Nursing Assistant) #1 concerning Resident #22. She stated, She gets her hair washed on shower days. She doesn't have any dentures. When she did she would take them out. She gets her showers on the 3-11 shift when she doesn't refuse them. She's a picky eater on a puree diet.
On 9/23/21 Resident observed in Activity room at 9:40 AM. No dentures intact.
A review of Social worker progress notes dated 9/28/21 at 12:22 PM reads: Called son to inform of Ear, Nose, Throat appointment for Resident's hearing aids. No answer. Message left on VM (Voice Mail)to return call back re: appointment. Medical Records called to schedule transportation for appointment. To soon to schedule transportation.
On 9/23/21 at approximately 12:44 PM an interview was conducted with Resident #22's son concerning her dentures and weight loss. He stated, I never saw her pull them out (her dentures) nor the hearing aids. Not wearing the dentures makes her face sunken in. Constant lack of not shaving her.(Whiskers on her face). The dietician would talk about her weight loss at the quarterly meetings.
Received Investigation document dated on 9/24/21 on 9/27/21 from Social Worker (OSM/Other Staff Member) #8. It reads as follows: During investigation one hearing aid is in place. No dentures found. Appointment was scheduled October 7, 2021 @10:00 AM with Affordable Dentures. Resident's son was called and informed of upcoming appointment. Reached out to ENT (Ear, Nose and Throat) on 9/24/21 office was closed. Will follow up on Monday September 27, 2021 to schedule an appointment.
On 09/30/21 at approximately 6:20 p.m., the above findings were shared with the Administrator, and Corporate Staff Members. An opportunity was offered to the facility's staff to present additional information but no additional information was provided.
This is a complaint deficiency
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0712
(Tag F0712)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #28, the facility staff failed to provide physician visits in a timely manner during the month of June 2021.
Res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident #28, the facility staff failed to provide physician visits in a timely manner during the month of June 2021.
Resident #28 was originally admitted to the facility 9/14/17 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified and Muscle Weakness.
The annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 07/18/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #28 cognitive abilities for daily decision making were intact.
In section G(Physical functioning) the resident was coded as requiring supervision after set-up only with bed mobility, transfers, locomotion, dressing, eating, toileting, personal hygiene and bathing June 2021.
A review of the resident's clinical record show that NP (Nurse Practitioner) visits were conducted on the following dates: 5/05/21, 6/14/2021, 6/18/21.
A review of the clinical record show that Physician visits were conducted on the following dates: 7/08/21, 7/27/21, 8/03/21 and 9/23/21.
A review of the clinical record showed that no physician visits were conducted for the month of June 2021.
On 09/30/21 at approximately 6:20 p.m., the above findings were shared with the Administrator, The Interim Director of Nursing, The Regional Director of Clinical Services and The Regional Director of Operations. The Regional Director of Operations stated, The Physician Visits are still under a waiver.
Based on record review and staff interviews the facility staff failed to provide physician services for two residents in the survey sample (Residents #28 and #83) of 42 residents.
The findings included:
1. Resident #83 was admitted to the facility on [DATE] with diagnoses which included atherosclerotic heart disease, benign prostatic hyperplasia, transient cerebral ischemic attack, dysphagia, muscle weakness and dementia. A 9/2/21 Quarterly Minimum Data Set (MDS) indicated this resident was not able to be coded in the Cognitive Pattern area for Brief Interview for Mental status. This resident required extensive assistance in all areas of Activities of Daily Living.
A review of a Care Plan dated 08/02/21 indicated: Focus- Resident is on antibiotic therapy due to infection. Goal- Resident will be free of any discomfort or adverse side effects of antibiotic therapy. Interventions- Administer Antibiotic medication as ordered by physician. Monitor/document side effects and effectiveness Q-shift.
Focus- Resident has dehydration or potential fluid deficit r/t- Goal- The resident will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor. Interventions- Administer medications as ordered. Monitor/document for side effects and effectiveness. Monitor vital signs as ordered/per protocol and record. Notify MD of significant abnormalities.
A review of the clinical records indicated the physician's last visited Resident #83 on 5/14/21. During an interview on 09/30/21 at 7:15 P.M. with Regional Nurse Consultant she stated, the physician's Nurse Practitioner had been visiting the resident.
The facility staff failed to ensure physician visits were conducted in a time manner.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected 1 resident
Based on extended survey task, staff interview and documentation review the facility staff failed to ensure 3 out of 3 Certified Nursing Assistant (CNA) received their required 12 hours of mandatory a...
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Based on extended survey task, staff interview and documentation review the facility staff failed to ensure 3 out of 3 Certified Nursing Assistant (CNA) received their required 12 hours of mandatory annual competencies and 1 out of 3 CNA's completed her mandatory Dementia training.
The findings included:
On 09/22/21 at approximately 8:58 a.m., the surveyor requested evidence that CNA #7, CNA #11 and CNA #12 received their required 12 hours of mandatory annual competencies to include abuse and dementia training.
The admission Coordinator presented the list of Yearly Competency Training completed on 08/17/21. The training showed zero (0) hours. The competency training consisted of the following training:
-Shower/Tub Bath
-Nail Grooming
-Oral Care
-Elastic Stocking (Ted Hose)
-Height & Weight
-Vital Signs
-Sit to Stand Lift / bedside to wheel chair
-Positioning
-SWAT-Full Body Lift (bed to wheel chair)
-Catheter care
-Perineal Care Male and Female
-Heimlich maneuver
-Hand washing
-Intake/output
-Personal protective equipment (PPE)
On 09/29/21 at approximately 1:16 p.m., an phone interview was conducted with the Staff Development Coordinator who said she was not able to locate the 12 hours of mandatory annual competencies on the three (3) CNA's requested and was not able to provide the mandatory dementia training for CNA #12.
The Administrator, Interim Director of Nursing, Chief Operating Officer, Regional Director of Operations and Regional Director of Clinical Services was informed of the findings during the pre-exit meeting on 09/30/21 at approximately 7:40 p.m. The facility did not have any further questions or present any further information about the findings.
The facility's policy titled Continuing Education - revision date 10/28/20.
Compliance with the facility's standards, policies, and procedures is a condition of employment. This includes compliance with the policies and procedures of the facility's training program.
Policy Explanation and Compliance Guidelines:
1. All levels of employees are expected to complete required training within designated time frames.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to maintain a complete and accurate clinical record for Resident #93. The resident was admitted to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to maintain a complete and accurate clinical record for Resident #93. The resident was admitted to the nursing facility on 09/11/19. Diagnosis for Resident #93 included but not limited to Chronic Myeloid Leukemia and Muscle Weakness.
The most recent Minimum Data Set (MDS - an assessment protocol) a Medicare 5-day assessment with an Assessment Reference Date (ARD) of 09/18/19 coded Resident #93 with a 14 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. The MDS coded Resident #93 with total dependence of one with bathing, extensive assistance of one with bed mobility, transfer, dressing, toilet use and personal hygiene and supervision with set-up help only with eating for Activities of Daily Living (ADL) care.
During the review of Resident #93's clinical record revealed the following documents: Vital signs, progress notes and daily skilled notes since admission, pain, mobility and skin assessment dated [DATE] and an incomplete list of physician orders. There were no other documents located in the resident's clinical record under their current software program Point Click Care (PCC).
On 09/29/21 at approximately 10:30 a.m., a phone interview was conducted with the Administrator, Regional Director of Clinical Services, MDS Coordinator and Infection Preventionist/Staff Development Coordinator. The MDS Coordinator reviewed Resident #93's clinical record then stated, His clinical record is not complete, the clinical record is missing the Hospital Discharge Summary, admission Agreement, hospital Medication Administration Record (MAR) and hospital Treatment Administration Record (TAR), hospital progress notes, insurance information, admission paperwork etc. The Regional Director of Clinical Services said when Resident #93 was admitted to the facility on (09/11/19) the facility was not completely integrated with the software program Point Click Care (PCC) and that paper charting was still being utilized. The Administration team said they will reach out to the Regional [NAME] President of Clinical Services for assistance.
On 09/30/21 at approximately 1:44 p.m., the Regional [NAME] President of Clinical Services provided a letter that read: Resident #93 was admitted to the facility on [DATE] and was discharged from the facility on 9/20/2019. During that time period the facility used PCC as the Electric Medical Record (EMR). The PCC was not fully integrated at the time nor did the facility use all the functions of PCC. The facility was acquired on 7/1/2019 from (name of previous nursing home). The facility transitioned the EMR from American HealthTech (AHT) to PCC over the following weeks and much of the medical records during that timeframe would have been completed on paper. These records would have included physician orders, Medication Administration Records, Treatment Administration Records, Care Plans, and paper medical records being scanned into the Documents tab. The facility medical records department has reached out to Iron Mountain (offsite document storage) in an attempt to locate the paper medical record, in addition reached out to (name of pharmacy) to get copies of any documents, physician orders, or hospital records that may have been sent to the pharmacy. If we are able to obtain these records we will reach out to the survey team and provide them with the requested medical records.
On 09/30/21 at approximately 2:03 p.m., an email was received from the Regional [NAME] President of Clinical Services that read in part: The only additional documents obtained were the admission physician orders that were faxed to the pharmacy and the manifest. The documents have been uploaded in Resident #93's record and can now can be viewed in PCC.
The Administrator, Interim Director of Nursing, Chief Operating Officer, Regional Director of Operations and Regional Director of Clinical Services was informed of the findings during the exit meeting on 09/30/21 at approximately 7:40 p.m. The facility did not have any further questions or present any further information about the findings.
COMPLAINT DEFICIENCY
Based on a clinical record review, staff interviews, facility document review and during the course of a complaint investigation the facility staff failed to ensure a complete and accurate clinical record for 2 of 42 residents in the survey sample, Resident #8 and Resident #93.
The findings included:
1. The facility staff failed to ensure Resident #8's clinical record documentation was complete to include a fall, nursing fall assessment, physician notification and physician order follow-up during the 11-7 shift on 10/23/20.
Resident #8 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses to include but not limited to Right Femur Fracture and Dementia.
Resident #8's most recent Minimum Data Set (MDS) was a quarterly with an Assessment Reference Date (ARD) of 9/22/21. Resident #8's Brief Interview for Mental Status (BIMS) was not attempted because the resident was coded as rarely or never understood. Resident #8 was also coded as having long and short term memory recall.
On 9/22/21 at 10:00 a.m., the facility Administrator was asked if he had information about a fracture for Resident #8. The Administrator stated, Yes, I have a FRI(facility reported incident), a follow-up and statements regarding the incident with him for October 2020. The Administrator provided the surveyor with all of the above documents for review.
The Facility Reported Incident dated 10/29/20 was reviewed and is documented in part, as follows:
Residents involved: Name (Resident #8).
Incident Type: Injury of Unknown origin.
Describe incident, including location, and action taken: Resident Name (Resident #8) was noted to have bruising and leg pain. Order for x-ray revealed fracture. Resident sent out 911.
Name of employee involved and their position: Name, (Certified Nursing Assistant #13 (CNA).
Employee action initiated or taken:
Employee suspended based on statements from nurse on duty.
The facility 5-day follow-up to the FRI submitted on 10/29/20 dated 11/3/2020 was reviewed and is documented in part, as follows:
Situation: This is a follow-up to the initial FRI sent on October 29, 2020 concerning an injury of unknown origin for fracture to Name (Resident #8).
Investigation: Based on review of the written statements and interviews with employees it was determined that the CNA (CNA #13) on 11-7 did report a fall to an agency nurse. The agency nurse failed to complete documentation concerning the fall and to notify nursing management of a fall. All notifications have been made and the resident is currently in acute care receiving treatment for his injury.
Conclusion: This injury is, in fact, attributed to a fall.
-CNA returned back to work after the internal investigation.
-100% re-education to all nurses on notification and documentation of falls in Name(electronic medical record).
-100% re-education of notification to DON(Director of Nursing)/Administrator with falls with major injuries.
The facility staff interviews obtained during the investigation of Resident#8's injury of unknown injury were reviewed and are documented in part, as follows::
Statement from CNA #13 who worked 11/7 on 10/23/20:
Accident date: 10/24/20
This morning I was with Name (Resident #8), I directed him to his room. As I was standing in the hall at his (Resident #8's) door, he got up and walked to the sink, got on the floor. I yelled to them (Registered Nurse(RN) #2 and Licensed Practical Nurse #5) Name (Resident #8) is on the floor. I said Name (Resident #8) get up, he did. Then he walked out to the hall, holding on to the rail, then he fell on the floor in the hall. The 2 nurses (RN #2 and LPN #5) came to him. It was change of shift. My relief came, I told her what was going on and I left the floor.
Statement from LPN #5 who worked 7-3 on 10/24/20:
On 10/24/2020 I came on shift at 7 a.m., Name (Resident #8) was in his room. Night shift CNA came to desk saying that patient was crying out in pain. Night shift nurse and I went down to see patient and he was crying that his right knee was hurting. Patient was given as needed tylenol throughout the day. patient was limping throughout the hall and I kept redirecting him to sit down and not walk on injured leg. X-ray was done on my shift.
Statement from RN #2 who worked 11-7 on 10/23/20:
Dated 10/29/20
On 10/21 at around 0400(4:00 a.m.), I noticed resident walking out of his room, Name (CNA #13) was redirecting him back to his room. I continued doing my rounds. When I walked past the resident's room I saw the CNA sitting in a wheelchair watching over him. She said she was making sure that the resident will stay in bed and would not fall. I went to see the resident and asked how's he doing. He said his right knee hurts. I asked him if he fell, he said no. I asked him what happened, he said, I don't know. I asked him to flex his leg, he said it hurts. I assessed for any visible trauma, there was none. CNA was in the room all this time. So I emailed the MD (medical doctor) requesting for a stat x-ray related to right knee pain, placed the order to Name (mobile x-ray company) and endorsed the incident to the incoming LPN.
CNA #13 is no longer employed with the facility, the Director of Nursing provided the employee's phone number to surveyor. This surveyor attempted to call CNA #13 on 9/22/21 a total of 8 times. With each call the phone was answered by someone briefly speaking Spanish, them the call was immediately disconnected. No opportunity was given for a voice message to be left.
On 9/21/21 at 12:06 p.m., a phone interview was conducted with LPN #5. LPN #5 was asked to explain her involvement with Resident #8 on the morning of 10/24/20. LPN #5 stated, I was the 7-3 nurse that morning and I was relieving Name (RN #2). Name (RN #2) and I were at the nurses desk and the CNA (CNA #13) came up right around 7 because it was shift change and said Name (Resident #8) had fallen in the hall. We (RN #2) and I got up and went to his room. Name (RN #2) assessed him. When she assessed him, he complained of right leg pain. She said she would call the doctor and for me to give him some tylenol. Name (RN #2) told me before she left that she called the doctor and got an order for an x-ray of the right knee. She said she put the order in and for me to watch for them (mobile x-ray) to come. The x-ray was done on my shift. When I left, I told the next shift what happened and that we were waiting on the x-ray results. LPN #5 was asked if she documented anything about the resident's fall or the assessment oh her shift. LPN #5 stated, No, I thought she (RN#2) was going to document everything that happened and that she called the doctor.
On 9/23/21 at 3:06 p.m., an interview was conducted with RN #2. RN #2 was asked to review her written statement dated 9/29/20 and asked if her incident date of 10/21 was correct. RN #2 stated, No, the date on the statement should have been 10/23/20, the 10/21 was the wrong date. RN #2 was asked to explain what care she provided to Resident #8 on the morning of 10/24/20. RN #2 stated, It was around 3 am, Name (Resident #8) is an early riser and he is in and out of his room all day. Name (CNA #13) redirected him back to his room. I was walking back to the nurses station and I saw Name (CNA #13) and Name (Resident #8) in his room. When I walked by Name (CNA #13) said Name (Resident #8) was complaining of pain in his right or left knee, I can't remember which one. I went into the room and pulled down his pants, there was no bruising. I asked him where the pain was, he said his knee. I asked him if he fell and he said no, I asked Name (CNA #13) if he fell and she said no. I did range of motion on the leg and he said, oh that hurts. I told him I would email the doctor and get an x-ray. I let the oncoming nurse know that the mobile x-ray had been called to do the x-ray.
RN #2 was asked if CNA #13 came to the nurses station that morning around the change of shift and alerted her and LPN #5 that Resident #8 had fallen in the hall. RN #2 stated, No he didn't fall in the hall. I did tell the oncoming nurse about what had happened, that he had knee pain and I assessed him.
RN #2 was asked if she documented her assessment of Resident #8, that the physician was called and the orders she received. RN #2 stated, No, I couldn't find anything in the nurses notes, but I did email the doctor.: RN #2 was asked why she didn't document the care she provided Resident #8. RN #2 stated, It just slipped my mind. I was in a rush to get the order from the doctor. I figured that would be my proof that I did something. I know now that emailing does not take the place of documenting because if you don't chart it, then there is no proof the care was given.:
Resident #8's Progress Notes were reviewed and revealed no entries from RN #2 regarding a fall, an assessment, physician notification or follow-up orders for Resident #8 during her 11-7 shift on 10/23/20.
On 9/28/21 at 10:50 a.m., an interview was conducted with the Director of Nursing (DON) regarding RN #2 failing to document a fall, a resident assessment, physician notification or follow-up orders on 10/23/20 for Resident #8. The DON stated, Name (RN #2) should have documented the fall, her full assessment of the resident, that the physician was called and the follow-up orders she received. Documentation allows for continuity of care to continue for the resident with the next shifts. When there is no documentation we have no idea what has been done.
On 9/29/21 at 1:30 p.m., an interview was conducted with the Administrator and asked what were his expectations for ensuring resident records were complete and accurate. The Administrator stated, The nurse who the incident was reported to failed to document what she had done. The doctor was notified and the x-rays were done. We just failed to document. I expect all staff to document all care rendered to the residents so the clinical record will be complete.
The facility policy titled Maintenance of Electronic Clinical Records dated 11/1/20 was reviewed and is documented in part, as follows:
Policy: The facility will maintain electronic clinical records for each resident in accordance with acceptable standards of practice.
Policy Explanation and Compliance Guidelines:
1. A complete and accurate electronic clinical record will be maintained on each resident and kept accessible and systematically organized for appropriate personnel to deliver the appropriate level of care for each resident while maintaining the confidentiality of the resident's information
On 9/30/21 at 6:42 p.m., a pre-exit debriefing was conducted with the Administrator, the acting Director of Nursing, the Regional Director of Clinical Services and the Regional Director of Operations, where the above information was shared. Prior to exit no further information was shared.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected multiple residents
**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 send a copy of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record review and facility documentation review the facility staff failed to send a copy of the Resident's Care Plan for 3 out of 42 residents (Resident #33, Resident #42 and Resident #21) after being transferred to the hospital.
The findings included:
1. The facility staff failed to ensure Resident #33's Plan of Care Summary to include her care plan goals was sent upon or shortly after transfer/discharge to the hospital on [DATE]. Resident #33 was originally admitted to the facility on [DATE]. Diagnosis for Resident #33 included but not limited to Anxiety disorder.
Resident #33's Minimum Data Set (MDS-an assessment protocol) a significant change MDS with an Assessment Reference Date of 07/28/21 coded Resident #33 with short and long-term memory problems and cognitive skills severely impaired-never/rarely made decisions.
The Discharge MDS assessments was dated for 07/15/21 - discharged with return anticipated.
A nurse's note entered on 07/15/21 at approximately 8:02 a.m., revealed the following documentation: Resident observed in supine position, not easily aroused, eyes unresponsive to light and sternal rub given in order to be aroused. The note included the physician was notified of change in condition with Resident #33 with new orders to start Intravenous (IV) fluids and send to the emergency room (ER) for evaluation and treatment. The nurse's note indicated the vital signs were but not limited to the following: (BP) 95/60 - (hypotension) (P) 105 - (tachycardia) (R) 12 and oxygen saturation levels at 98%-on room air.
On 09/29/21 at approximately 10:30 a.m., a phone interview was conducted with the Administrator, Regional Director of Clinical Services, MDS Coordinator and Infection Preventionist/Staff Development Coordinator. Corporate said the care plan should have been sent when discharge to the new provider (acute care setting). She said the care plan ensures the new provider knows what kind of care the resident needs to maintain continuity of care.
2. The facility staff failed to ensure Resident #42's Plan of Care Summary to include his care plan goals was sent upon or shortly after transfer/discharge to the hospital on [DATE]. Resident #42 was originally admitted to the facility on [DATE]. Diagnosis for Resident #42 included but not limited to Dementia without behavioral disturbance.
Resident #42's Minimum Data Set (MDS-an assessment protocol) a quarterly Medicare 5-day assessment with an Assessment Reference Date of 09/06/21 coded Resident #42 with short and long-term memory problems and cognitive skills severely impaired-never/rarely made decisions.
The MDS assessment was dated for 09/06/21 - discharged with return anticipated.
A nurse's note entered by on 09/04/21 at approximately 9:13 a.m., revealed the following documentation: Resident #42 noted with cough and congestion; lungs sounds noted with crackles in the left upper lobe. The note included resident refusing all medications, fluids and breakfast at this time. The nurse's note indicated the vital signs were but not limited to the following: (BP) 158/92 - (hypertension) (P) 102 - (tachycardia) (R) 20, (T) 100.9 and oxygen saturation levels at 94% on room air. On the same day at approximately 4:28 p.m., the nurse's note indicated the resident was in the emergency room (ER).
On 09/05/21 at approximately 7:58 p.m., the nurse's note revealed a note that read, Resident in hospital.
On 09/29/21 at approximately 10:30 a.m., a phone interview was conducted with the Administrator, Regional Director of Clinical Services, MDS Coordinator and Infection Preventionist/Staff Development Coordinator. Corporate said the care plan should have been sent when discharge to the new provider (acute care setting). She said the care plan ensures the new provider knows what kind of care the resident needs to maintain continuity of care.
The Administrator, Interim Director of Nursing, Chief Operating Officer, Regional Director of Operations and Regional Director of Clinical Services was informed of the above findings during the exit meeting on 09/30/21 at approximately 7:40 p.m. The facility did not have any further questions or present any further information about the findings.
The facility policy titled Transfer and Discharge including Against Medical Advice (AMA) revised on 10/20/20.
7. Emergency Transfer/Discharges - initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified).
Section D. Complete and send with the resident or provide as soon as practical) a Transfer Form which documents: Comprehensive care plan goals.
3. The facility staff failed to ensure that Comprehensive Care Plan Goals were sent upon transfer to the hospital on 4/26/21 and 8/22/21 for Resident #21.
Resident #21 was admitted on [DATE] with diagnoses to include but not limited to Dementia, Paranoid Schizophrenia, Psychosis and Difficulty Swallowing.
Resident #21's most recent Minimum Data Set (MDS) was a quarterly with an Assessment Reference Date (ARD) of 9/7/21. Resident #21's Brief Interview for Mental Status (BIMS) was coded as a 00, indicating severe cognitive impairment and the inability to perform daily decision making.
Resident #21's Clinical Census was reviewed and revealed the resident was discharged on 4/26/21 and 8/22/21.
Resident #21's Nursing Progress Notes were reviewed and are documented in part, as follows:
4/26/2021 17:12 (5:12 p.m.), eINTERACT SBAR(Situation, Background, Assessment, Recommendations) Summary: The Change In Condition/s reported are/were: Functional decline (worsening function and/or mobility)
- Mental Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse)
Primary Care Provider Feedback: Primary Care Provider responded with the following feedback:
A. Recommendations: SEND OUT VIA 911.
4/26/2021 21:32 (9:39 p.m.), Nursing Progress Note: Nurse was notified by CNA(certified nursing assistant) that patient had been acting different than usual today and has not got up out of bed. This nurse went to assess pt(patient) and noted pt to be having seizure-like movements. Pt was able to respond to verbal stimuli by lifting his head up and looking towards nurse. Pt was non-vocal at this time with grunting noises noted NP(nurse practitioner)/MD(medical doctor) notified, 911 called, pt sent out to hospital. Unit Manager and ADON(assistant director of nursing), were notified. Called the hospital for an update and the ER(emergency room) Nurse stated pt was intubated and being admitted for AMS(altered mental status), Seizures, and Renal Failure. MD(medical doctor)/NP(nurse practitioner) and ADON(assistant director of nursing) made aware.
8/21/2021 19:24 (7:24 p.m.), Nursing Progress Note: Resident noted to have extreme lethargy and weakness and frequent jerking of BUE(bilateral upper extremities) and BLE(bilateral lower extremities) noted and resident extremely pale. Resident pocketing food and difficulty swallowing food and liquids. B/P-83/53. MD on call made aware and new order to send patient to hospital to be evaluated for altered mental status.
8/21/2021 19:44 (7:44 p.m.), eINTERACT SBAR Summary: The Change In Condition/s are/were: Altered mental status
- Blood Pressure: BP 83/53
- Mental Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse)
- Functional Status Evaluation: Swallowing difficulty.
- Neurological Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse)
Nursing observations, evaluation, and recommendations are:
Primary Care Provider Feedback: Primary Care Provider responded with the following feedback:
A. Recommendations: Send resident to ER(emergency room) to be evaluated.
8/22/2021 06:25 a.m. Nursing Progress Note: Call placed to ED(emergency department) for admitting diagnosis. Informed there was no admitting diagnosis only that resident was admitted to the ICU(intensive care unit) for further treatment.
There was no documentation in Resident #21's clinical record to indicate that the resident's comprehensive care plan goals were sent with the resident upon transfer from the facility to the hospital on 4/26/21 or 8/22/21.
On 9/28/21 at 10:40 a.m., an interview was conducted with the Director of Nursing (DON) regarding Resident #21's hospital transfers on 4/26/21 and 8/22/21 and if comprehensive care plan goals were sent with him. The DON stated, I couldn't find no documentation that the care plan goals were sent to the hospital with him for 4/26/21 or 8/22/21. They should have been sent with him so the hospital staff would know specific information about him and about the care he required.
On 9/29/21 at 4:10 p.m., an interview was conducted with the Regional Director of Clinical Services regarding what was expected to be sent with resident's upon transfer to the hospital. The Regional Director of Clinical Services stated, The care plan goals should go with the resident because the receiving provider needs to know the person-centered care required for the resident. It should also be documented in the resident's medical record that it was sent.
The facility policy titled Transfer and Discharges dated 11/1/20 was reviewed and is documented in part, as follows:
7. Emergency Transfer/Discharges: d. Complete and sent with the resident: viii. Comprehensive care plan goals.
On 9/30/21 at 6:42 p.m., a pre-exit debriefing was conducted with the Administrator, the acting Director of Nursing, the Regional Director of Clinical Services and the Regional Director of Operations, where the above information was shared. Prior to exit no further information was shared.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
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 send a copy of the ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility documentation review and clinical record review the facility staff failed send a copy of the Bed-Hold Policy upon discharge/transfer for 4 of 42 resident's (Resident #33, Resident #42, Resident #21 and Resident #92) after being transferred to the hospital.
The findings included:
1. The facility staff failed to ensure that Resident #33 or his resident's representative was provided a copy of the bed hold policy upon discharge/transfer to the hospital on [DATE]. Resident #33 was originally admitted to the facility on [DATE]. Diagnosis for Resident #33 included but not limited to Anxiety disorder.
Resident #33's Minimum Data Set (MDS-an assessment protocol) a significant change MDS with an Assessment Reference Date of 07/28/21 coded Resident #33 with short and long-term memory problems and cognitive skills severely impaired-never/rarely made decisions.
The Discharge MDS assessments was dated for 07/15/21 - discharged with return anticipated.
A nurse's note entered on 07/15/21 at approximately 8:02 a.m., revealed the following documentation: Resident observed in supine position, not easily aroused, eyes unresponsive to light and sternal rub given in order to be aroused. The note included the physician was notified of change in condition with the Resident #33 with new orders to start Intravenous (IV) fluids and send to the emergency room (ER) for evaluation and treatment. The nurse's note indicated the vital signs were but not limited to the following: (BP) 95/60 - (hypotension) (P) 105 - (tachycardia) (R) 12 and oxygen saturation levels at 98%-on room air.
On 09/29/21 at approximately 10:30 a.m., a phone interview was conducted with the Administrator, Based on staff interviews, clinical record review and facility documentation review the facility staff failed to send a copy of the Resident #33 care plan after being transferred to the hospital.
The facility staff failed to ensure Resident #33's Plan of Care Summary to include her care plan goals was sent upon or shortly after transfer/discharge to the hospital on [DATE]. Resident #33 was originally admitted to the facility on [DATE]. Diagnosis for Resident #33 included but not limited to Anxiety disorder.
Resident #33's Minimum Data Set (MDS-an assessment protocol) a significant change MDS with an Assessment Reference Date of 07/28/21 coded Resident #33 with short and long-term memory problems and cognitive skills severely impaired-never/rarely made decisions.
The Discharge MDS assessments was dated for 07/15/21 - discharged with return anticipated.
A nurse's note entered on 07/15/21 at approximately 8:02 a.m., revealed the following documentation: Resident observed in supine position, not easily aroused, eyes unresponsive to light and sternal rub given in order to be aroused. The note included the physician was notified of change in condition with Resident #33 with new orders to start Intravenous (IV) fluids and send to the emergency room (ER) for evaluation and treatment. The nurse's note indicated the vital signs were but not limited to the following: (BP) 95/60 - (hypotension) (P) 105 - (tachycardia) (R) 12 and oxygen saturation levels at 98%-on room air.
On 09/29/21 at approximately 10:30 a.m., a phone interview was conducted with the Administrator, Regional Director of Clinical Services, MDS Coordinator and Infection Preventionist/Staff Development Coordinator. Corporate said the care plan should have been sent when discharge to the new provider (acute care setting). She said the care plan ensures the new provider knows what kind of care the resident needs to maintain continuity of care.
2. The facility staff failed to ensure Resident #42's Plan of Care Summary to include his care plan goals was sent upon or shortly after transfer/discharge to the hospital on [DATE]. Resident #42 was originally admitted to the facility on [DATE]. Diagnosis for Resident #42 included but not limited to Dementia without behavioral disturbance.
Resident #42's Minimum Data Set (MDS-an assessment protocol) a quarterly Medicare 5-day assessment with an Assessment Reference Date of 09/06/21 coded Resident #42 with short and long-term memory problems and cognitive skills severely impaired-never/rarely made decisions.
The MDS assessment was dated for 09/06/21 - discharged with return anticipated.
A nurse's note entered by on 09/04/21 at approximately 9:13 a.m., revealed the following documentation: Resident #42 noted with cough and congestion; lungs sounds noted with crackles in the left upper lobe. The note included resident refusing all medications, fluids and breakfast at this time. The nurse's note indicated the vital signs were but not limited to the following: (BP) 158/92 - (hypertension) (P) 102 - (tachycardia) (R) 20, (T) 100.9 and oxygen saturation levels at 94% on room air. On the same day at approximately 4:28 p.m., the nurse's note indicated the resident was in the emergency room (ER).
On 09/05/21 at approximately 7:58 p.m., the nurse's note revealed a note that read, Resident in hospital.
On 09/29/21 at approximately 10:30 a.m., a phone interview was conducted with the Administrator, Regional Director of Clinical Services, MDS Coordinator and Infection Preventionist/Staff Development Coordinator. Corporate said the care plan should have been sent when discharge to the new provider (acute care setting). She said the care plan ensures the new provider knows what kind of care the resident needs to maintain continuity of care.
The Administrator, Interim Director of Nursing, Chief Operating Officer, Regional Director of Operations and Regional Director of Clinical Services was informed of the above findings during the exit meeting on 09/30/21 at approximately 7:40 p.m. The facility did not have any further questions or present any further information about the findings.
The facility policy titled Transfer and Discharge including Against Medical Advice (AMA) revised on 10/20/20.
7. Emergency Transfer/Discharges - initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified).
Section D. Complete and send with the resident or provide as soon as practical) a Transfer Form which documents: Comprehensive care plan goals.
The Administrator, Interim Director of Nursing, Chief Operating Officer, Regional Director of Operations, Regional Director of Clinical Services was informed of the findings during the exit meeting on 09/30/21 at approximately 7:40 p.m. The facility did not have any further questions or present any further information about the findings.
2. The facility staff failed to ensure that Resident #42 or his resident's representative was provided a copy of the bed hold policy upon discharge/transfer to the hospital on [DATE]. Resident #42 was originally admitted to the facility on [DATE]. Diagnosis for Resident #42 included but not limited to Dementia without behavioral disturbance.
Resident #42's Minimum Data Set (MDS-an assessment protocol) a quarterly Medicare 5-day assessment with an Assessment Reference Date of 09/06/21 coded Resident #42 with short and long-term memory problems and cognitive skills severely impaired-never/rarely made decisions.
The MDS assessment was dated for 09/06/21 - discharged with return anticipated.
A nurse's note entered by on 09/04/21 at approximately 9:13 a.m., revealed the following documentation: Resident #42 noted with cough and congestion; lungs sounds noted with crackles in the left upper lobe. The note included resident refusing all medications, fluids and breakfast at this time. The nurse's note indicated the vital signs were but not limited to the following: (BP) 158/92 - (hypertension) (P) 102 - (tachycardia) (R) 20, (T) 100.9 and oxygen saturation levels at 94% on room air. On the same day at approximately 4:28 p.m., the nurse's note indicated the resident was in the emergency room (ER).
On 09/05/21 at approximately 7:58 p.m., the nurse's note revealed a note that read, Resident in hospital.
On 09/29/21 at approximately 10:30 a.m., a phone interview was conducted with the Administrator, Regional Director of Clinical Services, MDS Coordinator and Infection Preventionist/Staff Development Coordinator. The Administrator said the bed is hold policy should have been sent when discharged to the hospital. He said the bed hold policy informs the resident of their rights when returning back to the facility along with the bed hold requirement.
The Administrator, Interim Director of Nursing, Chief Operating Officer, Regional Director of Operations, Regional Director of Clinical Services was informed of the findings during the exit meeting on 09/30/21 at approximately 7:40 p.m. The facility did not have any further questions or present any further information about the findings.
The facility policy titled Transfer and Discharge including Against Medical Advice (AMA) revised on 10/20/20.
7. Emergency Transfer/Discharges - initiated by the facility for medical reasons, or for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified).
Section I. Provide a notice of the resident's bed hold policy to the resident and representative at the time of transfer, as possible, but no later than 24 hours of the transfer.
3. The facility staff failed to ensure that a Bed Hold Notice was provided or sent upon transfer to the hospital on 4/26/21 and 8/22/21 for Resident #21.
Resident #21 was admitted on [DATE] with diagnoses to include but not limited to Dementia, Paranoid Schizophrenia, Psychosis and Difficulty Swallowing.
Resident #21's most recent Minimum Data Set (MDS) was a quarterly with an Assessment Reference Date (ARD) of 9/7/21. Resident #21's Brief Interview for Mental Status (BIMS) was coded as a 00, indicating severe cognitive impairment and the inability to perform daily decision making.
Resident #21's Clinical Census was reviewed and revealed the resident was discharged on 4/26/21 and 8/22/21.
Resident #21's Nursing Progress Notes were reviewed and are documented in part, as follows:
4/26/2021 17:12 (5:12 p.m.), eINTERACT SBAR(Situation, Background, Assessment, Recommendations) Summary: The Change In Condition/s reported are/were: Functional decline (worsening function and/or mobility)
- Mental Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse)
Primary Care Provider Feedback: Primary Care Provider responded with the following feedback:
A. Recommendations: SEND OUT VIA 911.
4/26/2021 21:32 (9:39 p.m.), Nursing Progress Note: Nurse was notified by CNA(certified nursing assistant) that patient had been acting different than usual today and has not got up out of bed. This nurse went to assess pt(patient) and noted pt to be having seizure-like movements. Pt was able to respond to verbal stimuli by lifting his head up and looking towards nurse. Pt was non-vocal at this time with grunting noises noted NP(nurse practitioner)/MD(medical doctor) notified, 911 called, pt sent out to hospital. Unit Manager and ADON(assistant director of nursing), were notified. Called the hospital for an update and the ER(emergency room) Nurse stated pt was intubated and being admitted for AMS(altered mental status), Seizures, and Renal Failure. MD(medical doctor)/NP(nurse practitioner) and ADON(assistant director of nursing) made aware.
8/21/2021 19:24 (7:24 p.m.), Nursing Progress Note: Resident noted to have extreme lethargy and weakness and frequent jerking of BUE(bilateral upper extremities) and BLE(bilateral lower extremities) noted and resident extremely pale. Resident pocketing food and difficulty swallowing food and liquids. B/P-83/53. MD on call made aware and new order to send patient to hospital to be evaluated for altered mental status.
8/21/2021 19:44 (7:44 p.m.), eINTERACT SBAR Summary: The Change In Condition/s are/were: Altered mental status
- Blood Pressure: BP 83/53
- Mental Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse)
- Functional Status Evaluation: Swallowing difficulty.
- Neurological Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse)
Nursing observations, evaluation, and recommendations are:
Primary Care Provider Feedback: Primary Care Provider responded with the following feedback:
A. Recommendations: Send resident to ER to be evaluated.
8/22/2021 06:25 a.m. Nursing Progress Note: Call placed to ED(emergency department) for admitting diagnosis. Informed there was no admitting diagnosis only that resident was admitted to the ICU(intensive care unit) for further treatment.
There was no documentation in Resident #21's clinical record to indicate that a bed hold notice was provided or sent with Resident #21 upon transfer from the facility to the hospital on 4/26/21 or 8/22/21.
On 9/28/21 at 10:40 a.m., an interview was conducted with the Director of Nursing (DON) regarding Resident #21's hospital transfers on 4/26/21 and 8/22/21 and if a bed hold notice was sent with him. The DON stated, I couldn't find no documentation that a bed hold notice was sent to the hospital with him for 4/26/21 or 8/22/21.
On 9/29/21 at 4:10 p.m., an interview was conducted with the Regional Director of Clinical Services regarding what was expected to be sent with resident's upon transfer to the hospital. The Regional Director of Clinical Services stated, The bed hold notice should go with the resident each time they go out. It should also be documented in the resident's medical record that it was sent.
The facility policy titled Transfer and Discharge dated 11/1/20 was reviewed and is documented in part, as follows:
7. Emergency Transfer/Discharges: d. Complete and sent with the resident: i. Provide a notice of the resident's bed hold policy to the resident and representative at the time of transfer, as possible, but no later than 24 hours of the transfer.
The facility policy titled Bed Hold Notice Upon Transfer dated 11/1/20 was reviewed and is documented in part, as follows:
Policy: At the time of transfer for hospitalization or therapeutic leave, the facility will provide to the resident and/or resident representative written notice which specifies the duration of the bed-hold policy and addresses information explaining the return of the resident to the next available bed.
Policy Explanation and Compliance Guidelines: Bed Hold Notice Upon Transfer.
1. Before a resident is transferred to the hospital or goes on therapeutic leave, the facility will provide to the resident and/or resident representative written information that specifies:
a. The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility.
b. The reserve bed payment policy.
c. The facility policies regarding bed-hold periods to include allowing a resident to return to the next available bed.
d. Conditions upon which the resident would return to the facility.
2. In the event of an emergency transfer of a resident, the facility will provide within 24 hours written notice of the facility's bed-hold policies, as stipulated in the State's plan.
On 9/30/21 at 6:42 p.m., a pre-exit debriefing was conducted with the Administrator, the acting Director of Nursing, the Regional Director of Clinical Services and the Regional Director of Operations, where the above information was shared. Prior to exit no further information was shared.4. The facility staff failed to provide Resident #92 with a Notice on Bed - Hold Policy and readmission before transfer.
Resident #92 had an original admission date of 08/19/15. Diagnoses included schizophrenia, anxiety, traumatic brain injury, benign prostatic hyperplasia, dementia, mood disorder, seizures, hypertension,muscle weakness, dysphagia.
This resident was assessed on a quarterly Minimum Data Set (MDS) in the area of Cognitive Patterns as 15 on the BIMS assessment. This resident was assessed as requiring one person physical assist in the area of Activities of Daily Living (ADL's) in the area of transfer, dressing, personal hygiene and toileting.
A Care plan dated 01/15/20 indicated: Focus- No plans to discharge. Goal- Participate in care decisions for long term stay. Interventions- Monitor for signs and symptoms of anxiety, distress, withdrawal or depression relating to not return to previous home environment.
A Nursing Note dated 02:35 on 08/10/20 indicated: Resident became combative around 0145 threatening roommate waving walking cane in his roommates face. Turning up his radio loud, treating other residents and staff members. Resident went to another unit and called 911. Officers came to the facility. Resident stated he wanted to go to jail and continued to open lobby door. Police officer called medical transport and resident was sent to ER. RP and NP were notified.
A Social Service note dated 13:39 on 08/10/20 indicated: IDT met to discuss resident's possible re-admission to facility and decided that a 30 day notice would be the safest option for the facility. Hospital notes indicate that resident is still exhibiting dangerous behaviors and psych concerns still persist even after medication adjustment. Resident made some alarming threats and put both himself and others in danger. 30 day notice was sent to the hospital, and two agency's.
A Social Service note dated 13:39 on 08/10/20 indicated: IDT met to discuss resident's possible re-admission to facility and decided that a 30 day notice would be the safest option for the facility. Hospital notes indicate that resident is still exhibiting dangerous behaviors and psych concerns still persist even after medication adjustment. Resident made some alarming threats and put both himself and others in danger. 30 day notice was sent to the hospital, and two agency's.
During an interview on 09/22/21 at 11:10 a.m. with the administrator he was asked why Resident #92 was not permitted to return to the facility? The Administrator stated, Resident #92 was a danger to himself and other residents. The Administrator stated, Resident #92 had attempted to set fire to the curtains in his room. When asked for documentation of Resident #92 attempting to set fire to the curtains, the administrator stated, he did not have any documentation to support the allegation. When asked for documentation of the Bed-Hold Notice provided to Resident #92, the administrator stated the resident voluntarily discharged himself from the facility and was not provided a Bed Hold Notice.
During an interview on 9/22/21 at 11:29 a.m. with the Complainant, she stated, Resident #92 had appealed the facility's ruling and the facility still refused to re admit him.
A review of Department of Medical Assistance Services Appeal Decision dated February 5, 2021 indicated the following: Issue - Nursing Home Discharge- Endangerment of Staff and Residents; Bed Hold Policy - Appeal filed August 14, 2020 Hearing Date December 16, 2020. Bed Hold - Notice on Bed Hold Policy and Readmission- Notice before transfer. Before a resident of a nursing facility is transferred for hospitalization or therapeutic leave, a nursing facility must provide written information to the resident and an immediate family member or legal representative concerning re-admittion to the facility immediately upon the first availability of a bed in a semiprivate room in the facility.
On August 10, 2020, the Appellant was involuntarily discharged from the Nursing Facility to the hospital for a psychiatric evaluation. As a Medicaid recipient who was discharged to a hospital for medical treatment, the Nursing Facility was required by law to provide the Appellant with bed hold policy and the opportunity to retain his bed at the Nursing Facility for re-entry. The evidence and testimony in the record shows that the Nursing Facility did not do so and never intended to allow the Appellant's readmission back into the Nursing Facility. This is evidenced by the fact that the Nursing Facility Representatives testified that the Appellant's readmission was denied due to his endangerment of the nursing facility staff and residents. There was evidence provided to show that the Appellant was in fact a danger to the nursing facility staff and residents in this matter.
The facility did not comply with the required Bed hold regulations, and refused to the Appellant's lawful readmission into the Nursing Facility.
The facility staff failed to provide Resident #92 with a Bed Hold policy or readmission to the facility.
Compliant deficiency
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility document review and staff interviews the facility staff failed to revise a care plan t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility document review and staff interviews the facility staff failed to revise a care plan to include an indwelling foley catheter upon re-admission for 1 or 42 residents in the survey sample, Resident #21.
The findings included:
The facility staff failed to revise Resident #21's care plan upon re-admission to the facility on 9/1/21 for 21 days to include an indwelling foley catheter.
Resident #21 was re-admitted to the facility on [DATE] with diagnoses to include but not limited to Urinary Tract Infection, and Stage 3 Chronic Kidney Disease.
Resident #21's most recent comprehensive Minimum Data Set (MDS) was a Significant Change with an Assessment Reference Date (ARD) of 5/21/21. Resident #21's Brief Interview for Mental Status (BIMS) was coded as a 02, indicating severe cognitive impairment and the inability to perform daily decision making. Under Section H - Bladder and Bowel H0100 Appliances; A. Indwelling catheter (including suprapubic catheter and nephrostomy tube), Resident #21 was coded as: Yes. H0300. Urinary Continence; Urinary continence - Select the one category that best describes the resident. Resident #21 was coded as: 3. Always incontinent.
The following observations were made of Resident #21's indwelling foley catheter:
On 09/20/21 at 8:00 p.m., Resident noted to have intact foley catheter, draining clear yellow urine.
On 09/21/21 at 10:38 a.m., Resident has indwelling foley catheter in place and covered with privacy bag, Catheter care being performed by Certified Nursing Assistant with no issues noted.
On 09/22/21 at 1:00 p.m., Resident's indwelling foley catheter in place, privacy maintained, and draining clear urine.
Resident #21's Admission/re-admission Screening Assessment completed By Licensed Practical Nurse (LPN) #4 dated 9/1/21 at 3:53 p.m., was reviewed and is documented in part, as follows:
SECTION I. Bladder/Bowel
34. Bladder:
a. Residents Continence Status: 7. admitted with Catheter.
CATHETER
d. Catheter Type/Size: foley 16fr (french) 10cc.
Resident #21's Progress Notes were reviewed and are documented in part, as follows:
9/1/2021 15:58(3:58 p.m.) Nursing Progress Note: Patient admitted to facility from Hospital dx (diagnosis): septic shock d/t (due to) complicated UTI (urinary tract infection). Patient has a 16fr 10cc foley catheter r/t (related to) urinary retention. All orders verified by provider.
On 9/23/21 at 12:28 p.m., an interview was conducted with LPN #4, who was the admitting nurse for Resident #21 on 9/1/21. LPN #4 was asked is she updated/revised Resident #21's care plan to include the indwelling foley catheter that was present on re-admission. LPN #4 stated, No, I have never been educated on who does or that I was to update the care plan. I really thought management would follow-up with the foley and add it to his care plan.
Resident #21's comprehensive care plan was reviewed and is documented in part, as follows:
Focus: The resident has Indwelling Catheter: related to obstructive uropathy and places him at risk for complications. Date Initiated: 9/22/2021
Created on: 9/22/2021
Interventions:
Check tubing for kinks each shift and as needed. Date Initiated: 9/22/2021.
Foley cath care as needed and ordered including positioning and securing. Date Initiated: 9/22/2021.
Monitor/document for pain/discomfort due to catheter. Date Initiated: 9/22/2021.
Monitor/record/report to Medical Doctor for signs and symptoms of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Date Initiated: 9/22/2021.
On 9/23/21 at 2:00 p.m., an interview was conducted with the Regional Director of Operations. The Regional Director of Operations was asked who in the facility is responsible for revising a resident's care plan if there is a change upon re-admission. Regional Director of Operations stated, The Charge Nurse should update the care plan if there are changes.
On 9/29/21 at 4:11 p.m. an interview was conducted with the Regional Director of Clinical Services and the above information was share. The Regional Director of Clinical Services was asked when should a resident care plan be revised and who in the facility was responsible to revise it if there is a change upon re-admission. The Regional Director of Clinical Services stated, The care plan should be revised whenever there is a change with the resident, quarterly and annually. Upon re-admission the clinical staff should update the care plan within 24 hours. Name (Resident #21's) foley catheter should have been updated on his care plan when he was recently re-admitted .
The facility policy provided for Care Plan Revision is the Resident Assessment Instrument (RAI) 4.7: The RAI and Care Planning which was reviewed and is documented in part, as follows:
The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving.
On 9/30/21 at 6:42 p.m., a pre-exit debriefing was conducted with the Administrator, the acting Director of Nursing, the Regional Director of Clinical Services and the Regional Director of Operations, where the above information was shared. Prior to exit no further information was shared.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility document review and staff interviews the facility staff failed to obtain physician ord...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility document review and staff interviews the facility staff failed to obtain physician orders upon re-admission for an indwelling foley catheter for 1 or 42 residents in the survey sample, Resident #21.
The findings included:
The facility staff failed to obtain physician orders for an indwelling foley catheter for Resident #21 for 21 days upon re-admission to the facility on 9/1/21.
Resident #21 was re-admitted to the facility on [DATE] with diagnoses to include but not limited to Urinary Tract Infection, and Stage 3 Chronic Kidney Disease.
Resident #21's most recent comprehensive Minimum Data Set (MDS) was a Significant Change with an Assessment Reference Date (ARD) of 5/21/21. Resident #21's Brief Interview for Mental Status (BIMS) was coded as a 02, indicating severe cognitive impairment and the inability to perform daily decision making. Under Section H - Bladder and Bowel H0100 Appliances; A. Indwelling catheter (including suprapubic catheter and nephrostomy tube), Resident #21 was coded as: Yes. H0300. Urinary Continence; Urinary continence - Select the one category that best describes the resident. Resident #21 was coded as: 3. Always incontinent.
The following observations were made of Resident #21's indwelling foley catheter:
On 09/20/21 at 8:00 p.m., Resident noted to have intact foley catheter, draining clear yellow urine.
On 09/21/21 at 10:38 a.m., Resident has indwelling foley catheter in place and covered with privacy bag, Catheter care being performed by Certified Nursing Assistant with no issues noted.
On 09/22/21 at 1:00 p.m., Resident's indwelling foley catheter in place, privacy maintained, and draining clear urine.
Resident #21's Admission/re-admission Screening Assessment completed By Licensed Practical Nurse (LPN) #4 dated 9/1/21 at 3:53 p.m., was reviewed and is documented in part, as follows:
SECTION I. Bladder/Bowel
34. Bladder:
a. Residents Continence Status: 7. admitted with Catheter.
CATHETER
d. Catheter Type/Size: foley 16fr (french) 10cc.
On 9/22/21 Resident #21's clinical record was reviewed. During the clinical record review no physician orders for Resident #21's indwelling foley catheter or the care of the indwelling catheter were identified.
Resident #21's Progress Notes were reviewed and are documented in part, as follows:
9/1/2021 15:58(3:58 p.m.) Nursing Progress Note: Patient admitted to facility from Hospital dx (diagnosis): septic shock d/t (due to) complicated UTI (urinary tract infection). Patient has a 16fr 10cc foley catheter r/t (related to) urinary retention. All orders verified by provider.
9/2/2021 06:49 a.m. Nursing Progress Note: Foley cath (catheter) intact, draining clear yellow urine. Output 700ml (milliliters).
9/3/2021 14:13 (2:13 p.m.), Nursing Progress Note: Foley draining clear, straw-colored urine. No foul odor or sediment noted. Urine output this shift 750mls.
9/8/2021 11:41 a.m., Nursing Progress Note: Foley draining clear, straw-colored urine.
9/15/2021 22:50 (10:50 p.m.), Nursing Progress Note: Resident foley catheter patent and flowing clear yellow, odorless urine.
9/21/2021 13:27 (1:27 p.m.), Nursing Progress Note: Foley draining clear, straw-colored urine with small amounts of sediment.
On 9/23/21 at 12:28 p.m., an interview was conducted with LPN #4, who was the admitting nurse for Resident #21 on 9/1/21. LPN #4 was asked if Resident #21 was readmitted on [DATE] with an indwelling foley catheter and if so did she obtain physician orders for the catheter. LPN #4 stated, Yes, I put that he had a foley on the admission assessment and I documented the foley in my admission nurses note. I assessed the patient upon admission and then I check the discharge summary for the orders. The foley was not mentioned in the discharge orders, but I knew he had a foley before looking at them. I remember telling the Nurse Practitioner (NP) that he had a foley. I just forgot to write the order for the foley. This was my first time doing an admission here and I wasn't sure how the foley orders were to be written. I called the NP and put the catheter orders in today.
Resident #21's Physician Orders were reviewed and are documented in part, as follows:
Order Date: 9/22/21
Order Summary: Foley catheter used for obstructive uropathy 16 Fr 10 cc balloon.
On 9/29/21 at 4:10 p.m. an interview was conducted with the Regional Director of Clinical Services regarding what the expectation was for staff when verifying and transcribing admission orders. The Regional Director of Clinical Services stated, After doing the physical assessment and reviewing the discharge summary the nurse is expected to enter the orders accurately after verifying them with the physician. If a foley catheter was noted upon assessment the nurse needs to contact the physician to see if the foley is necessary and write the order.
The facility policy titled admission Orders dated 11/1/21 was reviewed and is documented in part, as follows:
Policy: A physician, physician assistant, nurse practitioner or clinical nurse specialist must provide orders for the residents' immediate care and needs.
Policy Explanation and Compliance Guidelines:
1. The written orders should include at a minimum: c. Routine care orders.
2. The orders should allow facility staff to provide essential care to the resident consistent with the resident's mental and physical status on admission.
On 9/30/21 at 6:42 p.m., a pre-exit debriefing was conducted with the Administrator, the acting Director of Nursing, the Regional Director of Clinical Services and the Regional Director of Operations, where the above information was shared. Prior to exit no further information was shared.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected multiple residents
Based on staff interviews and facility information, 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:
During rev...
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Based on staff interviews and facility information, 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:
During review of the facility's staffing for RN coverage in a 60-day lookback revealed the facility did not provide 8 consecutive hours of RN coverage on the following days: 08/07/21, 08/08/21, 08/21/21, 08/22/21 and 09/18/21.
On 09/29/21 at approximately 10:30 a.m., a phone interview was conducted with the Administrator, Regional Director of Clinical Services, MDS Coordinator and Infection Preventionist/Staff Development Coordinator who were informed that the facility did not have 8 consecutive hours of RN coverage on the days mentioned above. The administration team did not have any further questions or present any information about the findings.
An interview was conducted with the Administrator on 09/30/21 at approximately 2:27 p.m., who stated, I expect RN coverage 8 hours a day, 7 days a week.
The Administrator, Interim Director of Nursing, Chief Operating Officer, Regional Director of Operations and Regional Director of Clinical Services was informed of the findings during the pre-exit meeting on 09/30/21 at approximately 7:40 p.m. The facility did not have any further questions or present any further information about the findings.
The facility's policy titled Nursing Services-Registered Nurse (RN) revision date: 10/28/20. Under policy included the intent of the facility to comply with Registered Nurse staffing requirements.
Policy Explanation and Compliance Guidelines:
1. The facility will utilize the services of a Registered Nurse for at least 8 consecutive hours per day, 7 days per week.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on information gleamed during the Antibiotic Stewardship task, staff interview, and clinical record review, the facility's...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on information gleamed during the Antibiotic Stewardship task, staff interview, and clinical record review, the facility's staff failed to have a system to ensure that an antibiotic was prescribed based on laboratory results and/or clinical signs and symptoms of true infections when prescribing an antibiotic for 1 of 42 residents (Resident #75), in the survey sample.
The findings included:
Resident #75 was originally admitted to the facility 1/3/19 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Alzheimer's disease.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/27/21 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired daily decision making abilities.
In section G (Physical functioning) the resident was coded as requiring total care of two people with transfers, personal hygiene, dressing and bathing, total care of one person with on unit locomotion, extensive assistance of two with bed mobility.
An interview was conducted with the Infection Preventionist (IP) during the Antibiotic Stewardship review on 09/28/21 12:34 p.m. A 7/19/21 Practitioner's progress note read Her 7/14 UA/CS reported 25,000 CFU/ML Proteus Mirabilis - orders to Repeat UA C&S (A sensitivity analysis is a method to determine if bacteria are resistant to certain drugs).
The IP stated Resident #75 had a urinalysis/culture and sensitivity (C&S) ordered 7/20/21 and the results were received 7/23/21. The lab results were not available on the resident's clinical record but the IP was able to obtain the information from her records. The results were 100,000 CFU/ML (E-coli) but; the resident was asymptomatic for a UTI and the clinical record offered no signs/symptoms related to an acute infection.
The Practitioner ordered Keflex 500 milligrams, one capsule by mouth four times each day for seven days.
The list of antibiotics the bacteria was susceptible (antibiotic is effective against the bacteria.) was reviewed by the IP; the antibiotics Keflex was not listed. The antibiotic was not adjusted to to a drug the bacteria was susceptible to and resident completed the seven day course of Keflex; an antibiotic the bacteria wasn't susceptible.
On 9/30/21 at approximately 6:30 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultants. An opportunity was offered to the facility's staff to present additional information or comment but no additional 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 resident interview, staff interview, and clinical record review, the facility staff failed to provide documentation in...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on resident interview, staff interview, and clinical record review, the facility staff failed to provide documentation in the resident's clinical record of the immunization and the administration or the refusal of or medical contraindications to vaccines for 3 of 42 residents (Resident #50, 24 and 5 ), in the survey sample.
The findings included:
1. Resident #50 was originally admitted to the facility 8/7/21 and was discharged to an acute care hospital 9/3/21, returning to the facility on 9/8/21. The current diagnoses included; SARS-CoV-2 infection, urinary tract infection, diabetes, high blood pressure and strokes.
The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/15/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 7 out of a possible 15. This indicated Resident #50's cognitive abilities for daily decision making were severely impaired. The resident did not answer questions when asked.
Review of Resident #50's 9/8/21 hospital discharge summary revealed the resident received one dose of the Moderna vaccine 2/21 and it would be necessary for the resident to receive the second dose. The clinical record revealed no immunization information except on the MDS. The MDS was coded not in the facility during the flu season to receive the vaccination and the Pneumococcal Immunization wasn't offered.
An interview was conducted with the Regional Reimbursement Consultant (RRC) on 9/23/21 at 11:45 a.m. The RRC stated the resident was offered and declined the Pneumococcal vaccine and a modification had been completed on the 8/12/21 MDS assessment to reflect the new information. Documents were presented as printed on 9/23/21 from the hospital data system which provided the following information: Pneumococcal vaccine13 (PCV13) vaccine received 1/29/14, Pneumococcal vaccine23 (PCV23) administered 1/29/13, COVID-19 vaccine Moderna 5/15/21 and Influenza vaccine 8/1/21.
If Pneumococcal vaccine23 (PPSV23) was administered prior to age [AGE] years, administer 1 dose PPSV23 at least 5 years after previous dose (https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html#note-pneumo)
On 9/30/21 an additional review of the resident's clinical record was made. The above information still wasn't documented in the record.
On 9/30/21 at approximately 6:30 p.m., the above information was reviewed with the Administrator, Interim Director of Nursing, Regional Director of Operations, Regional Reimbursement Consultant and the Regional Director of Clinical Services. An opportunity was afforded for presentation of additional information but they did not.
2. Resident #24 was originally admitted to the facility 7/15/20 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; stroke with right hemiparesis, COPD and a seizure disorder.
The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/14/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident 24's cognitive abilities for daily decision making were intact.
On 9/27/21 at approximately 12:40 p.m. an interview was conducted with Resident #24. The resident stated he hadn't received the COVID-19 vaccination but he wants all three of his shots. The records provided by the Infection Preventionist stated the resident's consent wasn't completed therefore; the vaccine wasn't administered. The clinical record revealed the Influenza vaccine was administered 11/6/20 in the facility, the Pneumococcal vaccine information was only available on the MDS assessment. It was coded as not offered.
On 9/30/21 at approximately 12:05 p.m., the IP provided a consent form indicating the responsible party for Resident #24 authorized administration of the Pneumococcal vaccine23 and the Influenza vaccine for this flu season. Status of consent for the COVID-19 vaccination is unknown. The IP stated if a resident refuses a vaccine at intervals (quarterly) it should be reoffered but this resident's problem was consents.
On 9/30/21 at approximately 6:30 p.m., the above information was reviewed with the Administrator, Interim Director of Nursing, Regional Director of Operations, Regional Reimbursement Consultant and the Regional Director of Clinical Services. An opportunity was afforded for presentation of additional information but they did not.
3. Resident #5 was originally admitted to the facility 7/18/20 and the resident has never been discharged from the facility. The current diagnoses included; dementia, .
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/6/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 13 out of a possible 15. This indicated Resident #5's cognitive abilities for daily decision making were intact.
Review of the resident's clinical record revealed no information the COVID-19 was administered. The resident tested COVID-19 positive 8/31/21. The clinical record revealed neither the Pneumococcal vaccine23 or the Influenza vaccine for the previous flu season had been administered. An Influenza consent form dated 11/14/20 was in the clinical record.
An interview was conducted with the RRC on 9/23/21 at 11:45 a.m. The RRC stated the 9/6/21 MDS assessment was coded the resident was not offered the flu vaccine and the Pneumococcal vaccine was offered and decline but the Pneumococcal vaccine coding was incorrect for the resident wasn't offered the vaccine. The RRC stated a modification had been completed on the 9/6/21 MDS assessment to reflect the new information.
On 9/23/21 at 10:20 a.m. and interview was conducted with Resident #5. The resident stated he had not received the COVID-19 vaccine or any other vaccine that he could recall.
The IP stated if a resident doesn't have a consent; at intervals (quarterly) an attempt should be made to obtain consent. Resident #5 needed consents for Pneumococcal vaccine23, this season Influenza vaccine and the COVID-19 vaccine when be becomes eligible to receive it.
On 9/30/21 at approximately 6:30 p.m., the above information was reviewed with the Administrator, Interim Director of Nursing, Regional Director of Operations, Regional Reimbursement Consultant and the Regional Director of Clinical Services. An opportunity was afforded for presentation of additional information but they did not.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0885
(Tag F0885)
Could have caused harm · This affected multiple residents
Based on resident interview, clinical record review, and review of facility documents, the facility staff failed to provide cumulative updates for residents, their representatives, and families at lea...
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Based on resident interview, clinical record review, and review of facility documents, the facility staff failed to provide cumulative updates for residents, their representatives, and families at least weekly or by 5 p.m. the next calendar day following the subsequent occurrence of either: each time a confirmed infection of COVID-19 is identified, or whenever three or more residents or staff with new onset of respiratory symptoms occur within 72 hours of each other.
The findings included:
During an interview with the Infection Preventionist (IP) on 9/22/21 at 10:10 a.m., she stated the SARS-CoV-2 outbreak began 8/28/21 when an alert and oriented resident tested positive after a Rapid test. The resident was confirmed positive on 8/31/21 after the Polymerase Chain Reaction (PCR) test results were received.
The IP stated on 8/30/21 all residents in the facility except the first resident who tested positive were tested with the rapid antigen test for the SARS-CoV-2 infection and the test results revealed multiple positive cases. The IP stated as a result of the rapid test, PCR test were performed and the results were available to the facility staff 9/1/21. The IP stated the COVID-19 unit was built because of the number of SARS-CoV-2 positive cases. The facility staff was unable to provide documentation that residents, their representatives, and families were informed of subsequent occurrences.
The IP stated on 9/7/21 outbreak testing continued for all residents who previously tested negative and the results were available to the facility 9/9/21. The results disclosed more SARS-CoV-2 positive cases.
The IP stated on 9/13/21 outbreak testing continued for all residents who previously tested negative and the results were available to the facility 9/15/21. The results disclosed more SARS-CoV-2 positive cases.
The IP stated on 9/21/21 outbreak testing continued for all residents who previously tested negative and the results were available to the facility 9/22/21. The results disclosed more SARS-CoV-2 positive cases.
The Regional Director of Clinical Services stated facility wide rapid testing of all negative residents was completed 9/25/21 through 9/29/21 and six residents tested positive for SARS-CoV-2.
A random sample of residents and families revealed they were notified of the 8/28/21 SARS-CoV-2 positive case. Notification of residents, their representatives, and families of subsequent occurrences of SARS-CoV-2 case weren't documented.
On 9/28/21 at approximately 12:59 p.m., the Administer provided a copy of the letter sent to update representatives and families of the facility status. It was dated 8/27/21, the day before the first positive resident SARS-CoV-2 case.
On 9/30/21 at approximately 6:30 p.m., the above information was reviewed with the Administrator, Interim Director of Nursing, Regional Director of Operations, Regional Reimbursement Consultant and the Regional Director of Clinical Services. The stated they inform residents and some families verbally as well as by email and the 8/27/21 letter was the last update sent.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff interviews, the facility staff failed to ensure resident rooms who were identifi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff interviews, the facility staff failed to ensure resident rooms who were identified as COVID-19 positive (Resident #16, #27 and #53) were cleaned and sanitized.
The findings included:
During the survey on 09/21/21-through 09/30/21 observations were made on Unit II. Resident #16, #27 and #53 were identified as being COVID-19 positive during this time period.
1. Resident #53 was admitted to the facility on [DATE] with diagnoses which included hemiplegia, insomnia, type 2 diabetes, major depression, convulsions, hypothyroidism, cerebral infarction, cognitive impairment and contracture of left hand. In the area of Cognitive Patterns Basis Interview for Mental Status this resident was coded as a 15. A Care Plan dated 09/25/21 indicated: Focus- COVID-19 active diagnosis. Resident #53 was identified as able to move around using a wheelchair.
Resident #53 was observed on 09/20/21 at 7:53 P.M. and 09/21/20 at 9:43 A.M. seated in a wheelchair in room [ROOM NUMBER] door way. This resident was observed without a mask. On 09/21/20 Resident #53 was identified as COVID-19 positive. Resident #53 was observed moving in and out of her room with the door open. Resident #53 remained in room [ROOM NUMBER] bed A until 09/23/21. Resident #53's bed linen, personal items, unfinished orange juice and food container were observed in the room for days after she vacated her room.
This resident was observed to be moved across the hall way to room [ROOM NUMBER]. Observations made during the survey indicated Resident #53 bed at 25-A remained uncleaned and unsanitized. Resident #53's roommate Resident #65 was idenitifiied as COVID-19 positive on 09/27/21.
2. Resident #16 was admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder, cervical spinal cord sequela, spinal stenosis, chronic pain, hypertension, dysphagia and mood disorder. Resident #16 was identified as COVID-19 positive on 09/22/21. Resident #16 was a resident living on Unit II in room [ROOM NUMBER].
Resident #16's was transferred out of bedroom [ROOM NUMBER] on 09/25/21. Resident #16's bed linen, personal items and food container remained in his room until 09/30/21. Resident #16's floor, bed and other areas of the room remained unsanitized and not cleaned after she vacated the room.
3. Resident #27 was admitted to the facility on [DATE] and re-admitted on [DATE]. Diagnoses for this resident included Multiple Sclerosis, Rhabomylysis, muscle weakness, epilepsy, ataxia, dysphagia, dementia, traumatic subduaral hemorrhage without loss of consciousness, major depression, cerebral vascular disease, and altered mental status. Resident #27 was identified as COVID-19 positive on 09/27/21. Resident #27 was transferred out of his bedroom [ROOM NUMBER] on 09/27/21. Resident #27's floor, bed, linen, personal items, and other areas of the room remained unsanitized and not cleaned afte she vacated her room.
On 09/30/21 11:29 A.M. during an interview with the Regional Director of Housekeeping and the Administrator. They were asked how long should a resident's room remain uncleaned and unsanitized after the resident tested Positive for COVID-19. The Regional Director of Housekeeping stated, the room be deep cleaned as soon as the resident moves out. The Administrator and the Regional Director of Housekeeping were shown the condition of Resident rooms, 25, 22, and 15.
A facility policy and procedure dated 11/1/20 indicated: Routine Cleaning and Disinfection: Policy: It is the policy of this facility to ensure the ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Definitions: Transmission Based Precautions refers to a group of infection prevention and control practices that are used in addition to standard precautions for residents who may be infected or colonized with infectious agents that require additional control measures to prevent transmission effectively.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0837
(Tag F0837)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, and staff interview, the facility staff failed to have a governing body of persons to ensure policies ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, and staff interview, the facility staff failed to have a governing body of persons to ensure policies regarding the management and operations of the facility during COVID-19 outbreak.
The findings included:
The facility staff failed to conduct and document a facility wide assessment to determine what resources were necessary to assist in the prevention of the spread of COVID -19.
The facility staff failed to use outside resources including the Local Health Department during a Major COVID-19 outbreak in the facility.
During interaction with the Administrator and Infection Preventionist from [DATE] through [DATE] resulted in the facility's inability to provide COVID-19 cumulative data (total of COVID-19 positive residents/staff, number of residents/staff hospitalized COVID-19 related, number of resident/staff deaths, current number of quarantined resident/staff and number of affected residents/staff that were vaccinated since the outbreak began and currently) for the facility.
A review of the data presented to the survey team on [DATE] indicated: 53 residents were identified with COVID-19. No information was provided as to how many residents were sent to the hospital. Nine residents were identified who expired from COVID-19. Eight staff were identified as COVID-19 positive. One staff was identified as out of work on quarantine. One resident was identified as never returned to work. One resident was identified who expired from COVID-19.
During an interview on [DATE] at 3:30 P.M. with the Administrator and Infection Preventionist they were asked if the facility staff had reached out to the local Health Department for assistants and guidance. The Administrator stated, the facility had not.
A [DATE] Local Health Report on the facility after an unannounced visit indicated: As of 9:30 am [DATE] we have had notification form the local hospital of 11 total admissions since [DATE] and 4 known deaths among patients arriving from the facility.
A determination was made for an immediate visit was necessary to:
1.
Assess status of patients regarding numbers currently ill
2.
Determine vaccination status of patients and staff
3.
Assess staffing and medical coverage
4.
Explore PPE use and availability; assist with procuring additional if needed
5.
Based on the number of patients ill, determine what, if any cohorting possibilities there are within the facility that could help limit transmission
6.
Look at any other mitigation strategies the IP and epi team believe could help
It was also determined that Local Health Department staff touch base with the facility's corporate office to let them know of our concerns and request their engagement.
A CDC Interim Infection Prevention and Control Recommendations to Prevent SARS-COV-2 Spread in Nursing Homes dated [DATE] indicated: Notify HCP (Health Care Professionals), Residents, and families about Outbreaks, and Report SARS-COV-2 Infections, Facility staffing, Testing, and Supply Information to Public Health Authorities
Notify the health department promptly about the following:
¢
1 residents or HCP with suspected or confirmed SAR-Cov-2 infection
¢
Resident with severe respiratory infection resulting in hospitalization or death
¢
3 residents or HCP with acute illness compatible with COVID-19 with onset within 72 hour period.
Find the contact information for the healthcare-associated infections program in your state health department, as well as your local health department.
Notify HCP, residents and family's promptly about identification of SARS-Cov-2 in the facility and maintain ongoing, frequent communication with HCP, residents, and families with updates on the situation and facility actions.
Report SARS-Cov-2 infections, facility staffing and supply information, and point of care testing data to the National HealthCare Safety Network (NHSN) Long term Care Facility (LTCF) COVID-19 Module weekly. CDC NHSN provides long term care facilities with a secure reporting platform to track infections and prevention process measures in a systematic way. Weekly data submission to NHSN will meet the Centers for Medicare and Medicaid Services (CMS) COVID-19 reporting requirements. Professional Resources: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html
A review of the Facility Assessment policy dated [DATE] indicated:
2. The facility assessment is completed at the facility level utilizing the following individuals:
a. Administrator
b. A representative from the governing body
c. The Medical Director
d. The Director of Nursing
A review of the Governing Body Policy dated [DATE] indicated:
The governing body is responsible and accountable for the Quality Assurance and Performance Improvement (QAPI) program/Quality Assurance (QA).
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility staff failed to conduct and document a facility wide assessment to determine what resources were necessary to assis...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility staff failed to conduct and document a facility wide assessment to determine what resources were necessary to assist in the prevention of the spread of COVID -19.
The findings included:
The facility staff failed to use outside resources including the Local Health Department during a Major COVID-19 outbreak in the facility. The level of Community Transmission was noted to be high (Red).
Upon entering the facility the Director of Nursing stated the facility was experiencing a major COVID outbreak. During the entrance conference the Administrator was asked how many COVID -19 positive residents and staff did the facility have. The Administrator stated there were 36 residents in the facility with COVID-19. On [DATE] the survey team was present with the 802 Resident matrix that coded three residents with COVID in the Infections section. On [DATE] the Infection Preventionist presented to the survey team with a list of residents on the 802 Resident matrix that totaled 21 residents with COVID -19. On [DATE] the Administrator presented to the survey team an 802 Resident matrix with 24 residents.
During interaction with the Administrator and Infection Preventionist from [DATE] through [DATE] resulted in the facility's inability to provide COVID-19 cumulative data (total of COVID-19 positive residents/staff, number of residents/staff hospitalized COVID-19 related, number of resident/staff deaths, current number of quarantined resident/staff and number of affected residents/staff that were vaccinated since the outbreak began and currently) for the facility.
A review of the data presented to the survey team on [DATE] indicated: 53 residents were identified with COVID-19. No information was provided as to how many residents were sent to the hospital. Nine residents were identified who expired from COVID-19. Eight staff were identified as COVID-19 positive. One staff was identified as out of work on quarantine. One resident was identified as never returned to work. One resident was identified who expired from COVID-19.
A review of the facility's COVID-19 Action Plan stated there would be three units set-up for the resident population in accordance with CDC Guidelines. The Units were described as a Well/Cool Unit, a Quarantine/Warm Unit for new admission and readmissions and an Isolation/Hot Unit for COVID-19 positive Unit. The facility had only one general well unit, one well memory unit, one well/COVID-19 positive memory unit and a full COVID-19 positive unit.
The facility staff failed to follow CDC guidance to ensure Health Care Personal (HCP) to include contract, agencies and vendors required COVID-19 testing was completed based on the level of community transmission and the results of each test was documented. As a result of the non-compliance with testing while the facility was in a major COVID-19 outbreak there had been further transmission, hospitalizations and deaths.
On [DATE], staff testing was observed and the documentation of the testing was reviewed. The Infection Preventionist stated testing for staff was two times weekly (Tuesday and Thursday). Review of those listed as tested revealed no documentation of their test results. The Infection Preventionist stated that indicated the results were negative. The results remained undocumented.
The Infection Preventionist was not able to provide how the facility HCP's met the requirements to be tested based on the level of community transmission. In accordance to CDC guidance the Facility's Assessment Program failed infection control measures and practices during a major outbreak to prevent further transmission of COVID-19:
1. Entry Notification/Visitation
2. PPE usage during major outbreak
3. COVID-19 surveillance plan
4. Unit set up in accordance with CDC Guidelines and facility policies and procedures
During an interview on [DATE] at 3:30 P.M. with the Administrator and Infection Preventionist they were asked if the facility staff had reached out to the local Health Department for assistants and guidance. The Administrator stated, the facility had not.
A [DATE] Local Health Report on the facility after an unannounced visit indicated: As of 9:30 am [DATE] we have had notification form the local hospital of 11 total admissions since [DATE] and 4 known deaths among patients arriving from the facility.
A determination was made for an immediate visit was necessary to:
1.
Assess status of patients regarding numbers currently ill
2.
Determine vaccination status of patients and staff
3.
Assess staffing and medical coverage
4.
Explore PPE use and availability; assist with procuring additional if needed
5.
Based on the number of patients ill, determine what, if any cohorting possibilities there are within the facility that could help limit transmission
6.
Look at any other mitigation strategies the IP and epi team believe could help
It was also determined that Local Health Department staff touch base with the facility's corporate office to let them know of our concerns and request their engagement.
A CDC Interim Infection Prevention and Control Recommendations to Prevent SARS-COV-2 Spread in Nursing Homes dated [DATE] indicated: Notify HCP (Health Care Professionals), Residents, and families about Outbreaks, and Report SARS-COV-2 Infections, Facility staffing, Testing, and Supply Information to Public Health Authorities
Notify the health department promptly about the following:
¢
1 residents or HCP with suspected or confirmed SAR-Cov-2 infection
¢
Resident with severe respiratory infection resulting in hospitalization or death
¢
3 residents or HCP with acute illness compatible with COVID-19 with onset within 72 hour period
Find the contact information for the healthcare-associated infections program in your state health department, as well as your local health department.
Notify HCP, residents and family's promptly about identification of SARS-Cov-2 in the facility and maintain ongoing, frequent communication with HCP, residents, and families with updates on the situation and facility actions.
Report SARS-Cov-2 infections, facility staffing and supply information, and point of care testing data to the National HealthCare Safety Network (NHSN) Long term Care Facility (LTCF) COVID-19 Module weekly. CDC NHSN provides long term care facilities with a secure reporting platform to track infections and prevention process measures in a systematic way. Weekly data submission to NHSN will meet the Centers for Medicare and Medicaid Services (CMS) COVID-19 reporting requirements.
A review of the facility's COVID-19 Action Plan dated [DATE] indicated:
COVID Response Plan
1.
There will be 3 units set for resident populations in accordance with CDC Guidelines
2.
Well/Cool Unit
3.
Quarantine/Warm Unit- for new admission and readmissions
4.
Isolation/Hot Unit-COVID-19 Positive Residents
5.
Goals:
All residents will remain free from complications related to the COVID-19 pandemic
Reduce the transmission of the COVID-19 Virus
A Facility assessment dated [DATE] indicated:
The facility must conduct and document a facility -wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for any changes that would require a substantial modification to any part of this assessment. The facility assessment must address or include:
1. The facility's resident population, including, but not limited to,
(ii) The care required by the resident's population considering the type of diseases
2. The facility's resources\, including but not limited to,
(v) Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies;
Additional References to the Facility Assessment:
Infection Control- Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum,, the following elements: (1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to and following accepted national standards.
In the area of Special Treatments/Resident Care Needs: Special Services- Transmission Based Precautions (Isolation) zero (0) was indicated in the average number of resident's per-month column.
In the Facility Assessment Section 3.11- indicated: The facility's infection control program is monitored and reviewed at the monthly QAPI meeting. The QAPI team reviews metrics and trends to evaluate the infection prevention and control program as well as monitor effective systems for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, volunteers, and visitors.
During an interview at 2:21 PM on [DATE] with the Administrator he was asked for the facility's Risk Assessment and Patient Population Emergency Preparedness Plan including policy's and procedures. The Administrator provided a Facility Assessment Tool 2021. A Facility and Community Risk Assessment - Hazard and Vulnerability Tool for Naturally Occurring Events 2021 was provided. When asked how many residents were identified with COVID-19 and had been hospitalized the Administrator stated he did not know.
A review of the facility's COVID-19 Action Plan stated there would be three units set-up for the resident population in accordance with CDC Guidelines. The Units were described as a Well/Cool Unit, a Quarantine/Warm Unit for new admission and readmissions and an isolation/Hot Unit for COVID-19 positive Unit. The facility had only one general well unit, one well memory unit, one well/COVID-19 positive memory unit and a full COVID-19 positive unit.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0840
(Tag F0840)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility staff failed to utilize outside resource to assist in the prevention of the spread of COVID -19 which resulted in h...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility staff failed to utilize outside resource to assist in the prevention of the spread of COVID -19 which resulted in hospitalizations and deaths.
The findings included:
The facility staff failed to use outside resources including the Local Health Department during a Major COVID-19 outbreak in the facility. The outbreak started on 08/28/21 according to the facility's records. During entrance to the facility on [DATE] signage on the front door at the visitor's entrance read face mask required at all times. The signage lacked clear information/alerts to visitors. Review of other visitor entrances (kitchen, construction unit and the laundry door connecting with Unit 1 revealed no signage).
Upon entering the facility, staff members stated screening was a self-performed task. After multiple days of reviewing the screening logs the team was unable to account for many on duty staff.
Multiple attempts between 09/21/21 and 09/23/21 were made with the infection Preventionist to review the facility's COVID-19 system for capturing COVID-19 cases. Upon entrance on 09/20/21 the Administrator stated there were 36 incidences of COVID-19 in the facility and two staff. A review of the facility's 802 Resident Matrix as presented to the survey team identified (3) residents with COVID-19. Each interaction with the Administrator and Infection Preventionist resulted in the facility's inability to provide COVID-19 cumulative data ( total of COVID 19 positive residents/staff, number of residents/staff hospitalized COVID-19 related, number of resident/staff deaths, current number of quarantined resident/staff and number of affected residents/staff that were vaccinated since the outbreak began and currently) for the facility.
A review of the facility's COVID-19 Action Plan stated there would be three units set-up for the resident population in accordance with CDC Guidelines. The Units were described as a Well/Cool Unit, a Quarantine/Warm Unit for new admission and readmissions and an isolation/Hot Unit for COVID-19 positive Unit. The facility had only one general well unit, one well memory unit, one well/COVID-19 positive memory unit and a full COVID-19 positive unit.
Various types of mask were observed donned by the facility staff but regardless of the type of mask worn most staff were observed not appropriately positioned to cover the nose and mouth.
The facility staff failed to follow CDC guidance to ensure Health Care Personal (HCP) to include contract, agencies and vendors required COVID-19 testing was completed based on the level of community transmission and the results of each test was documented. As a result of the non-compliance with testing while the facility was in a major COVID-19 outbreak.
On 09/21/21 staff testing was observed and the documentation of the testing was reviewed. The Infection Preventionist stated testing for staff was two times weekly (Tuesday and Thursday). Review of those listed as tested revealed no documentation of their test results. The Infection Preventionist stated that indicated the results were negative. The results remained undocumented.
During an interview on 09/23/21 at 2:15 P.M. with the administrator he was asked had the Local Health Department been contacted to assist the facility in assessing the status of residents and the number of resident who have been hospitalized . The Administrator, stated, No the facility had not contacting the Local Health Department for that purpose. The administrator was asked if the facility had outside resources whom he could consult regarding the COVID-19 outbreak. The administrator stated, corporate office had sent several regional staff including a Regional Corporate Nurse to assist with the outbreak.
A 09/17/21 Local Health Report on the facility after an unannounced visit indicated: As of 9:30 am September 17, 2021 we have had notification form the local hospital of 11 total admissions since [DATE] and 4 known deaths among patients arriving from the facility.
A determination was made for an immediate visit was necessary to:
1.
Assess status of patients regarding numbers currently ill
2.
Determine vaccination status of patients and staff
3.
Assess staffing and medical coverage
4.
Explore PPE use and availability; assist with procuring additional if needed
5.
Based on the number of patients ill, determine what, if any cohorting possibilities there are within the facility that could help limit transmission
6.
Look at any other mitigation strategies the IP and epi team believe could help
It was also determined that Local Health Department staff touch base with the facility's corporate office to let them know of our concerns and request their engagement.
A CDC Interim Infection Prevention and Control Recommendations to Prevent SARS-COV-2 Spread in Nursing Homes dated 09/10/21 indicated: Notify HCP (Health Care Professionals), Residents, and families about Outbreaks, and Report SARS-COV-2 Infections, Facility staffing, Testing, and Supply Information to Public Health Authorities
Notify the health department promptly about the following:
-1 residents or HCP with suspected or confirmed SAR-Cov-2 infection
-Resident with severe respiratory infection resulting in hospitalization or death
-3 residents or HCP with acute illness compatible with COVID-19 with onset within 72 hour period. Find the contact information for the healthcare-associated infections program in your state health department, as well as your local health department.
Notify HCP, residents and family's promptly about identification of SARS-Cov-2 in the facility and maintain ongoing, frequent communication with HCP, residents, and families with updates on the situation and facility actions.
Report SARS-Cov-2 infections, facility staffing and supply information, and point of care testing data to the National Healthcare Safety Network (NHSN) Long term Care Facility (LTCF) COVID-19 Module weekly. CDC NHSN provides long term care facilities with a secure reporting platform to track infections and prevention process measures in a systematic way. Weekly data submission to NHSN will meet the Centers for Medicare and Medicaid Services (CMS) COVID-19 reporting requirements. Professional source: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html
An Administration Facility policy revised 10/22/20 Indicated: The facility will provide polices and systems that it is administered in a manner that will focus on attaining and maintaining the highest practicable physical, mental and psychosocial well-being of each resident.
Policy Explanation and Compliance Guidelines:
The facility will follow the accepted professional standards and principles of the various practice acts and regulations for the various licensed personnel within the facility. The facility will employ professionals necessary to carry out the provisions of requirements.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected most or all residents
Based on deficiencies determined during this survey the QAA (Quality Assessment and Assurance) and Quality Assurance and Performance Improvement (QAPI) committee failed to develop and implement correc...
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Based on deficiencies determined during this survey the QAA (Quality Assessment and Assurance) and Quality Assurance and Performance Improvement (QAPI) committee failed to develop and implement corrective plans of action and monitoring to ensure the necessary systems were in place and correct identified quality deficiencies during a major outbreak of SARS-CoV-2 in the facility beginning 08/28/2021. Immediate Jeopardy to the resident health and safety was identified on 09/23/21 in the area of Infection Control at (F-880 and F886) at a scope and severely level 4 Widespread (L) which constituted Substandard Quality of Care.
The findings included:
On 9/23/21 at 8:37 p.m., the facility Administrator, Director of Nursing and three Corporate Consultants were informed of the above Immediate Jeopardy concerns at F-880; Infection Prevention and Control Program secondary to an outbreak of SARS-CoV-2 infections within the facility. On the same day and at the same time, the Administrator, Director of Nursing and three Corporate Consultants were also informed of the above Immediate Jeopardy concerns at F-886; COVID-19 Testing; during an outbreak of SARS-CoV-2 infections within the facility. Observations were made of staff non-compliance with screening, improper use Personal Protective Equipment (PPE), no post visual signs at the entrance and/or in strategic places with instructions about current Infection Prevention Control recommendations related to SARS-CoV-2, staff's inability to provide documentation of staff and resident vaccination status, cumulative clinical data of cases of SARS-CoV-2 infections, and measures/practices and the necessary systems were in place and correct identified quality deficiencies to protect the health and safety of the residents during a major outbreak of SARS-CoV-2 in the facility.
The QAPI document was received via email from the admission Coordinator on 09/21/21 at approximately 2:52 p.m. The most recent QAPI meeting was held on 09/14/21, when the facility was already in a major outbreak of SARS-CoV-2. The facility also provided the attendance sheet which showed all the required members were present.
Review of the facility's QAPI for 09/14/21 did not provide any evidence a system in place for routine monitoring of managing residents with suspected or confirmed SARS-CoV-2, screening of visitors and healthcare personnel, monitoring of unvaccinated employees, improper wear of Personal Protective Equipment (PPE), cumulative clinical data of cases of SARS-CoV-2 infections and unit set up in accordance with CDC Guidelines.
On 09/29/21 at approximately 10:30 a.m., a phone interview was conducted with the Administrator, Regional Director of Clinical Services, MDS Coordinator and Infection Preventionist (IP)/Staff Development Coordinator (SDC). The IP said the issues related to the most recent outbreak was discussed and acted upon during the QAPI meeting held on 09/14/21. IP stated, I will get that information to you right away.
After several attempts to reach the IP via phone on 09/29/21, the IP was reached on 09/30/21 at approximately 8:43 a.m., who stated, I' not able to provide evidence that the issues that were discussed during the QAPI meeting held on 09/14/21 related to the recent outbreak of COVID-19 on 08/28/21 was every addressed by me or the QAA committee.
A phone interview was conducted with the Administrator on 09/30/21 at approximately 2:27 p.m., who stated, The COVID-19 outbreak started in the facility on 08/28/21 and we had our QAPI meeting on 09/14/21. He said IP should have started COVID education once we (QAA meeting) realized there was an outbreak on 08/28/21 and that training and education should have continued until everyone were reeducated and the QAA committee should have put the necessary steps inn place to identify the cause and correct the issue (outbreak of COVID-19) in the building.
A phone interview was conducted with the Administrator on 09/30/21 at approximately 2:27 p.m., who stated that the facility had a QAPI meeting on 09/14/21 but did not address the issues related to the recent outbreak of COVID-19 within the facility. He said an action plan should have been put in place to address the recent outbreak but that did not occur.
The QAA committee is responsible for identify and correcting identified quality deficiencies. The facility was not able to provide evidence that the facilities QAA meeting had a systematic plan in place to maintain and improve the safety and quality in the facility involving the resident and staff and took the necessary steps to identify the cause and correct the problem.
The Administrator, Interim Director of Nursing, Chief Operating Officer, Regional Director of Operations and Regional Director of Clinical Services was informed of the findings during the exit meeting on 09/30/21 at approximately 7:40 p.m. The facility did not have any further questions or present any further information about the findings.
The facility's policy titled Quality Assessment and Assurance Committee (QAA) - revision date 10/22/20. This facility will maintain a (QAA) Committee to identify quality issues and develop appropriate plans of action to correct quality deficiencies through an interdisciplinary approach.
Policy Explanation and Compliance Guidelines include but not limited to:
4. The QAA committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAA program. The committee will:
-Meet at least quarterly and as needed.
-Provide oversite of the QAPI program.
-Identify and respond to quality deficiencies throughout the facility.
-Develop and implement corrective plans of action, and monitor to ensure performance goals or targets are achieved and sustained.
The facility's policy titled Quality Assurance and Performance Improvement (QAPI) - revision date 12/22/20. It is the policy of the facility to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life.
Policy Explanation and Compliance Guidelines include but not limited to:
-Develop and implement appropriate plans of action to correct identified quality deficiencies.
3. The QAPI plan will address the following elements:
-Process for addressing how the committee will conduct activities necessary to identify and correct quality deficiencies. Key components of this process include, but are not limited to, the following: Tracking and measuring performances, establishing goals and thresholds for performance improvements, identifying and prioritizing quality deficient, systematically analyzing underlying causes of systemic quality deficiencies, developing and implementing corrective action or performance improvement activities and a process to ensure care and services delivered meet acceptable standards of quality.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interview, the facility staff failed to maintain an effective pest control progr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interview, the facility staff failed to maintain an effective pest control program.
The findings included:
Roaches and fly's were observed through the facility on all days of the survey and on all units. These units included: The closed unit 4, Rehab Unit, locked units 3 and 5, as well as Unit 1 COVID-19.
Roaches were observed in the front corridor bathrooms, as well as the wall ways. A brownish waste like matter was observed oozing from the roaches leaving a trail like substance on the floor. A house keeper was observed walking around with a spray container daily, spraying various areas of the facility. During an interview on 09/22/21 at 10:00 A.M. with the house keeper he stated, his job was to spray the building daily to help control the roaches.
A customer service report of a pest control firm dated 4/13/21 indicated: Treated rooms, 9, 11, 13, 15, 17, 21, 23, 25, 26, 28, 29, and 30 for roaches. Rats noted during service bait station 1-8. A pest Sighting Log dated 7/28/21 indicated: Roaches- Unit 1 room [ROOM NUMBER]- several roaches in room. Sighting Log dated 6/9/21 indicated Roaches Unit 1 Nurses Station. A Sighting Log dated 7/21/21 and 8/2/21 indicated Kitchen prep area: mouse in back storage area near bread rack.
A 7/30/21 Pest Sighting Log indicated: Roaches nest in nursing med cart Unit 2.
During an interview on 09/29/21 with the Administrator he stated, I have a staff member going around daily spraying all areas of the facility to help control the roaches.
A Pest Control policy and procedure revised 10/28/20 indicated: It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. An effective pest control program is defined as measures to eradicate and contain common household pests (e.g. bed bugs, lice, roaches, ants, mosquitos, flies, mice and rats).
Mar 2020
24 deficiencies
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, the facility staff failed to ensure Medicare Beneficiary Notices in accordance with applicable Federal regulations, were is...
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Based on staff interview, clinical record review and facility documentation, the facility staff failed to ensure Medicare Beneficiary Notices in accordance with applicable Federal regulations, were issued to 2 of 3 residents (Resident #3 and #87) in the survey sample.
The findings included:
1. The facility staff failed to issue a Notice of Medicare Non-Coverage (NOMNC) letter to Resident #3 who was discharged from skilled services with Medicare days remaining. Resident #3 was admitted to the nursing facility on 11/11/19. Diagnoses for Resident #3 included but not limited to Muscle Weakness. Resident #3's Minimum Data Set (MDS) a significant change assessment with an Assessment Reference Date (ARD) date of 11/18/19 coded Resident #3 with an 02 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating severely impaired cognitive skills for daily decision-making.
On review of the Beneficiary Notification Checklists provided by the facility to surveyor, it was noted that Resident #3 was not listed for having been issued the Notice of Medicare Non-Coverage (NOMNC) letter. The resident had received the SNF ABN (Skilled Nursing Facility-Advanced Beneficiary Notice) however, no copies of the (NOMNC) was provided.
Resident #3 started a Medicare Part A stay on 10/04/19 and the last covered day of this stay was 12/04/19. Resident #3 was discharged from Medicare Part A services when benefit days were not exhausted and should have been issued a SNF ABN (CMS-10055) and an NOMNC (CMS-10123). Resident #3 had only used 31 days of her Medicare Part A services. Only a SNF ABN letter was issued.
An interview was conducted with the Social Services Director (SSD) on 03/03/20 at approximately 2:00 p.m. The SSD stated, I did not realize they could receive both; an ABN and NOMNC letter. The SSD said she only gave Resident #3 an ABN letter.
A briefing was held with the Administrator and Director of Nursing on 03/03/20 at approximately 4:00 p.m. The facility did not present any further information about the findings.
2. The facility staff failed to issue a Notice of Medicare Non-Coverage (NOMNC) letter to Resident #87 who was discharged from skilled services with Medicare days remaining. Resident #87 was admitted to the nursing facility on 01/19/20. Diagnoses for Resident #87 included but not limited to Muscle Weakness. Resident #87's Minimum Data Set (MDS) a 5-day PPS with an (ARD) date of 01/23/20 coded Resident #87 with short and long-term memory problems and cognitive skills severely impaired-never/rarely made decisions.
On review of the Beneficiary Notification Checklists provided by the facility to surveyors, it was noted that Resident #87 was not listed for having been issued the Notice of Medicare Non-Coverage (NOMNC) letter. The resident had received the SNF ABN (Skilled Nursing Facility-Advanced Beneficiary Notice) however, no copies of the (NOMNC) was provided.
Resident #87 started a Medicare Part A stay on 01/19/20, and the last covered day of this stay was 02/11/20. Resident #87 was discharged from Medicare Part A services when benefit days were not exhausted and should have been issued a SNF ABN (CMS-10055) and an NOMNC (CMS-10123). Resident #87 only used 37 days of her Medicare Part A services. Only an NOMNC was issued.
An interview was conducted with the Social Services Director (SSD) on 03/03/20 at approximately 2:00 p.m. The SSD stated, I did not realize they could receive both; an ABN and NOMNC letter. The SSD said she only gave Resident #87 an ABN letter.
A briefing was held with the Administrator and Director of Nursing on 03/03/20 at approximately 4:00 p.m. The facility did not present any further information about the findings.
CONCERN
(D)
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 and facility document review, the facility staff failed to implement their Abuse Investig...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and facility document review, the facility staff failed to implement their Abuse Investigation and Reporting Policy after a witnessed allegation of abuse/mistreatment for 1 of 57 Residents in the survey sample, Resident #64.
The findings included:
Resident #64 was admitted to the facility on [DATE] with diagnoses to include but not limited to Schizophrenia, Major Depressive Disorder, Bipolar Disorder and Dementia.
Resident #64's most recent comprehensive Minimum Data Set (MDS) was an annual assessment with an Assessment Reference Date (ARD) of 1/7/2020. The Brief Interview for Mental Status (BIMS) for Resident #64 was coded as having short and long term memory recall problems and severely impaired for cognition and daily decision making.
On 3/3/20 at approximately 12:15 P.M. a test tray food cart was followed onto Unit 5, the secured unit. At the first doorway of the dining area of the secure unit CNA (Certified Nursing Assistant) #2 was observed behind Resident #64's wheelchair pushing him with full force under the table and yelling at him Put your legs down. When Resident #64 resisted being pushed up to the table, CNA #2 went to the other side of the table and pushed the table into him. Resident #64 yelled, Stop. CNA #2 then said, Don't you yell at me. There was no other resident at the table and there was also no other staff members in the room at the time of this incident. The Dietary Manager was standing on my left side in the hallway and did hear the incident when asked about it. The Dietary Manager stated, I couldn't see what was happening I just heard her loud tone I thought she was redirecting him. CNA #3 and LPN (Licensed Practical Nurse) #5 were down near the entrance of the secured unit when the incident occurred, the dining area is at the back of the unit.
On 3/3/20 at 12:40 P.M. the Administrator was made aware of the above witnessed interaction by the surveyor between CNA #2 and Resident #64 with physical demonstration. The Administrator was told to please provide any documentation to the surveyor of the facility's response to the incident.
Prior to leaving the facility on 3/3/20 at 5:00 P.M. no facility documentation was provided to the surveyor.
On 3/4/20 at 9:40 A.M. the Administrator was asked for the Facility Reportable Incident (FRI) Form that was sent to the State Agency regarding the incident between Resident #64 and CNA #2 on 3/2/20 witnessed by this surveyor. The Administrator stated, Give us a minute.
On 3/4/20 at approximately 11:00 A.M. the Administrator provided an Investigational Summary which was reviewed and is documented in part, as follows:
Investigation Regarding: Abuse allegation
Date Prepared: 3/2/20
Prepared By: Name (Administrator)
I. Cause to Initiate Investigation:
Survey team member (Name) informed Administration that she witnessed (Name) CNA #2 pushing (Name) Resident #64 up to the dining room table in an aggressive manner. Surveyor states that the CNA was yelling at the resident to put down your legs:. She states that she overheard the resident say stop and (Name) CNA #2 allegedly stated don't you yell at me. The CNA was placed on administrative suspension pending investigation.
II. Investigation:
Statements were taken from other staff members who were witness to the event including (Name) Dietary Manager and (Name) CNA #3. Both statements indicate that they did not observe anything that could be considered abuse and did not feel that (Name) CNA #2 was inappropriate with (Name) Resident #64. Family members for two other residents who reside on the unit were contacted to determine if they have had any issues with the care provided by the CNA's on the unit. Both stated that they do not have any care issues or concerns about how staff treat the residents. Staff member (Name) LPN #5 was not a witness to the incident but works with (Name) CNA #2 on the unit. She states that she has never witnessed (Name) CNA #2 being inappropriate or abusive with residents. (Name) CNA #2 was interviewed regarding the incident. She states that (Name) Resident #64 attempted to kick the table with his feet and she was concerned that the table was going to fall on the legs of another resident. She pulled (Name) Resident #64 back and steadied the table and told the resident to put his legs down so that he could be positioned under the table in preparation for the meal. (Name) CNA #2 was asked if she felt that she was inappropriate with the resident and she responded by stating that she knows that she is very loud and sometimes people misinterpret that but that she would never be abusive towards a resident. (Name) CNA #2's personnel record was reviewed and she does not have and disciplinary actions or violations of policy in her file.
III. Summary of Investigation:
After speaking with the CNA involved in the incident, the staff on the unit, family members and colleagues who work with (NAME) CNA #2, we were unable to substantiate that the survey team member witnessed an abuse situation. Staff members report that (NAME) CNA #2 is an excellent CNA and she is very respectful and affectionate with her residents.
IV. Recommendations:
Even though the facility was unable to substantiate abuse in this incident the facility will continue to provide regular staff training on the abuse policy and report allegations of abuse per regulatory guidelines.
No FRI was presented at the time the Investigational Summary was given to this surveyor.
On 3/4/20 at approximately 5:45 P.M. the Administrator was asked if she had submitted a FRI to the State Office regarding the abuse/mistreatment allegation for Resident #64. The Administrator stated, No, we didn't, I thought (NAME) Regional Director of Operations told you that we didn't.
The facility policy titled Abuse Prevention Program revised December 2016 was reviewed and is documented in part, as follows:
Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse and physical or chemical restraint not required to treat the resident's symptoms.
Policy Interpretation and Implementation:
3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents.
6. Identify and assess all possible incidents of abuse.
7. Investigate and report any allegations of abuse within timeframes as required by federal requirements.
The facility policy titled Abuse Investigation and Reporting revised July 2017 was reviewed and is documented in part, as follows:
Policy Statement: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigation will also be reported.
Role of the Investigator:
e. Interview the resident (as medical appropriate).
i. Interview other residents to whom the accused employee provides care or services.
Reporting:
1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies:
a. The State licensing/certification agency responsible for surveying/licensing the facility;
b. The local/State Ombudsman;
c. The Resident's Representative (Sponsor) of Record;
d. Adult Protective Services;
e. Law enforcement officials;
f. The resident's Attending Physician;
g. The facility Medical Director.
2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than:
a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or
b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.
On 3/5/20 at 3:50 P.M. a pre-exit debriefing was held with the Administrator, the Director of Nursing and the Regional Director of Operations where the above information was discussed.
Prior to exit 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and facility document review the facility staff failed to report an allegation of abuse/m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and facility document review the facility staff failed to report an allegation of abuse/mistreatment to the State Survey Agency and Adult Protective Services within the required time frame for 1 of 57 Residents in the survey sample, Resident #64.
The findings included:
Resident #64 was admitted to the facility on [DATE] with diagnoses to include but mot limited to Schizophrenia, Major Depressive Disorder, Bipolar Disorder and Dementia.
Resident #64's most recent comprehensive Minimum Data Set (MDS) is an annual assessment with an Assessment Reference Date (ARD) of 1/7/2020. The Brief Interview for Mental Status (BIMS) for Resident #64 was coded as having short and long term memory recall problems and severely impaired for cognition and daily decision making.
On 3/3/20 at approximately 12:15 P.M. a test tray food cart was followed onto Unit 5 the secured unit. At the first doorway of the dining area of the secure unit CNA (Certified Nursing Assistant) #2 was observed behind Resident #64's wheelchair pushing him with full force under the table and yelling at him Put your legs down. When the Resident #64 resisted being pushed up to the table, CNA #2 went to the other side of the table and pushed the table into him. Resident #64 yelled, Stop. CNA #2 then said, Don't you yell at me. There was no other resident at the table and there was also no other staff members in the room at the time of this incident. The Dietary Manager was standing on my left side in the hallway and did hear the incident when asked about it. The Dietary Manager stated, I couldn't see what was happening I just heard her loud tone I thought she was redirecting him. CNA #3 and LPN (Licensed Practical Nurse) #5 were down near the entrance of the secured unit when the incident occurred, the dining area is at the back of the unit.
On 3/3/20 at 12:40 P.M. the Administrator was made aware of the above witnessed interaction by the surveyor between CNA #2 and Resident #64 with physical demonstration. The Administrator was told to please provide any documentation to the surveyor of the facilities response to the incident.
Prior to leaving the facility on 3/3/20 at 5:00 P.M. no facility documentation was provided to the surveyor.
On 3/4/20 at 9:40 A.M. the Administrator was asked for the Facility Reportable Incident (FRI) Form that was sent to the State Agency regarding the incident between Resident #64 and CNA #2 on 3/2/20 witnessed by this surveyor. The Administrator stated, Give us a minute.
On 3/4/20 at approximately 11:00 A.M. the Administrator provided an Investigational Summary which was reviewed and is documented in part, as follows:
Investigation Regarding: Abuse allegation
Date Prepared: 3/2/20
Prepared By: Name (Administrator)
I. Cause to Initiate Investigation:
Survey team member (Name) informed Administration that she witnessed (Name) CNA #2 pushing (Name) Resident #64 up to the dining room table in an aggressive manner. Surveyor states that the CNA was yelling at the resident to put down your legs:. She states that she overheard the resident say stop and (Name) CNA #2 allegedly stated don't you yell at me. The CNA was placed on administrative suspension pending investigation.
II. Investigation:
Statements were taken from other staff members who were witness to the event including (Name) Dietary Manager and (Name) CNA #3. Both statements indicate that they did not observe anything that could be considered abuse and did not feel that (Name) CNA #2 was inappropriate with (Name) Resident #64. Family members for two other residents who reside on the unit were contacted to determine if they have had any issues with the care provided by the CNA's on the unit. Both stated that they do not have any care issues or concerns about how staff treat the residents. Staff member (Name) LPN #5 was not a witness to the incident but works with (Name) CNA #2 on the unit. She states that she has never witnessed (Name) CNA #2 being inappropriate or abusive with residents. (Name) CNA #2 was interviewed regarding the incident. She states that (Name) Resident #64 attempted to kick the table with his feet and she was concerned that the table was going to fall on the legs of another resident. She pulled (Name) Resident #64 back and steadied the table and told the resident to put his legs down so that he could be positioned under the table in preparation for the meal. (Name) CNA #2 was asked if she felt that she was inappropriate with the resident and she responded by stating that she knows that she is very loud and sometimes people misinterpret that but that she would never be abusive towards a resident. (Name) CNA #2's personnel record was reviewed and she does not have and disciplinary actions or violations of policy in her file.
III. Summary of Investigation:
After speaking with the CNA involved in the incident, the staff on the unit, family members and colleagues who work with (NAME) CNA #2, we were unable to substantiate that the survey team member witnessed an abuse situation. Staff members report that (NAME) CNA #2 is an excellent CNA and she is very respectful and affectionate with her residents.
IV. Recommendations:
Even though the facility was unable to substantiate abuse in this incident the facility will continue to provide regular staff training on the abuse policy and report allegations of abuse per regulatory guidelines.
No FRI was presented at the time the Investigational Summary was given to this surveyor.
On 3/4/20 at approximately 5:45 P.M. the Administrator was asked if she had submitted a FRI to the State Office regarding the abuse/mistreatment allegation for Resident #64. The Administrator stated, No, we didn't, I thought (NAME) Regional Director of Operations told you that we didn't
The facility policy titled Abuse Prevention Program revised December 2016 was reviewed and is documented in part, as follows:
Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse and physical or chemical restraint not required to treat the resident's symptoms.
Policy Interpretation and Implementation:
3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents.
6. Identify and assess all possible incidents of abuse.
7. Investigate and report any allegations of abuse within timeframes as required by federal requirements.
The facility policy titled Abuse Investigation and Reporting revised July 2017 was reviewed and is documented in part, as follows:
Policy Statement: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigation will also be reported.
Reporting:
1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies:
a. The State licensing/certification agency responsible for surveying/licensing the facility;
b. The local/State Ombudsman;
c. The Resident's Representative (Sponsor) of Record;
d. Adult Protective Services;
e. Law enforcement officials;
f. The resident's Attending Physician;
g. The facility Medical Director.
2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than:
a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or
b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.
On 3/5/20 at 3:50 P.M. a pre-exit debriefing was held with the Administrator, the Director of Nursing and the Regional Director of Operations where the above information was discussed. Prior to exit no further information was provided.
CONCERN
(D)
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 and facility document review the facility staff failed to thoroughly investigate a witnes...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and facility document review the facility staff failed to thoroughly investigate a witnessed allegation of abuse/mistreatment for 1 of 57 Residents in the survey sample, Resident #64.
The findings included:
Resident #64 was admitted to the facility on [DATE] with diagnoses to include but mot limited to Schizophrenia, Major Depressive Disorder, Bipolar Disorder and Dementia.
Resident #64's most recent comprehensive Minimum Data Set (MDS) is an Annual Assessment with an Assessment Reference Date (ARD) of 1/7/2020. The Brief Interview for Mental Status (BIMS) for Resident #64 was coded as having short and long term memory recall problems and severely impaired for cognition and daily decision making.
On 3/3/20 at approximately 12:15 P.M. a test tray food cart was followed onto Unit 5 the secured unit. At the first doorway of the dining area of the secure unit CNA (Certified Nursing Assistant) #2 was observed behind Resident #64's wheelchair pushing him with full force under the table and yelling at him Put your legs down. When the Resident #64 resisted being pushed up to the table, CNA #2 went to the other side of the table and pushed the table into him. Resident #64 yelled, Stop. CNA #2 then said, Don't you yell at me. There was no other resident at the table and there was also no other staff members in the room at the time of this incident. The Dietary Manager was standing on my left side in the hallway and did hear the incident when asked about it. The Dietary Manager stated, I couldn't see what was happening I just heard her loud tone I thought she was redirecting him. CNA #3 and LPN (Licensed Practical Nurse) #5 were down near the entrance of the secured unit when the incident occurred, the dining area is at the back of the unit.
On 3/3/20 at 12:40 P.M. the Administrator was made aware of the above witnessed interaction by the surveyor between CNA #2 and Resident #64 with physical demonstration. The Administrator was told to please provide any documentation to the surveyor of the facilities response to the incident.
Prior to leaving the facility on 3/3/20 at 5:00 P.M. no facility documentation was provided to the surveyor.
On 3/4/20 at 9:40 A.M. the Administrator was asked for the Facility Reportable Incident (FRI) Form that was sent to the State Agency regarding the incident between Resident #64 and CNA #2 on 3/2/20 witnessed by this surveyor. The Administrator stated, Give us a minute.
On 3/4/20 at approximately 10:30 A.M. an interview was conducted with Resident #64. Resident #64 was asked if anything happen when he was in the dining room for lunch yesterday. Resident stated, She banged my knee, I don't like to be yelled at. Resident #64 was able to verbalize his name, the correct year and who the current President was.
On 3/4/20 at approximately 10:45 A.M. an interview was conducted with the Dietary Manager regarding what he witnessed with Resident #64 in the dining area on 3/3/20 around 12:15 P.M. The Dietary Manager stated, I did not see anything, I was outside of the room I heard the CNA being loud I thought she was redirecting the resident. I did not hear the actual verbage. I was concentrating on you and focused on getting the temperatures of the test trays. I didn't process the verbage of what I heard.
On 3/4/20 at approximately 10:50 A.M. an interview was conducted with CNA #3 regarding what he witnessed with Resident #64 in the dining area on 3/3/20 around 12:15 P.M. CNA #3 stated, I didn't see anything prior to passing trays. I was probably gathering other residents. When I was asked about it I thought they were talking about when we were passing trays, I wasn't in the room prior to passing trays.
On 3/4/20 at approximately 11:00 A.M. the Administrator provided an Investigational Summary which was reviewed and is documented in part, as follows:
Investigation Regarding: Abuse allegation
Date Prepared: 3/2/20
Prepared By: Name (Administrator)
I. Cause to Initiate Investigation:
Survey team member (Name)) informed Administration that she witnessed (Name) CNA #2 pushing (Name) Resident #64 up to the dining room table in an aggressive manner. Surveyor states that the CNA was yelling at the resident to put down your legs:. She states that she overheard the resident say stop and (Name) CNA #2 allegedly stated don't you yell at me. The CNA was placed on administrative suspension pending investigation.
II. Investigation:
Statements were taken from other staff members who were witness to the event including (Name) Dietary Manager and (Name) CNA #3. Both statements indicate that they did not observe anything that could be considered abuse and did not feel that (Name) CNA #2 was inappropriate with (Name) Resident #64. Family members for two other residents who reside on the unit were contacted to determine if they have had any issues with the care provided by the CNA's on the unit. Both stated that they do not have any care issues or concerns about how staff treat the residents. Staff member (Name) LPN #5 was not a witness to the incident but works with (Name) CNA #2 on the unit. She states that she has never witnessed (Name) CNA #2 being inappropriate or abusive with residents. (Name) CNA #2 was interviewed regarding the incident. She states that (Name) Resident #64 attempted to kick the table with his feet and she was concerned that the table was going to fall on the legs of another resident. She pulled (Name) Resident #64 back and steadied the table and told the resident to put his legs down so that he could be positioned under the table in preparation for the meal. (Name) CNA #2 was asked if she felt that she was inappropriate with the resident and she responded by stating that she knows that she is very loud and sometimes people misinterpret that but that she would never be abusive towards a resident. (Name) CNA #2's personnel record was reviewed and she does not have and disciplinary actions or violations of policy in her file.
III. Summary of Investigation:
After speaking with the CNA involved in the incident, the staff on the unit, family members and colleagues who work with (NAME) CNA #2, we were unable to substantiate that the survey team member witnessed an abuse situation. Staff members report that (NAME) CNA #2 is an excellent CNA and she is very respectful and affectionate with her residents.
IV. Recommendations:
Even though the facility was unable to substantiate abuse in this incident the facility will continue to provide regular staff training on the abuse policy and report allegations of abuse per regulatory guidelines.
No FRI was presented at the time the Investigational Summary was given to this surveyor.
On 3/4/20 at approximately 11:20 A.M. an interview was conducted with Resident # 20 whom also resides on the secure unit regarding what he witnessed with Resident #64 in the dining area on 3/3/20 around 12:15 P.M. Resident #20's most recent MDS was reviewed which was an Annual Assessment with an ARD of 2/20/20. The BIMS for Resident #20 was a 15 out of a possible 15 indicating that the resident is cognitively intact and capable of daily decision making. Resident #20 stated, I saw (Name) CNA #2 pushing (Name) Resident #64 legs under the table. She was yelling and rough with him. I see that often and it's not good. Resident #20 was asked how seeing that makes him feel. Resident #20 stated, Makes me feel bad because they can't speak for themselves. I was sitting right there I saw it. Resident #20 was asked if any staff had been rough with him or other residents. Resident #20 stated, Yes, a lot of people, but not me I won't let them. Resident #20 was asked if he had ever reported want he has seen. Resident #20 stated, No, I'm to scared to report it. Resident #20 was asked if any staff member has interviewed him yesterday regarding CNA #2 or if he witnessed in the dining area during lunch on 3/3/20. Resident #20 stated, No.
On 3/4/20 at approximately 5:45 P.M. the Administrator was asked if she had submitted a FRI to the State Office regarding the abuse/mistreatment allegation for Resident #64. The Administrator stated, No, we didn't, I thought (NAME) Regional Director of Operations told you that we didn't
The facility policy titled Abuse Prevention Program revised December 2016 was reviewed and is documented in part, as follows:
Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse and physical or chemical restraint not required to treat the resident's symptoms.
Policy Interpretation and Implementation:
3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents.
6. Identify and assess all possible incidents of abuse.
7. Investigate and report any allegations of abuse within timeframes as required by federal requirements.
The facility policy titled Abuse Investigation and Reporting revised July 2017 was reviewed and is documented in part, as follows:
Policy Statement: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigation will also be reported.
Role of the Investigator:
e. Interview the resident (as medical appropriate).
i. Interview other residents to whom the accused employee provides care or services.
Reporting:
1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies:
a. The State licensing/certification agency responsible for surveying/licensing the facility;
b. The local/State Ombudsman;
c. The Resident's Representative (Sponsor) of Record;
d. Adult Protective Services;
e. Law enforcement officials;
f. The resident's Attending Physician;
g. The facility Medical Director.
2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than:
a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or
b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.
On 3/5/20 at 3:50 P.M. a pre-exit debriefing was held with the Administrator, the Director of Nursing and the Regional Director of Operations where the above information was discussed.
I asked if anyone had interviewed Resident #64 or any other residents on the unit during the investigation. The Regional Director of Operations stated, No, because (Name) Resident #64 has a low BIMS score and is not interviewable as well as the other residents on the locked unit. The Regional Director of Operations was made aware that Resident #20 on the secure unit had a BIMS score of 15 and was cognitively intact. Prior to exit no further information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
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 a discharge assessment (MDS) was submit...
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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 a discharge assessment (MDS) was submitted for 2 of 57 residents (Residents #91 and Resident #1), in the survey sample.
The findings included:
1. The facility staff failed to complete a discharge MDS assessment for Resident #91. Resident #91 was admitted to the nursing facility on 01/22/20. Resident #91 was discharged from the facility to home on [DATE]. Diagnoses for Resident #91 included but not limited to Muscle Weakness.
Resident #91's last Minimum Data Set (MDS), an admission Assessment with an Assessment Reference Date of 01/27/20 coded Resident #91's Brief Interview for Mental Status (BIMS) scoring a 09 out of a possible 15 indicating moderately impaired cognitive skills for daily decision-making.
Review of Resident #91's clinical note dated 02/07/20 read in part: Resident discharged from facility at 3:00 p.m.
An interview was conducted with Licensed Practical Nurse (LPN) #2 (Assistant MDS Coordinator) on 03/03/20 at approximately 3:25 p.m. She reviewed Resident #91's clinical record then stated, Resident #91 was discharged home on [DATE]. She said a discharge MDS was not completed. The MDS Coordinator said a discharge MDS should have been completed within 14 days after Resident #91's discharge from the facility.
A briefing was held with the Administrator and Director of Nursing on 03/03/20 at approximately 4:00 p.m. The facility did not present any further information about the findings.
CMS' RAI Version 3.0 Manual (Chapter 1: Resident assessment Instrument (RAI).
-Discharge Assessment-return not anticipated: Must be completed when the resident is discharge from the facility and the resident is not expected to return to the facility within 30 days.
-Must be completed (Item Z0500B) within 14 days after the discharge date (A200 + 14 calendar days).
-Must be submitted within 14 days after the MDS completion date (Z0500B + 14 calendar days).
2. Resident #1 was admitted to the facility 6/25/18, and was discharged from the facility to the hospital 10/21/19. The last assessment accepted into the MDS databank was a quarterly assessment dated [DATE].
Review of the clinical record revealed a nurse's note dated 10/21/19 which stated the resident was sent to a local emergency room for evaluation.
An interview was conducted with the MDS Coordinator on 3/4/20, at approximately 11:30 a.m. The MDS Coordinator stated the resident's discharge MDS assessment wasn't completed and transmitted to CMS. The MDS Coordinator present a completed discharge MDS assessment on 3/4/20 at approximately 2:15 p.m., along with a validation report indicating the MDS assessment was transmitted to the CMS data bank.
On 3/5/19, at approximately 3:50 p.m., the above findings were shared with the Administrator, Director of Nursing and the Regional Director of Operations. The Administrator stated no addition information would be provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility staff failed to accurately code the Minimum Data Set (MDS) as...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility staff failed to accurately code the Minimum Data Set (MDS) assessment for 1 of 57 residents (Resident #76), in the survey sample.
The findings included;
Resident #76 was originally admitted to the facility 11/7/19 and has never been discharged from the facility. The current diagnoses included dementia and coronary artery disease.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/19/20 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 6 out of 15. This indicated the resident was with severely impaired daily decision making abilities.
In section O0100k2of the 12/12/18 MDS assessment, the resident was coded for hospice care while a resident.
Review of the physician order summary revealed no physician's order for hospice care, nor did the active care plan [NAME] hospice services.
On 3/2/20 at approximately 11:00 a.m., Licensed Practical Nurse (LPN) #3 was asked which days the hospice staff visited Resident #76. LPN #3 stated she wasn't aware the resident received hospice services but she would review the record for information. LPN #3 stated there was no orders or information in Resident #76's record indicating hospice services.
An interview was conducted with the Social Service Director (SSD) on 3/4/20 at approximately 1:35 p.m., the SSD stated upon admission to the facility the resident's daughter stated the resident was admitted to hospice services and would resume the services but later the hospice agency stated Resident #76 didn't qualify at the time for hospice services but they would periodically re-evaluate the resident to determine if she qualified.
An interview was conducted with the MDS Coordinator on 3/4/19 at approximately 11:30 a.m., the MDS Coordinator stated the 11/7/18, MDS assessment should not have been coded for hospice care because the hospice agency didn't pick the resident up for hospice services. At approximately 4:35 p.m., the MDS Coordinator stated a modification was made to the 11/7/19, MDS assessment and presented a copy of the modified assessment.
On 3/5/20, at approximately 3:50 p.m., the above findings were shared with the Administrator, Director of Nursing and Regional Director of Operations. The Administrator stated she understood the concern and had no additional information the offer.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility documentation review, the facility staff failed to develop a perso...
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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 person centered care plan to include depression and anxiety for 1 of 57 residents in the survey sample, Resident #100.
The findings included:
Resident #100 was admitted to the facility on [DATE]. Diagnoses for Resident #100 included but are were limited to, Major Depressive Disorder and Anxiety Disorder Due to Known Physiological Condition. Resident #100's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 02/04/2020 coded Resident #100 with short-term memory problems, long-term memory problems, and with severely impaired cognitive skills for daily decision making.
Review of Resident #100's clinical record on 03/04/2020 revealed the following:
The Medication Administration Record (MAR) for the period of 03/01/2020 - 03/31/2020 revealed the following: Paroxetine (used for the treatment of depression) Tab 40 MG (Milligram) Give 1 tablet orally one time a day related to Anxiety Disorder Due To Known Physiological Condition. Start Date: 08/28/2019 and Xanax (used for the treatment of anxiety) Tablet 0.5 MG (Alprazolam) Give 1 tablet by mouth as needed for anxiety 3 times a day Q (every) 8 H (hours) Start Date: 02/11/2020.
The MAR also included the following: Behavior Monitoring - Anxiolytic: Alternative Used Before Administering PRN; 1=Music; 2=low stern activity; 3=Relaxation every 8 hours as needed for Behavior Monitoring. Start Date: 01/08/2020.
Review of Order Summary Report Dated with Active Orders As Of: 3/04/2020 revealed the following:
Document on behaviors, how long it last, any intervention pharmical (sic) or non pharmical (sic) and was it effective. Notify MD every shift Order Date: 02/12/2020 Start Date: 02/12/2020
(Name Psychological Services) May Provide Psychological Services / Med Management Associates to Provide Psychiatric Services Order Date: 02/21/2020
Review of Nurse Practitioner Notes dated 02/24/2020 revealed and is documented in part, as follows: He had significant anxiety during today's exam and was holding his breath during auscultation. Staff stated he does often as a coping mechanism for his anxiety., but it is interfering with his ADL's (Activities of Daily Living). He is on Xanax and Risperdal as well as Paxil for depression. A referral to the psych nurse to manage his anxiety was ordered.
Review of Resident #100's comprehensive care plan on 03/04/2020 did not include a care plan for depression or anxiety.
On 03/05/2020 at 11:15 a.m., an interview was conducted with Licensed Practical Nurse (LPN) #2, the MDS Coordinator, when asked if Resident #100 had a diagnosis of depression and anxiety, LPN #2 stated, Yes. When asked if the diagnosis of depression and anxiety was addressed in the residents care plan, LPN #2 stated, No, it probably should have been. May have been left off, we have been changing things over. When asked if the care plan had been reviewed since change over, LPN #2 stated, Yes. LPN #2 stated, I will add it to the care plan. When asked what is the purpose of the care plan, LPN #2 stated, It's to help us take care of the resident.
On 03/05/2020 at 2:30 p.m., during briefing the Director of Nursing was made aware of finding. When asked what her expectations were, Director of Nursing stated, Yes, depression and anxiety should have been addressed individually in the care plan. No further information was presented about the finding.
The facility policy titled Care Planning, Care Plan Updated - InterdisciplinaryTeam
Policy Statement: Our facility's Updating Care Plan/Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan/Updating for each resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review staff interview and review of facility documentation, the facility staff failed to revise the ca...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review staff interview and review of facility documentation, the facility staff failed to revise the care plan for 1 of 57 residents (Resident #96) in the survey sample.
The findings include:
Resident #96 was admitted to the nursing facility on 7/12/18 with diagnoses that included non-Alzheimer's disease dementia and generalized muscle weakness. The resident was readmitted on [DATE] with diagnoses that included *dysphagia, *meniere's disease and urinary tract infection (UTI).
The most recent Minimum Data Set (MDS) assessment dated [DATE] was a significant change is status and coded Resident #96 was coded on this assessment as having short and long term memory and never/rarely made decisions. Resident #96 was coded to need assistance with personal care. This assessment indicated the resident had no significant weight loss or gain. Significant weight loss is a loss of 5% or more in the last month or a loss of 10% in the last 6 months. Significant weight gain is a gain of 5% or more in the last month or 10% or more in the last 6 months. The height of the resident was coded as 49 inches (4 feet and 1 inch) and weight 120 lb (pounds). The resident was coded to be on a mechanically altered therapeutic diet.
The Care Area Assessment (CAA) dated 2/5/20 identified nutritional status as a care area that was triggered with a decision to care plan the area.
The aforementioned care plan was not revised to reflect the physician prescribed diet order change dated 2/14/20 of NAS (no added salt) diet pureed texture, regular/thin consistency liquids.
On 3/4/20 at 10:00 a.m., and interview was conducted with the Minimum Data Set (MDS) coordinator. She stated although it is an interdisciplinary approach, the MDS Coordinator usually enters updates to the care plan, as she should have to reflect any changes in the resident's diet and just missed it.
On 3/5/20 at approximately 4:30 p.m., a debriefing session was conducted with the Administrator, Director of Nursing and the Regional Director of Operations. The aforementioned issue was reviewed and discussed. No further information was provided prior to survey exit.
The facility's policy and procedures titled Care planning, Care Plan Updated-Interdisciplinary Team dated 9/2013 indicated the facility's updating care plan/care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan/updating for each resident.
The policy and procedure titled Resident Nutrition Services dated 7/2017 indicated that the multidisciplinary staff, including the nursing staff, the attending physician and the dietician will assess each resident's nutritional need, food likes, dislikes and eating habits. They will develop and revise a resident care plan based on this assessment.
*People with dysphagia have difficulty swallowing and may even experience pain while swallowing (odynophagia). Some people may be completely unable to swallow or may have trouble safely swallowing liquids, foods, or saliva(https://www.nidcd.nih.gov/health/dysphagia#1).
*Meniere's disease is a disorder of the inner ear that can lead to dizzy spells (vertigo) and hearing loss. In most cases, Meniere's disease affects only one ear (https://www.mayoclinic.org/diseases-conditions/meniere's-disease/symptoms-causes/syc-20374910).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility staff failed to provide supervision for one resident (Resident #167) in ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility staff failed to provide supervision for one resident (Resident #167) in the survey sample of 57 to prevent an elopement.
The findings included:
Resident #167 was admitted to the facility on [DATE] with diagnoses of diabetes mellitus, Alzheimer's Disease, cardiovascular accident (CVA), dementia, Asthma, violent behavior, and dysphagia. Resident #167 eloped from the facility on 12/23/19.
A Quarterly Minimum Data Set (MDS) dated [DATE] assessed this resident in the area of Cognitive Patterns -Brief Interview for Mental Status as a 7 which indicated severe cognitive impairment. In the area of Behaviors this resident was assessed as having behaviors for rejecting care. As well as other behavioral symptoms including pacing. In the area of Activities of Daily Living (ADL) this resident was assessed as requiring limited assistance with one person physical assist with transfer, dressing, and eating.
A care plan revision dated 12/21/19 indicated: Focus- The resident has a behavior problem. Resident was chasing and yelling at nurses stating I'M going to kill you ___. Goal- The resident will have no evidence of behavior problems. Interventions- Assist the resident to develop more appropriate methods of coping and interacting. Observe behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes.
A wandering assessment dated [DATE] indicated: Family requested a wander assessment. The assessment indicated- Significant Change in Condition. Mental Status- Can follow instructions. Mobility- Is ambulatory. History of Wandering -Has a history of wandering (past hospitalization or history from resident/family).
Comments/Notes - Resident stated to RP (Responsible Party) that once he got the strength he was going to leave and wasn't staying on the unit. Scoring (7) Low Risk.
A 12/21/19 Nursing note indicated: Resident was very combative with the nursing staff chasing the nurses around the unit say (sic) I am going to kill you ___ it had gotten so bad the police was call (sic), he calm down when he saw the police and took all med, now resting in his room. Resident RP was call (sic) left a message to call back when she get the message. MD was notify (sic).
A 12/23/19 (08:45) Nursing note indicated: Resident wandered outside of facility this shift and picked up by (Name of Ambulance Service) accompanied by an unknown woman, resident taken to local hospital for evaluation and treatment.
An Investigation Summary For Resident #167 included:
Event: Elopement 12/23/2019
Date- Monday, December 23, 2019 approximately 0530.
Resident was noted not to be in his room around 5:30 A.M. on 12/23/19 when CNA (certified nursing assistant) entered to provide care. Facility activated missing resident protocol and began to search the grounds. Facility staff called (DON) Director of Nursing and Administrator regarding the incident. Upon calling 911, the facility staff were informed another call had just come in and the description matched that provided for resident and stated, local EMS was in route to location. Local EMS called facility at 6:45 A.M. and asked which hospital to take resident to for evaluation and then transported to local hospital. DON spoke to hospital staff who reported that resident was doing fine just a little cold, and that they were running some tests to make sure nothing was bothering him. Resident returned to facility in early afternoon at his baseline with no noted injury and was placed on secured unit. DON and Administrator met with resident RP to discuss incident, facility investigation in progress, and previous elopement assessment.
Resident left the facility without knowledge of the staff, and the MD and RP were notified of the elopement. The resident was not on the low stem secured unit and not wearing a wander guard as resident had an elopement assessment on 10/09/19 at family request that produced 7.0 low risk. Resident had no changes in status since last 10/09/2019 (name) wandering assessment was completed. The facility elopement policy was re-educated to staff along with staff education to lock front doors. Facility maintenance staff ensured door bell was in place and functioning. maintenance further assessed the locks on the front doors and they were found to be functioning correctly.
During an Interview with the Administrator on 03/05/20 at 10:30 A.M. she stated, Resident #167 eloped from the facility. He did not have a wander guard at the time. All doors to the facility were to be locked at night. The Administrator stated, all staff were re-educated on residents who wander and possibly elope. Interviews were attempted with that staff on duty the night of the occurrence however the on duty certified nursing assistant and LPN were called several times but did not answer or return the call.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, medical record review, staff interviews and facility document review the facility staff failed to ens...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, medical record review, staff interviews and facility document review the facility staff failed to ensure 1 of 57 Residents in the survey sample, Resident #77, was free from unnecessary medications.
The findings included:
Resident #77 was admitted to the facility on [DATE] with diagnoses to include but not limited to Dementia, History of Falling and Schizoaffective Disorder.
The most recent Minimum Data Set (MDS) was an Annual Assessment with an Assessment Reference Date (ARD) of 1/14/20. The Brief Interview for Mental Status (BIMS) was a 9 out of a possible 15 indicating the resident has moderate cognitive impairment. Under Section O Special Treatments, Procedures and Programs 00250 Influenza Vaccine A. Did the resident receive the influenza vaccine in the facility Resident #77 was coded as 1-Yes.
On 3/3/20 at 12:20 P.M. a phone interview was conducted with Resident #77's daughter who was also the Resident's Responsible Party (RP) and Power of Attorney (POA). During the interview the POA stated, They gave her the flu shot after I told them I refused for her to have it.
Resident #77's Informed Consent for Influenza Vaccine was reviewed and is documented in part, as follows:
Under Informed Consent the following box was checked and Resident #77's POA's name was written in: I hereby DO NOT GIVE the facility permission to administer an influenza vaccination. Document was signed by LPN (Licensed Practical Nurse) #6.
Resident #77's Electronic Medical Record was reviewed under the Immunization tab which indicated the following information:
Update Immunization:
Immunization: Influenza
Given: Refused
Reason Refused: POA Refused
Consent Confirmed By: (Name) RN (Registered Nurse) #2
Consent Confirmed Date: 11/25/19
Resident #77's Physician Orders were reviewed and are documented in part, as follows:
Order Date: 12/09/2019
Order Status: Completed
Order Summary: Afluria Quadrivalent Suspension Prefilled Syringe 0.5 ML (milliliters) (Influenza Vac Split Quad) Inject 0.5 ml intramuscularly one time only for Routine Immunization for 1 Day.
Resident #77's Medication Administration Record dated 12/1/2019-12/31/2019 was reviewed and is documented in part, as follows:
Date 12//9/2019
Afluria Quadrivalent Suspension Prefilled Syringe 0.5 ML (milliliters) (Influenza Vac Split Quad) Inject 0.5 ml intramuscularly one time only for Routine Immunization for 1 Day.
-Start Date- 12/09/2019
Temp: 98.7
One Time: Nurse's Initials Time: 21:19 P.M.
On 3/5/20 at 2:00 P.M. an interview was conducted with Registered Nurse (RN) #2 who is also the Staff Development Coordinator regarding Resident #77's Informed Consent for the Influenza Vaccine. RN #2 stated, I called the daughter on the phone and explained what the shot was for and the precautions and she said No, I don't want her to have the flu shot because she got it last year and no one asked me if she could have it. I said ok. Once I had the refusal I went into the computer and marked her as refusing under the immunization tab. The nurse that gives the shot should check for allergies and the consent in the computer before giving the medication. The nurse that gave her the flu shot doesn't work here anymore.
On 3/5/20 at 2:40 P.M. an interview was conducted with Licensed Practical Nurse (LPN) #6 regarding Resident #77's Influenza Vaccine. LPN #6 stated, Before I wrote the order I went into the immunizations tab but I didn't open it all the way so I didn't see the consent was refused. I tried to stop the order but the nurse already gave it.
On 3/5/20 at 2:35 P.M. an interview was conducted with the Director of Nursing regarding what were her expectations of the staff with influenza vaccines. The Director of Nursing stated, I expect for them to follow the consent that is received. The Director of Nursing was also asked if it would be considered an unnecessary medication. The Director of Nursing stated, Absolutely, because it was by the daughter, we should not have given it.
The facility policy titled Influenza Vaccine revised August 2016 was reviewed and is documented in part, as follows:
6. A resident's refusal of the vaccine shall be documented on the Informed Consent for Influenza Vaccine and placed in the resident's medical record.
A facility Unnecessary Medication policy was not received from the facility prior to exit.
On 3/5/20 at 3:50 P.M. a pre-exit debriefing was held with the Administrator, the Director of Nursing and the Regional Director of Operations where the above information was discussed. Prior to exit no further information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility documentation review the facility staff failed to indicate the dur...
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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 indicate the duration for an as needed psychotropic medication for 1 resident (Resident #100) and failed to perform a gradual dose reduction for 1 resident (Resident #20) of 57 residents in the survey sample.
The findings included:
Resident #100 was admitted to the facility on [DATE]. Diagnosis for Resident #100 included but are not limited to, Major Depressive Disorder and Anxiety Disorder Due to Known Physiological Condition. Resident #100's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 02/04/2020 coded Resident #100 with short - term memory problems, long - term memory problems, and with severely impaired cognitive skills for daily decision making.
On 03/04/2020 at approximately 10:00 a.m., review of Consultant Pharmacist recommendation revealed the following: The resident is on a PRN psychotropic drug: ALPRAZOLAM Tablet 0.5 MG (Milligram) Give 1 tablet by mouth every 8 hours as needed for Anxiety PRN (As Needed) TID (Three Times A Day). Per federal regulations, PRN orders for psychotropic drugs are limited to 14 days. For extension of PRN orders for psychotropic medications beyond 14 days or renewal of PRN therapy, the attending physician or prescribing practitioner must evaluate to determine appropriateness of therapy. Recommendations: Please consider either (1) discontinuing the PRN order, or (2) provide rational for extended time period and indicate a specific duration. Printed: 01/14/20. Review of recommendation did not evidence Physician response.
On 03/04/2020 at approximately 11:00 a.m., review of Medication Administration Record for the period of 02/01/2020 - 02/29/2020 revealed the following: Alprazolam Tablet 0.5 MG Give 1 tablet by mouth every 8 hours as needed for Anxiety PRN TID Start Date: 11/29/2019 D/C (Discontinue) Date: 02/07/2020.
On 03/04/2020 at approximately 11:10 a.m., review of Medication Administration Record For the period of 03/01/2020 - 03/31/2020 revealed the following: Xanax Tablet 0.5 MG (Alprazolam) Give 1 tablet by mouth as needed for anxiety 3 times a day Q (every) 8 H (hours) Start Date: 02/11/2020
On 03/04/2020 at approximately 11:20 a.m., review of Nurse Practitioner's Referrals/Response Letter dated 02/24/2020 revealed and is documented in part, as follows: Resident is currently receiving PAROXETINE TAB 40MG PO (By Mouth) daily & RISPERIDONE TAB 0.5MG PO TID. The resident has an HX (History) of Panic & anxiety disorder Resident PRN medication was d/c'd. His Xanax was reordered and the patient improved.
On 03/05/2020 at 2:30 p.m., during briefing the Director of Nursing was made aware of finding. The Director of Nursing stated, I expect the nurses to call the doctor and ask him what he wants, ask him do you want to discontinue the order or schedule it? Director of Nursing stated, PRN order should be scheduled for 14 days. No further information was presented about the finding.
The facility policy titled - Antipsychotic Medication Use
Policy Statement: Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed.
Policy included the following: 14. The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order.2. The facility staff failed to attempt a gradual dose reduction (GDR) for a psychotropic medication for Resident #20.
Resident #20 was admitted to the facility on [DATE]. Diagnoses for this individual included hyperlipidemia, dementia, depression, and insomnia. A Quarterly Minimum Data Set (MDS) dated [DATE] assessed this resident in the area of Cognitive Patterns for Brief Interview for Mental Status (BIMS) was a 15 indicating no cognitive impairment.
A Consultant Pharmacist's Medication Regimen Review signed and dated 02/12/20 indicated: Recommendations:
Routing MD - Note written to physician
Resident is currently on Citalopram 10 Milligrams (mg) daily.
Please consider a dose reduction to Citalopram 5 (mg) daily, while concurrently monitoring for reemergence of depressive and/or withdrawal symptoms.
A review of a physician's order dated 02/15/20 included: Citalopram Tab 10 mg give 1 tablet orally one time a day related to other specified depressive episodes.
A review of the Medication Administration Record (MAR) for the month of March 2020 included: Citalopram tab 10 mg give one tablet orally one time a day related to other specified depressive episodes.
A Consultant Pharmacist's Medication Regimen Review signed and dated 1/14/20 indicated: Resident is currently on Trazodone 50 mg daily.
Recommendations: Please consider a dose reduction to Trazodone 25 mg daily, while concurrently monitoring for reemergence of depressive and/or withdrawal symptoms.
A Physician order dated 02/15/20 indicated: Trazodone tab 50 mg give 1 tablet orally at bedtime related to Insomnia, unspecified.
A review of the MAR for the month of March 2020 included: Trazodone 50 mg give one tablet orally at bedtime related to Insomnia.
A revised care plan dated 01/10/20 indicated: Focus-Resident #20 uses antidepressant medications r/t Depression, and Insomnia. Goal-The resident will be free from discomfort or adverse reactions related to antidepressant therapy. Interventions-Administer Antidepressant medications as ordered by physician. Observe/document side effects and effectiveness Q (every) shift. Educate the resident about risks, benefits and the side effects and/or toxic symptoms of anti-depressant drugs being given.
Observe/document/report PRN adverse reactions to Antidepressant therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL ability, continence, no voiding; constipation, fecal impaction, diarrhea, gait change, rigid muscles, balance probes, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia, appetite loss, wt loss, n/v dry mouth, and dry eyes.
During an interview on 03/04/20 at 2:30 P.M. with the Cooperate Director of Nursing she stated, the physician was given notice of the pharmacist recommendation, but there is no indication that the GDR had been attempted.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and review of facility documentation, the facility staff failed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and review of facility documentation, the facility staff failed to prepare food by methods that conserves nutritive value and provide and present food that is palatable and attractive for 1 of 57 residents (Resident #89) in the survey sample.
The findings include:
Resident #89 was admitted to the nursing facility on 7/12/18 with diagnoses that included non-Alzheimer's disease dementia and generalized muscle weakness. The resident was readmitted on [DATE] with diagnoses that included *dysphagia (difficulty swallowing), *meniere's disease and urinary tract infection (UTI).
The most recent Minimum Data Set (MDS) assessment dated [DATE] was a significant change is status and coded the resident with moderate difficulty in hearing, usually has the ability to express ideas and wants and usually comprehends most conversation. Resident #89 was coded on this assessment as having short and long term memory and never/rarely made decisions. She was not coded to have mood or behavioral problems to have rejected care to include medications, treatments and or assistance with daily activities. The resident was coded to require limited assistance with one person for eating which indicated assistance to lift, hold or support trunk or arms less than half of the time. Resident #89 was coded to need assistance with personal care. This assessment indicated the resident had no significant weight loss or gain. Significant weight loss is a loss of 5% or more in the last month or a loss of 10% in the last 6 months. Significant weight gain is a gain of 5% or more in the last month or 10% or more in the last 6 months. The height of the resident was coded as 49 inches (4 feet and 1 inch) and weight 120 lb (pounds). The resident was coded to be on a mechanically altered therapeutic diet.
The Care Area Assessment (CAA) dated 2/5/20 identified nutritional status as a care area that was triggered with a decision to care plan the area.
The care plan dated 2/14/20 identified ADL (Activities of Daily Living) deficits and was at risk for dehydration. The goal the staff set for the resident was that she would be free of symptoms of dehydration and would receive the assistance she needed for ADL. One of the approaches to accomplish this goal included staff assistance to support the resident to eat and drink. The care plan dated 12/3/19 identified Resident #89 at risk for a nutritional problem and was on a low sodium, mechanical soft thin liquid diet. The goal the staff set for the resident was that she would tolerate the physician prescribed diet and have no significant weight loss through review date of 1/8/20.
The aforementioned care plan was not revised to reflect the physician prescribed diet order change dated 2/14/20 of NAS (no added salt) diet pureed texture, regular/thin consistency liquids.
The rehabilitation screen dated 1/14/20 indicated the resident had a score of 9 out of a possible score of 15 which indicated Resident #96 was moderately impaired in the necessary cognitive skills for daily decision making. The screen noted that the nursing staff stated the resident suffered a decline in function following the death of her husband and was totally dependent for all ADLs. The resident had not been identified with weight loss at the time of this screen.
The following observations were conducted of Resident #89 during meals:
On 3/2/20 at 12:15 p.m., during tour of Unit 1, Resident #89 was observed in her room in a recliner. The lunch tray was sitting on the over bed table in front of the resident. Three pureed items (based on color) were noted on one plate. All three pureed items merged into each other that created one large multi-colored item. Individual sides included pureed bread and pureed cake. Un-opened ice cream, house shake and ice tea was also observed on the resident's tray. There was no soup on the resident's tray. When asked by this surveyor if she was hungry, she took her left hand and slightly lifted the side of the plate and said, I can't eat this slop. On 3/2/20 at 1:00 p.m. the lunch tray was removed. No portions or liquids had been consumed. The Certified Nursing Assistant (CNA) #5 said the resident required set up only and no help to eat and that she apparently was not hungry. CNA #5 recorded in the ADL record for the lunch meal on 3/2/20-0,0 (independent with no help or staff oversight at any time and no setup or physical help from staff). The CNA recorded the resident consumed 0 % of her meal. On 3/2/20 at 5:15 p.m., the evening meal plate had three items on the one plate in the same configuration as the lunch meal. Side items included house shake, applesauce, the broth of the soup of the day, ice cream and ice tea. The resident was not assisted to eat any portions of the dinner meal. CNA #6 stated that the resident could independently eat her meal. The tray was picked up at approximately 6:00 p.m. CNA #6 recorded the resident's meal as 0,0.
On 3/3/20 at approximately 12:20 p.m., the Resident Representative (RR) stated, The nurses leave the tray with no assistance. No alternatives offered because she does not like the meals, but will eat soup if they puree it. I was told by the current nutritionist in the kitchen that they do not puree soups. My Mom is losing too much weight now. The resident's tray had two main items on one plate merged into one with pureed bread, chocolate pudding, house shake and ice tea. The resident looked up at this surveyor, flicked the side of her plate and said, It looks like this everyday. They sit it in front of me day after day and walk off. The RR confirmed what the resident said. The RR stated when she asked how much weight the resident lost, they told her she was not losing weight, but she could tell based on how she looked in her clothes. The RR asked the resident if she would like thickened soup, to which the resident stated, I think I would accept that.
On 3/3/20 at 1:00 p.m., one of the cooks of the kitchen was asked if soup could be pureed to which he responded that the Dietary Manager told him, No soups could be pureed.
On 3/3/20, at approximately 1:22 p.m., the RR was at the bedside feeding the resident soup she brought in that was in a pureed consistency. The resident was observed to consume 75% of the soup and 100 % of ice tea. She stated the resident loved soup and would eat it if it was offered to her. She continued to say that she had a meeting with the nutritionist from the kitchen which was identified as the Dietary Manager and was told that he was unable to puree soup, but could strain the broth off the soup of the day and she felt that she had to accept his conditions. The RR stated, while crying, Her husband was also a resident here and they used to eat their meals together. He died two months ago. I am exhausted trying to keep my Mom going and I can only come every other day mostly. Things are different now she needs their help and without it she will keep losing more weight. She stated she was happy with everything and she did not expect miracles, but just help with her meals. The RR said she was told to consider Hospice, which she did, but stated she did not want the staff to write off Resident #89. Hospice services was implemented on 2/26/20 under diagnosis of senile degeneration. The resident has received ongoing psychological counseling to address stabilization/reduction of affective and/or cognitive symptoms from 6/26/19 to as recent as 2/13/20. The psychological counseling dated 12/17/19 to 2/13/20 continued to address the resident's grief from the loss of her husband.
There was no physician's order for strained broth. The current physician's order dated was 2/14/20 of NAS (no added salt) diet pureed texture, regular/thin consistency liquids.
On 3/3/20 at approximately 3:15 p.m., the Dietary Manager was asked what items could not be pureed to which he responded, Everything can be pureed, but lettuce.
An interview was conducted with the Physician's Assistant (PA) on 3/4/20 at 11:45 a.m. She stated there was a speech consult based on the resident having swallowing difficulties after her last hospitalization on January 2020. She stated she was out of the building in January and returned in the first week of February and did not know the resident was losing weight. The PA stated she expected if the resident was no longer eating, the staff would set up her tray accordingly and assist her to eat, offer alternatives and consult the RD. She stated she was with the attending physician's office and was playing catch up with seeing all of the facility residents, but possibly the attending was providing oversight for the resident's care when she was out.
On 3/4/20 at 12:40 p.m., CNA #1 was observed feeding the resident strained broth. The CNA stated that the resident loved soup, but she had to go to the kitchen and get it for the current meal and consistently have to send for it, stating that it was supposed to be on every tray because they knew she would eat it. She said she was not aware of any conversations that may have taken place about strained broth verses pureed soup, she just knew it was supposed to be on the tray every day for lunch and dinner. The CNA stated, As soon as she sees the pureed plate of food, she shakes her head. She won't touch it. The residents tell me they hate it. CNA #1 stated that she will sit and try and feed her all of the broth and hopefully she would eat the ice cream and mighty shake. The CNA stated for breakfast the resident had oatmeal and yogurt, but ate very little of it so she recorded 4,2 (total dependence-full staff assistance) with 0-25% meal consumption. CNA #1 stated she offered Resident #89 in between snacks to include yogurt, pudding and ice cream, but there was no where in their charting system to record intake of the between meal snacks.
On 3/5/20 at 10:15 a.m., and interview was conducted with the Rehabilitation Director (Rehab Director). The Rehab Director stated Resident #96 was screened 9/23/19 due to a cognitive decline and received speech therapy from 9/23/19 through 10/30/19 to facilitate safety and efficiency with visual aids to increase comprehension with receptive and expressive language training. There was a note that the resident was scheduled for an audiology appointment for hearing aids to decrease need for visual aids. The speech recommended and physician ordered diet dated 10/28/19 was for NAS (no added salt) diet mechanical soft texture, thin liquids consistency. The resident was screened again on 2/18/20 due to decrease in intake and significant weight loss (12/19/19=122.0; 1/20/20=120; 2/1/20=104). Her diet had been downgraded to a pureed texture during the January 2020 hospitalization. Resident #89 was assessed with a moderate to severe oropharyngeal dysphagia requiring modified diet of pureed texture and thin liquid with close supervision and severe weight loss risk due to poor intake with meals.
During the above interview with the Rehab Director she called the Speech Therapist that serviced the resident to ask her if soup could be pureed. The Speech Therapist returned her call and stated Yes. This speech therapist wrote in one of her daily skilled service notes dated 2/21/20 that the resident requested soup and the speech therapist provided prepared pureed texture soup which was tolerated well with minimal throat clearing. The note further indicated, Speech Therapy instructed nurse manager regarding patient's risk of further weight loss and dehydration, and minimum to no intake with meals. The Rehab Director stated she did not understand why the resident was receiving broth/strained soup instead of pureed soup which was recommended in light of the resident's preference, her toleration of the textured soup and that there would be more nutritional value to assist resident and minimize weight loss.
On 3/5/20 at 11:30 a.m., Resident #89's Speech Therapist joined the above interview and said that the resident was receiving the minimal of everything with strained soup/broth. The Dietary Manager joined the interview and stated although he did not have any notes or dates to refer to, he had a meeting with the family in February 2020 and told them that he would provide the resident with the broth of the soup of the day (cream of potato, cream of broccoli, noodle rice, Italian wedding, gumbo and tomato soup) and that the resident's family accepted his explanation. He stated, What do you expect me to do, pureed 4 ounces of soup. I would need to puree at least 20 ounces. If not done in bulk, it is difficult to puree. I don't have the equipment to puree small amounts and it would be a problem to reheat as well.
The Registered Dietitian's (RD) progress notes dated 2/17/20 indicated a weight warning and that he recommended fortified foods at every meal related to poor intake and significant weight loss. The RD was on vacation and not available for interview.
On 3/5/20 at 12:50 p.m., further interview was conducted with the Dietary Manager. He stated fortified foods included cereal, cream of wheat, oatmeal, house shake, frozen nutritional treats, mighty cups, yogurts and Jello pudding. He said although he did not have a date or had any notes of his discussion with the RD, he told her he was providing house shake, pudding, ice cream that would be equal to fortified foods. He stated he could not recall if he spoke to the RD about providing the resident broth of the soup of the day instead of the physician ordered pureed diet that could include pureed soup.
On 3/5/20 at 1:50 p.m. Licensed Practical Nurse (LPN) on Unit 1 said that all of the residents that are served the pureed meals told her it looked nasty and had difficulty eating it based on looks and taste. She stated she sent the diet communication to the kitchen on 2/24/20 about adding a cup of broth with meals not based on a physician's order, but what the Dietary Manager said he was going to be sending the resident.
On 3/5/20 at 2:30 p.m., the Director of Nursing (DON) stated although she was new in her position, she felt a different presentation of the meal could be more appealing to the residents on a pureed diet, either in individual small serving bowls or molds to represent the item served. She presented a list of 25 residents on pureed diet and stated that there would be no reason not the puree the soup of the day because there would be plenty of residents that could be offered pureed soups that could be prepared in bulk that would exceed 20 ounces. She stated she expected the resident to be provided as many fortified foods as possible at meal times and in between meals to foster an increase in calories. She said the resident required set up of all meals and that she expected the nursing staff to take the time to assist the resident to eat. Additionally, she said she did not know Resident #96 was receiving only broth and that she felt it was not offering enough calories to sustain the resident.
On 3/5/20 at approximately 4:30 p.m., a debriefing session was conducted with the Administrator, Director of Nursing and the Regional Director of Operations. The aforementioned issue was reviewed and discussed. No further information was provided prior to survey exit.
The Dietary Manager's signed job description dated 12/9/19 indicated one of his many administrative functions was to process diet changes and new diets as received from nursing services, assist in developing methods for determining quality and quantity of food served, visit residents periodically to evaluate the quality of meals served, likes and dislikes, involve the resident, as well as the family in planning objectives and goals for the resident, follow directives from the Registered Dietician, review therapeutic and regular diet plans and menus to assure they are in compliance with the physician's orders and provide substitute foods similar in nutritive value to the residents who refuse foods served.
The facility policy and procedure titled Nutrition (impaired)/Unplanned Weight loss-Clinical protocol dated 9/2012 indicated the physician will authorize and the staff will implement appropriate general or cause-specific interventions to include resident choice, nutritional needs (dietician and physician to determine appropriate diet, supplemental needs), hydration needs and functional factors (providing feeding assistance as needed).
The facility's policy and procedures titled Resident Nutrition Services dated 7/2017 indicated that each resident is provided with a nourishing, palatable and attractive well-balanced diet that meets his or her nutritional and special dietary needs, taking into consideration the preferences of each resident. Residents shall receive prompt meal service and appropriate feeding assistance.
The facility policy and procedure titled Assistance with Meals dated 7/2017 indicated residents shall receive assistance with meals in a manner that meets the individual needs of each resident.
*People with dysphagia have difficulty swallowing and may even experience pain while swallowing (odynophagia). Some people may be completely unable to swallow or may have trouble safely swallowing liquids, foods, or saliva(https://www.nidcd.nih.gov/health/dysphagia#1).
*Meniere's disease is a disorder of the inner ear that can lead to dizzy spells (vertigo) and hearing loss. In most cases, Meniere's disease affects only one ear (https://www.mayoclinic.org/diseases-conditions/meniere's-disease/symptoms-causes/syc-20374910).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, review of facility documentation, and in the course of a complaint investigati...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review, review of facility documentation, and in the course of a complaint investigation, the facility failed to maintain complete and accurately documented medical records for 2 out of 57 resident records reviewed, Resident #53 and Resident #77.
The findings included:
1. Resident #53 was initially admitted to the facility on [DATE] with diagnoses including, but not limited to, dysphagia, repeated falls, other Escherichia coli, urinary tract infection and metabolic encephalopathy.
Resident #53's most recent MDS (Minimum Data Set) assessment was a Quarterly Review Assessment with an ARD (Assessment Review Date) of 12/30/2019. Resident #53's BIMS (Brief Interview for Mental Status) score was recorded as unobtainable.
A review of the medical record for Resident #53 revealed a note documented on 12/24/2020 at 11:00 p.m., stating, Resident #53 remained in bed after returning from the ER. Further review of facility progress notes failed to provide dates and a description of events resulting in transfer to the emergency room (ER).
On 3/5/2020 at approximately 12:10 p.m. the Corporate Director of Nursing responded to a documentation request with a SNF/NF to Hospital Transfer form dated 12/24/2019 detailing a hematoma to forehead. Surveyor asked the Corporate DON, Does this form accurately, thoroughly describe the events leading up to the hospitalization on or about 12/24/2020?, she responded, This transfer form describes why he was transferred to the hospital. He experienced a hematoma. Surveyor asked, Does this form describe how he received a hematoma? The Corporate DON responded, It details that he received a hematoma and that is why he was transferred to the hospital.
These findings were reviewed with the Facility Administrator, DON and Corporate Staff during a briefing held on 3/5/2020 at approximately 5:00 p.m. There was no additional information provided.2. Resident #77 was admitted to the facility on [DATE] with diagnoses to include but not limited to Dementia, History of Falling and Schizoaffective Disorder.
The most recent Minimum Data Set (MDS) was an Annual Assessment with an Assessment Reference Date (ARD) of 1/14/20. The Brief Interview for Mental Status (BIMS) was a 9 out of a possible 15 indicating the resident has moderate cognitive impairment.
Resident #77's Comprehensive Care Plan was reviewed and is documented in part, as follows:
Focus: The resident has had episodes of Constipation related to diagnosis of Dementia and impaired mobility at times.
Intervention: Record bowel movement pattern each day. Describe amount, color and consistency.
During a complaint investigation Resident #77's Bowel Continence Documentation Flow Sheets for November 2019 were reviewed. Friday November 1st through the 4th for all three shifts were blank with no data entered. Resident #77's medical record and admission was reviewed and showed the resident was in the facility and receiving care from November 1-4, 2019.
On 3/5/20 at 9:45 A.M. an interview was conducted with the Director of Nursing regarding the missing data for Resident #77 on the Bowel Continence Documentation Flow Sheets for Friday November 1st through the 4th for all three shifts. After reviewing the document the Director of Nursing stated, It's an incomplete record. I expect the staff to document and not leave any holes.
The facility policy titled Charting and Documentation revised April 2008 was reviewed and is documented in part, as follows:
Policy Statement: All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record.
Policy Interpretation and Implementation:
1. All observations, medications administered, services performed, etc., must be documented in the resident's clinical record.
On 3/5/20 at 3:50 P.M. a pre-exit debriefing was held with the Administrator, the Director of Nursing and the Regional Director of Operations where the above information was discussed. Prior to exit no further information was provided.
Complaint deficiency.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, medical record review, staff interviews and facility document review the facility staff failed to fol...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, medical record review, staff interviews and facility document review the facility staff failed to follow the informed consent for the administration of the influenza vaccine for 1 of 57 Residents in the survey sample, Resident #77.
The findings included:
Resident #77 was admitted to the facility on [DATE] with diagnoses to include but not limited to Dementia, History of Falling and Schizoaffective Disorder.
The most recent Minimum Data Set (MDS) was an Annual Assessment with an Assessment Reference Date (ARD) of 1/14/20. The Brief Interview for Mental Status (BIMS) was a 9 out of a possible 15 indicating the resident has moderate cognitive impairment. Under Section O Special Treatments, Procedures and Programs 00250 Influenza Vaccine A. Did the resident receive the influenza vaccine in the facility Resident #77 was coded as 1-Yes.
On 3/3/20 at 12:20 P.M. a phone interview was conducted with Resident #77's daughter who was also the Resident's Responsible Party (RP) and Power of Attorney (POA). During the interview the POA stated, They gave her the flu shot after I told them I refused for her to have it.
Resident #77's Informed Consent for Influenza Vaccine was reviewed and is documented in part, as follows:
Under Informed Consent the following box was checked and Resident #77's POA's name was written in: I hereby DO NOT GIVE the facility permission to administer an influenza vaccination. Document was signed by LPN (Licensed Practical Nurse) #6.
Resident #77's Electronic Medical Record was reviewed under the Immunization tab which indicated the following information:
Update Immunization:
Immunization: Influenza
Given: Refused
Reason Refused: POA Refused
Consent Confirmed By: (Name) RN (Registered Nurse) #2
Consent Confirmed Date: 11/25/19
Resident #77's Physician Orders were reviewed and are documented in part, as follows:
Order Date: 12/09/2019
Order Status: Completed
Order Summary: Afluria Quadrivalent Suspension Prefilled Syringe 0.5 ML (milliliters) (Influenza Vac Split Quad) Inject 0.5 ml intramuscularly one time only for Routine Immunization for 1 Day.
Resident #77's Medication Administration Record dated 12/1/2019-12/31/2019 was reviewed and is documented in part, as follows:
Date 12//9/2019
Afluria Quadrivalent Suspension Prefilled Syringe 0.5 ML (milliliters) (Influenza Vac Split Quad) Inject 0.5 ml intramuscularly one time only for Routine Immunization for 1 Day.
-Start Date- 12/09/2019
Temp: 98.7
One Time: Nurse's Initials Time: 21:19 P.M.
On 3/5/20 at 2:00 P.M. an interview was conducted with Registered Nurse (RN) #2 who is also the Staff Development Coordinator regarding Resident #77's Informed Consent for the Influenza Vaccine. RN #2 stated, I called the daughter on the phone and explained what the shot was for and the precautions and she said No, I don't want her to have the flu shot because she got it last year and no one asked me if she could have it. I said ok. Once I had the refusal I went into the computer and marked her as refusing under the immunization tab. The nurse that gives the shot should check for allergies and the consent in the computer before giving the medication. The nurse that gave her the flu shot doesn't work here anymore.
On 3/5/20 at 2:40 P.M. an interview was conducted with Licensed Practical Nurse (LPN) #6 regarding Resident #77's Influenza Vaccine. LPN #6 stated, Before I wrote the order I went into the immunizations tab but I didn't open it all the way so I didn't see the consent was refused. I tried to stop the order but the nurse already gave it.
On 3/5/20 at 2:35 P.M. an interview was conducted with the Director of Nursing regarding what were her expectations of the staff with influenza vaccines. The Director of Nursing stated, I expect for them to follow the consent that is received.
The facility policy titled Influenza Vaccine revised August 2016 was reviewed and is documented in part, as follows:
6. A resident's refusal of the vaccine shall be documented on the Informed Consent for Influenza Vaccine and placed in the resident's medical record.
On 3/5/20 at 3:50 P.M. a pre-exit debriefing was held with the Administrator, the Director of Nursing and the Regional Director of Operations where the above information was discussed. Prior to exit no further information was provided.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and review of facility documentation, the facility staff failed to implement t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and review of facility documentation, the facility staff failed to implement the advance directive policy by not sending a resident's advance directive to the receiving hospital, and/or provide acknowledgement that allowed an opportunity to formulate an advance directive for 3 of 57 residents (#82, #63 and #109) in the survey sample.
The findings included:
1. Resident #82 was admitted to the nursing facility on 2/5/18 with diagnoses that included Alzheimer's disease, bipolar disorder and paranoid schizophrenia.
The most recent Minimum Data Set (MDS) assessment was an annual dated 1/15/20 and coded the resident with short and long term memory and moderately impaired in the cognitive skills for daily decision making.
A copy of the resident's Advance Directive was not sent with the resident when he was transferred to the local hospital on 6/2/19, 12/26/19 and 1/5/20. The Acute Care Transfer Document form for each of the resident's aforementioned transfers indicated the advance directives (durable power of attorney for health care, living will) to be sent at the time of transfer in addition to advance care orders (POLST, MOLST, POST, others), but they were not checked off as sent.
On 3/3/19 at 11:05 a.m., an interview was conducted with a Licensed Practical Nurse (LPN) #7. She stated when a resident is transferred to the hospital the following discharge documents are sent with the resident:
-Physician's order sheet (POS) with medication list
-Face Sheet
-Bedhold policy given to 911 or medical transport, not the resident or resident representative
-Laboratory reports
-The SBAR report
-Copy of the DNR form (as indicated)
The LPN stated the DNR form was the resident's advance directive and she had not been made aware of any other documents that were considered advance directives or where they were located.
On 3/5/20 at 1:45 p.m., the Medical Records Director located Resident #82's advance directives on the unit where the resident resided in his hard chart at the nurse's station.
On 3/5/20 at approximately 4:30 p.m., a debriefing session was conducted with the Administrator, Director of Nursing and the Regional Director of Operations. The aforementioned issue was reviewed and discussed. They shared they were not aware of the mandate to send a copy of the Advance Directive other than the DNR form upon transfer to the hospital. No further information was provided prior to survey exit.
The facility's policy and procedure dated 12/2016 indicated the Nurse Supervisor will be required to inform emergency medical personnel of a resident's advance directive regarding treatment options and provide such personnel with a copy of such directive when transfer from the facility via ambulance or other means is made.
2. The facility staff failed to provide Resident #63 with an opportunity to formulate an Advance Directive.
A review of the clinical records indicated that Resident #63 was admitted to the facility on [DATE]. Diagnoses for this resident included cancer, A-fib, heart failure, hypertension, diabetes mellitus, depression, psychotic disorder and asthma. A review of the annual Minimum Data Set (MDS) dated [DATE] assessed this resident as having a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition.
A review of the clinical records did not indicate Resident #63 was provided an opportunity to formulate an Advance Directive. During an interview with the Social Worker on 03/03/20 at 2:30 P.M. the Social Worker stated Resident #63 was not provided the opportunity to formulate an Advance Directive.
3. The facility staff failed provide Resident #109 with an opportunity to formulate an Advance Directive.
A review of the clinical record indicated that Resident #109 was admitted to the facility on [DATE]. Diagnoses for this resident included diabetes mellitus, hyperlipidemia, and dementia. A review of the Significant Change MDS dated [DATE] assessed this resident as having a BIMS score of 01 which indicated severe cognitive impairment.
A review of the clinical records did not indicate this resident was provided an opportunity to formulate an Advance directive. During an interview with the Social Worker on 03/03/20 at 2:30 P.M. the social worker stated Resident #109 was not provided the opportunity to formulate an Advance Directive.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observations and staff interviews, the facility staff failed to ensure a homelike environment on 3 units.
The findings included:
During the survey, the baseboard on Units III, IV and V were o...
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Based on observations and staff interviews, the facility staff failed to ensure a homelike environment on 3 units.
The findings included:
During the survey, the baseboard on Units III, IV and V were observed to be missing. The base boards were missing throughout the entire units.
During an interview with the Maintenance Director on 03/04/20 at 11:00 a.m. he stated, the facility staff had removed the baseboard last year and had not replaced it.
The Administrator was made aware of the findings on 03/04/20 at 3:15 P.M. The Administrator stated the new owners were going to renovate the facility. When asked for a capital improvement plan she was not able to provide one, nor was she able to give a date and time for the improvements. No further information was provided by the facility staff.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #53 was initially admitted to the facility on [DATE] with diagnoses including, but not limited to, dysphagia, repeat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #53 was initially admitted to the facility on [DATE] with diagnoses including, but not limited to, dysphagia, repeated falls, other Escherichia coli, urinary tract infection and metabolic encephalopathy.
Resident #53's most recent MDS (Minimum Data Set) assessment was a Quarterly Review Assessment with an ARD (Assessment Review Date) of 12/30/2019. Resident #53's BIMS (Brief Interview for Mental Status) score was recorded as unobtainable.
A review of Resident #53's clinical record revealed, there was no evidence that a Comprehensive Care Plan was sent to the receiving provider during a transfer to the hospital that occurred on, or about, 12/22/2019.
An interview with the facility Administrator on 3/5/2020 at approximately 11:00 a.m. regarding procedures to submit the Comprehensive Care Plan to receiving providers upon discharge, responded, No, we don't do that.
An interview with the Corporate Staff #2 regarding facility policy on submitting comprehensive care plans upon discharge produced the following response, There is no policy for submitting the care plan upon discharge.
These findings were reviewed with the facility Administrator, Director of Nursing, and Corporate Staff during a briefing held on 3/5/2020 at approximately 5:00 p.m. There was no additional information provided.
Based on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to send the comprehensive care plan goals upon transfer to the hospital for 4 out of 57 residents in the survey sample, Residents #119, #53, #82, and #21.
The findings included:
1. Resident #119 was admitted to the facility on [DATE] with diagnoses that included but were not limited to cognitive communication deficit, unspecified mood disorder, and dementia with other diseases with behavioral disturbance. Resident #119's most recent MDS (minimum data set) assessment was a 14 day scheduled assessment with an ARD (assessment reference date) of 1/27/20. Resident #119 was coded as being severely impaired in cognitive function on the staff interview for mental status exam.
Review of Resident #119's clinical record revealed that he was transferred to the hospital on 2/1/2020 for behaviors. The following was documented: Resident extremely agitated this shift, as exhibited by constantly walking in and out of other resident's room urinating, on their beds, pushing over furniture in the dining room and not responding at all to redirection. This activity culminated in resident becoming physically aggressive, kicking a nursing aide in the stomach when she tried to intervene resident physically threatening another resident. At this point, a nursing manager called 911 and resident was taken by stretcher to (name of hospital) (medical record) were notified of incident.
There was no evidence that care plan goals were sent with Resident #119 upon transfer to the hospital. Further review of the clinical record revealed that Resident #119 was not admitted back to the facility due to being a danger to staff and residents.
On 3/4/20 at 3:05 p.m. the nurse who transferred Resident #119 out to the hospital on 2/1/20 was attempted for an interview. She could not be reached.
On 3/4/20 at 4:22 p.m., an interview was conducted with the former DON (Director of Nursing) ASM (administrative staff member) #3. When asked when a resident is sent to the hospital what documents were sent upon transfer, ASM #3 stated that she expected staff to send the e-interact transfer form and the bed hold policy. When asked if she expected her nurses to document what items were sent with the resident upon transfer to the hospital, ASM #3 stated that she did. When asked if the e-interact form included the care plan goals, ASM #3 stated, I don't know. When asked if staff were expected to send the care plan or care plan goals upon transfer to the hospital, ASM #3 Not that I am aware of.
On 3/4/20 at 4:33 p.m., an interview was conducted with LPN (Licensed Practical Nurse) #7. When asked what documents were sent with residents upon transfer to the hospital, LPN #7 stated that she would send the face sheet, advanced directive, any pertinent laboratory tests, bed hold policy and the e-interact form. When asked if she would send care plan goals or the care plan with the resident upon transfer to the hospital, LPN #7 stated, I have never heard of that. LPN #7 stated that she also never heard of documenting what items were sent with the resident upon transfer to the hospital.
Review of Resident #119's e-interact form dated 2/1/2020 did not address care plan goals.
On 3/4/20 at 5:00 p.m., ASM (administrative staff member) #1, the Administrator, was made aware of the above concerns. ASM #1 stated that her admission/transfer/discharge policy did not address care plan goals. No further information was provided prior to exit.3. Resident #82 was admitted to the nursing facility on 2/5/18 with diagnoses that included Alzheimer's disease, bipolar disorder and paranoid schizophrenia.
The most recent Minimum Data Set (MDS) assessment was an annual dated 1/15/20 and coded the resident with short and long term memory and moderately impaired in the cognitive skills for daily decision making.
A copy of the resident's comprehensive care plan goals was not sent with the resident when he was transferred to the local hospital on 6/2/19, 12/26/19 and 1/5/20.
On 3/3/20 at 11:05 a.m., an interview was conducted with a Licensed Practical Nurse (LPN) #7. She stated when a resident is transferred to the hospital the following discharge documents are sent with the resident:
-Physician's order sheet (POS) with medication list
-Face Sheet
-Bedhold policy given to 911 or medical transport, not the resident or resident representative
-Laboratory reports
-The SBAR report
-Copy of the DNR form (as indicated)
LPN #7 stated she was never told to send anything with the patient or forward to the provider other that the aforementioned documents and never heard of a care plan summary and what it entails.
On 3/5/20 at approximately 4:30 p.m., a debriefing session was conducted with the Administrator, Director of Nursing and the Regional Director of Operations. The aforementioned issue was reviewed and discussed. They shared they were not aware of the mandate to send or fax a summary of the care plan goals to the transferring entity when residents are transferred from the facility. They stated they did not have a policy or procedure that outlined the directive. No further information was provided prior to survey exit.4. Resident #21 was re-admitted to the facility on [DATE]. Diagnoses for this resident included seizures, depression, and multiple sclerosis. Resident #21 was admitted to the hospital on [DATE]. A review of the Re-admit Minimum Data Set (MDS) dated [DATE] assessed this resident in the area of Cognitive Patterns - Brief Interview for Mental Status (BIMS) as a 15 which indicated intact cognition.
A review of the clinical records did not indicate a Care Plan Summary was sent to the hospital with Resident #21. During an interview on 03/05/20 at 11:00 A.M. with the Administrator, she stated care plans were not sent to the hospital with Resident #21 during his admission (to the hospital) on 11/24/19.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and facility documentation review, the facility staff failed to issue a bedhol...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and facility documentation review, the facility staff failed to issue a bedhold notice to the resident or resident representative at time of transfer to the hospital for 3 of 57 Residents (#89, #82 and #21) in the survey sample.
The findings include:
1. The facility staff failed to ensure Resident #89 or Resident Representative (RR) was issued a written notice of the bed hold reserve policy upon transfer to the local hospital on 1/14/20.
Resident #89 was admitted to the nursing facility on 7/12/18 with diagnoses that included non-Alzheimer's disease dementia and generalized muscle weakness. The resident was readmitted on [DATE] with diagnoses that included dysphagia, meniere's disease and urinary tract infection (UTI).
The most recent Minimum Data Set (MDS) assessment dated [DATE] was a significant change is status and coded the resident with moderate difficulty in hearing, usually has the ability to express ideas and wants and usually comprehends most conversation. Resident #89 was coded on this assessment as having short and long term memory and never/rarely made decisions.
The nurse's notes dated 1/14/20 indicated the resident was sent to the local hospital and admitted with a diagnosis of Altered Mental Status (AMS), Urinary Tract Infection (UTI) and elevated cardiac enzymes. The resident was readmitted to the nursing facility on 1/19/20. There was no documentation that a written notice of the bed hold reserve policy was issued to the RR upon transfer to the local hospital.
On 3/3/20 at 11:05 a.m., an interview was conducted with a Licensed Practical Nurse (LPN) #7. She stated when a resident is transferred to the hospital the following discharge documents are sent with the resident:
-Physician's order sheet (POS) with medication list
-Face Sheet
-Bedhold policy given to 911 or medical transport, not the resident or resident representative
-Laboratory reports
-The SBAR report
-Copy of the DNR form (as indicated)
LPN #7 stated she does not issue the bedhold policy to the resident or their families, but gave the bedhold notice to 911 or regular transportation. She stated, Maybe they give the bedhold notice to the resident and/or family.
The facility's policy and procedures titled Bed-Holds and Returns dated 3/2017 indicated prior to transfer, written information will be given to the residents and the resident's representatives that explains in detail the rights and limitation of the resident regarding bed-holds, reserve bed payment, perdiem rate and details of the transfer.
On 3/5/20 at approximately 4:30 p.m., a debriefing session was conducted with the Administrator, Director of Nursing and the Regional Director of Operations. The aforementioned issue was reviewed and discussed. No further information was provided prior to survey exit.
2. The facility staff failed to ensure Resident #82 or Resident Representative (RR) was issued a written notice of the bed hold reserve policy upon transfer to the local hospital on 6/2/19, 12/26/19 and 1/5/20.
Resident #82 was admitted to the nursing facility on 2/5/18 with diagnoses that included Alzheimer's disease, bipolar disorder and paranoid schizophrenia.
The most recent Minimum Data Set (MDS) assessment was an annual dated 1/15/20 and coded the resident with short and long term memory and moderately impaired in the cognitive skills for daily decision making.
The nurse's notes dated 6/2/19 with readmission to the facility on 6/3/19; the nurse's notes dated 12/26/19 with readmission on [DATE], and nurse's notes dated 1/5/20 with readmission on [DATE] did not reference documentation that a written notice of the bed hold reserve policy was issued to the RR upon transfer to the local hospital.
On 3/3/20 at 11:05 a.m., an interview was conducted with a Licensed Practical Nurse (LPN) #7. She stated when a resident is transferred to the hospital the following discharge documents are sent with the resident:
-Physician's order sheet (POS) with medication list
-Face Sheet
-Bedhold policy given to 911 or medical transport, not the resident or resident representative
-Laboratory reports
-The SBAR report
-Copy of the DNR form (as indicated)
LPN #7 stated she does not issue the bedhold policy to the resident or their families, but gave the bedhold notice to 911 or regular transportation. She stated, Maybe they give the bedhold notice to the resident and/or family.
On 3/5/20 at approximately 4:30 p.m., a debriefing session was conducted with the Administrator, Director of Nursing and the Regional Director of Operations. The aforementioned issue was reviewed and discussed. No further information was provided prior to survey exit.3. The facility staff failed to provide Resident #21 with a bed hold notice upon discharge to the hospital.
Resident #21 was discharged to the hospital on [DATE]. Diagnoses for this resident included seizures, depression, and multiple sclerosis. Resident #21 was admitted to the hospital on [DATE]. A review of the re-admission Minimum Data Set (MDS) dated [DATE] assessed this resident in the area of Cognitive Patterns - Brief Interview for Mental Status (BIMS) as a 15 which indicated intact cognition.
A review of the clinical records did not indicate a bed hold notice was provided to Resident #21 upon his discharge to the hospital on [DATE]. During an interview on 03/05/20 at 11:00 A.M. with the Administrator she stated, Resident #21 was not provided a bed hold notice upon discharge to the hospital on [DATE].
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected multiple residents
Based on staff interview and information obtained during the Sufficient and Competent Nurse Staffing task, the facility staff failed to staff a Registered Nurse (RN) for at least 8 consecutive hours a...
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Based on staff interview and information obtained during the Sufficient and Competent Nurse Staffing task, the facility staff failed to staff a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week potentially affecting all residents in the facility.
The findings included:
During the nursing staff review for July 4, 2019 through March 1, 2020 the facility staff was unable to provide nurse staffing documentation for July 4, 2019 through October 6, 2019. Nurse staffing for October 12, 2019 through March 1, 2010 revealed there were not RN presence in the facility for at least 8 consecutive hours on 10/5/19, 10/19/19, 10/20/19, 10/31/19, 11/3/19, 11/9/19, 11/10/19, 11/16/19, 11/17/19, 11/28/19, 11/29/19, 11/30/19, 12/1/19, 12/7/19, 12/8/19, 12/15/19, 12/21/19, 12/22/19, 12/23/19, 12/24/19, 12/25/19, 12/26/19, 12/28/19, 12/31/19, 1/1//20, 1/11/20, 1/18/20, 1/19/20, 1/25/20, 1/26/20, 2/1/20, 2/2/20, 2/8/20, and 2/28/20.
On 3/5/20 at approximately 3:50 p.m., the Staffing Coordinator was interviewed. The staffing coordinator stated she wasn't employed by the facility for all the requested dates and the staffing system was managed differently therefore; she couldn't verify the requested staffing.
On 3/5/20, at approximately 3:50 p.m., the above findings were shared with the Administrator, Director of Nursing and Regional Director of Operations. The Administrator stated she understood the concern and had no additional information the offer.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide an accurate record of controlled medications for 4 of 57 resident...
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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 for 4 of 57 residents (Residents #22, #37, #168 and #418), in a survey sample.
The findings included:
1. The facility staff failed to ensure an accurate account of controlled medication for Resident #22. Resident #22 was admitted to the nursing facility on 05/23/19. Diagnoses for Resident #22 included but not limited to Cognitive Decline.
On 3/02/20 at approximately 11:52 a.m., an inventory of controlled medication was conducted on the medication cart on Unit 1 with Licensed Practical Nurse (LPN) #2. The Medication Monitoring/Control Record was compared to the actual medication count with the following discrepancy:
Resident #22's, Ativan 1 mg count per record=23, actual count=22.
On 03/02/20 at approximately 11:55 a.m., an interview was conducted with LPN #2 who stated, I did not give Resident #22 her morning Ativan. She (LPN) said I retrieved the medication cart keys from Registered Nurse (RN)#1 this morning but we never did not do a narcotic count; that was my mistake; we should have counted.
An interview was conducted with RN #1 on 03/02/20 at approximately 1:15 p.m. The RN said I should have counted with LPN #2 but it actually slipped my mind.
Review of Resident #22's February 2020 Physician Order Sheet revealed the following order:
-10/23/19 - Ativan 1 mg - give 1 tablet by mouth two times a day for cognitive decline.
On 03/02/20, an interview was conducted with Director of Nursing (DON) at approximately 3:03 p.m. The DON stated, The nurse should not have taken possession of the medication cart keys until the narcotic count has been counted and was correct.
2. The facility staff failed to ensure an accurate account of controlled medications for Resident #37. Resident #37 was originally admitted to the nursing facility on 05/05/16. Diagnoses for Resident #37 included but not limited Anxiety disorder.
On 3/02/20 at approximately 12:45 p.m., an inventory of controlled medication was conducted on the medication cart on Unit 3 with Licensed Practical Nurse (LPN) #4. The Medication Monitoring/Control Record was compared to the actual medication count with the following discrepancy:
Resident #37's, Xanax 0.5 mg count per record=27, actual count=26.
On 03/02/20 at approximately 12:45 p.m., an interview was conducted with LPN #4. LPN #4 said I gave Resident #37 her morning Xanax. She said she should have signed the narcotic count sheet right away but was still getting used to the residents here. The LPN stated, I know the correct way to sign off narcotics but I'm still trying to get it together.
Review of Resident #37's February 2020 Physician Order Sheet revealed the following order:
-12/30/19 - Give Xanax 0.5 mg by mouth two times a day for agitation.
On 03/02/20, an interview was conducted with Director of Nursing (DON) at approximately 3:03 p.m. The DON stated, The nurse should not have taken possession of the medication cart keys until the narcotic count has been counted and was correct.
3. The facility staff failed to ensure an accurate account of controlled medications for Resident #168. Resident #168 was admitted to the nursing facility on 02/24/20. Diagnoses for Resident #168 included but not limited to Anxiety disorder.
On 3/02/20 at approximately 1:05 p.m., an inventory of controlled medication was conducted on the medication cart on Unit 5 with Licensed Practical Nurse (LPN) #5. The Medication Monitoring/Control Record was compared to the actual medication count with the following discrepancy:
Resident #168's, Clonazepam 0.5 mg count per record=11, actual count=10.
On 03/02/20 at approximately 1:05 p.m., an interview was conducted with LPN #5. LPN stated, I forgot to sign off on Resident #168's 9:00 a.m., Clonazepam. She said I should have signed off once I removed the medication from the card.
Review of Resident #22's February 2020 Physician Order Sheet revealed the following order:
-02/25/20 - Give Clonazepam 0.25 mg by mouth two times a day for Generalized Anxiety Disorder.
An interview was conducted with Director of Nursing (DON) on 03/02/20 at approximately 3:03 p.m. The DON stated, I expect for all nurses to sign off their controlled medication at the time the medication is administered.
4. The facility staff failed to ensure an accurate account of controlled medications for Resident #418. Resident #418 was admitted to the nursing facility on 02/17/20. Diagnoses for Resident #418 included but not limited to Pain.
On 3/02/20 at approximately 11:55 p.m., an inventory of controlled medication was conducted on the medication cart on Unit 1 with Licensed Practical Nurse (LPN) #2. The Medication Monitoring/Control Record was compared to the actual medication count with the following discrepancy:
Resident #418, Gabapentin 300 mg count per record=4, actual count=3.
On 03/02/20 at approximately 11:55 a.m., an interview was conducted with LPN #2 who stated, I did not give Resident #418 his morning Gabapentin, which was given by RN #1. She (LPN) said I retrieved the medication cart keys from RN #1 this morning but we never did a narcotic count; that was my mistake; we should have counted.
An interview was conducted with RN #1 on 03/02/20 at approximately 1:15 p.m. The RN stated, I should have followed the 5 right for administering medication. He said I should have signed off on Resident #418's 9:00 a.m.,
Gabapentin at the time it was administered. He said I should have counted with LPN #2 but it actually slipped my mind.
Review of Resident #418's February 2020 Physician Order Sheet revealed the following order:
-02/17/20 - Gabapentin 300 mg - give 1 capsule by mouth two times a day for pain.
On 03/02/20, an interview was conducted with Director of Nursing (DON) at approximately 3:03 p.m. The DON stated, The nurse should not have taken possession of the medication cart keys until the narcotic count has been counted and was correct.
A briefing was held with the Administrator and Director of Nursing on 03/03/20 at approximately 4:00 p.m. The facility did not present any further information about the findings.
The facility policy titled Controlled Substances (Revised December 2012).
-Policy statement: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Scheduled II and other controlled substances.
Definitions:
1) Ativan is used to relieve anxiety (www.nlm.nih.gov/medlineplus/drug).
2) Xanax is used to treat anxiety disorders.
3) Clonazepam is used alone or in combination with other medications to control certain types of seizures. It is also used to relieve panic attacks (sudden, unexpected attacks of extreme fear and worry about these attacks) (https://medlineplus.gov).
4) Gabapentin is used to help control certain types of seizures in people who have epilepsy. Gabapentin capsules, tablets, and oral solution are also used to relieve the pain of postherpetic neuralgia (PHN; the burning, stabbing pain or aches that may last for months or years after an attack of shingles) (https://medlineplus.gov).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
**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 monthly ...
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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 monthly medication reviews were readily available for review for 3 residents (Residents #21, #61, #71) and to ensure the physician reviewed pharmacy recommendations for 1 resident (Resident #112) of 57 residents in the survey sample.
The findings included:
On 03/05/2020 the following policy was reviewed regarding medication reviews: ORGANIZATIONAL ASPECTS IA2: CONSULTANT PHARMACIST SERVICES PROVIDER REQUIREMENTS POLICIES AND PROCEDURES-Pharmacy Services for Nursing Facilities 2006 American Society of Consultant Pharmacists and MED-PAS, INC (Revised January 2018) (Pharmacy Name) RX August 2019 Policy-Regular and Reliable consultant pharmacist services are provided to residents. A written agreement with a consultant pharmacist stipulates financial arrangements, at fair market price, and the terms of the services provided. Review of the procedures revealed and is documented in part, as follows: F. Specific activities that the consultant pharmacist performs includes, but is not limited to: 1) Reviewing the medication regimen (medication regimen review) of each resident at least monthly, or more frequently under certain conditions (e.g., upon admission or with a significant change in condition), incorporating federally mandated standards of care in addition to other applicable professional standards as outlined in the procedure for medication regimen review (See IIIA1:MEDICATION REGIMEN REVIEW), and documenting the review and findings in the resident's medical record or in a readily retrievable format if utilizing electronic documentation. 2) Communicating to the responsible prescriber and the facility leadership potential or actual problems detected and other findings relating to medication therapy orders including recommendations for changes in medication therapy and monitoring of medication therapy as well as regulatory compliance issues [ at least monthly].
1. Resident #21 was originally admitted to the facility on [DATE]. Diagnoses included but were not limited to, Multiple Sclerosis and Depression. Resident #21's Minimum Date Set (MDS-an assessment protocol) with an Assessment Reference Date of 12/05/2019 coded Resident #21 with a BIMS (Brief Interview for Mental Status) score of 11 indicating moderate cognitive impairment.
On 03/04/2020 at approximately 10:00 a.m., requested copies of Medication Regiment Reviews of Resident #21 for the past 12 months from the Administrator and Corporate Nurse Consultant. The Administrator stated, We acquired the facility in July 2019. We can provide Medication Regimen Reviews completed after August 2019. The Administrator also stated that they were part owners of the pharmacy, (Name).
On 03/04/2020, the facility provided copies of Medication Regimen Reviews for the period of July 2019 through February 2020.
On 03/05/2020 at approximately 9:00 a.m., requested copies of Medication Regimen Reviews for April, May and June 2019. The facility was unable to provide Medication Regimen Reviews for April and June 2019.
On 03/05/2020 at 2:30 p.m., during a briefing, the Director of Nursing was made aware of the finding. No further information was presented about the finding.
2. Resident #61 was originally admitted to the facility on [DATE]. Diagnoses included but were not limited to, Nontraumatic Subarachnoid Hemorrhage, unspecified and Vascular Dementia Without Behavioral Disturbance. Resident #61's Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 01/04/2020 coded Resident #61 with a BIMS (Brief Interview for Mental Status) score of 01 indicating severe cognitive impairment.
On 03/04/2020 at approximately 10:00 a.m., requested copies of Medication Regiment Reviews of Resident #61 for the past 12 months from the Administrator and Corporate Nurse Consultant. The Administrator stated, We acquired the facility in July 2019. We can provide Medication Regimen Reviews completed after August 2019. The Administrator also stated that they were part owners of the pharmacy, (Name).
On 03/04/2020, the facility provided copies of Medication Regimen Reviews for the period of July 2019 through February 2020.
On 03/05/2020 at approximately 4:00 p.m., the facility reported they were unable to provide evidence of Medication Regimen Reviews for April, May and June 2019.
On 03/05/2020 at 2:30 p.m., during briefing the Director of Nursing was made aware of finding. No further information was presented about the finding.
3. Resident #71 was originally admitted to the facility on [DATE]. Diagnoses included but were not limited to, Cerebral Infarction and Unspecified Dementia. Resident #71's Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 01/09/2020 coded Resident #71 with short-term memory problems and long-term memory problems with severely impaired cognitive skills for daily decision making.
On 03/04/2020 at approximately 10:00 a.m., requested copies of Medication Regiment Reviews for Resident #71 for the past 12 months from the Administrator and Corporate Nurse Consultant. The Administrator stated, We acquired the facility in July 2019. We can provide Medication Regimen Reviews completed after August 2019. The Administrator also stated that they were part owners of the pharmacy, (Name).
On 03/04/2020, the facility provided copies of Medication Regimen Reviews for the period of July 2019 through February 2020.
On 03/05/2020 at approximately 9:00 a.m., requested copies of Medication Regimen Reviews for April, May and June 2019. Medication Regimen review for April 2019 was received however they were unable to provide evidence of Medication Regimen Reviews for May and June 2019.
On 03/05/2020 at 2:30 p.m., during briefing the Director of Nursing was made aware of finding. No further information was presented about the finding.
4. Resident #112, the facility staff failed to ensure that the physician reviewed pharmacy recommendation. Resident #112 was originally admitted to the facility on [DATE]. Diagnosis included but were not limited to, Unspecified Dementia Without Behavioral Disturbance and Depression. Resident #112's Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 02/13/2020 coded Resident #112 with a BIMS (Brief Interview for Mental Status) score of 12 indicating moderate cognitive impairment.
On 03/04/2020 at approximately 10:00 a.m., requested copies of Medication Regiment Reviews of Resident #112 for the past 12 months from the Administrator and Corporate Nurse Consultant. The Administrator stated, We acquired the facility in July 2019. We can provide Medication Regimen Reviews completed after August 2019. The Administrator also stated that they were part owners of the pharmacy, (Name).
On 03/04/2020 at approximately 12:00 p.m., Resident #112's Consultant Pharmacist Medication Regimen Review was reviewed and revealed and is documented in part, as follows: Recommendations: Please consider a dose reduction to Zolpidem 5 mg (Milligram) at bedtime, while concurrently monitoring for reemergence of depressive and/or withdrawal symptoms. Date: 02/12/2020.
On 03/04/2020 at approximately 12:15 p.m., review of Resident #112's Medication Administration Record for the period of 02/01/2020 through 02/29/2020 revealed the following order: Ambien Tablet 10 MG (Zolpidem Tartrate) Give 1 tablet by mouth at bedtime for Insomnia. Start Date: 09/24/2019
On 03/04/2020 at approximately 12:20 p.m., review of Resident #112's Medication Administration Record for the period of 03/01/2020 through 03/31/2020 revealed the following order: Ambien Tablet 10MG (Zolpidem Tartrate) Give 1 tablet by mouth at bedtime for insomnia. Start Date: 09/24/2019.
An interview was conducted with Corporate Staff #3 on 03/05/2020 at 12:30 p.m Reviewed Consultant Pharmacist Medication Regiment Review with recommendations with Corporate #3. There was no evidence that the physician responded to the pharmacist recommendation. Reviewed Medication Administration records for months of February 2020 and March 2020 with Corporate #3. Corporate #3 stated, The process should be that the recommendation is posted to Polaris and then it goes to the DON (Director of Nursing) then the DON delegates to nursing or the Unit Manager then it is sent to the attending physician. The physician should document on the form, it should be documented and addressed on the pharmacist recommendation. Corporate #3 stated that he would check on it.
On 03/05/2020 facility policy and procedure on Medication Regimen Reviews was received and included: ORGANIZATIONAL ASPECTS IA2: CONSULTANT PHARMACIST SERVICES PROVIDER REQUIREMENTS POLICIES AND PROCEDURES-Pharmacy Services for Nursing Facilities 2006 American Society of Consultant Pharmacists and MED-PAS, INC (Revised January 2018) .Specific activities that the consultant pharmacist performs includes, but is not limited to: 1) Reviewing the medication regimen (medication regimen review) of each resident at least monthly, or more frequently under certain conditions (e.g., upon admission or with a significant change in condition), incorporating federally mandated standards of care in addition to other applicable professional standards as outlined in the procedure for medication regimen review ., and documenting the review and findings in the resident's medical record or in a readily retrievable format if utilizing electronic documentation. 2) Communicating to the responsible prescriber and the facility leadership potential or actual problems detected and other findings relating to medication therapy orders including recommendations for changes in medication therapy and monitoring of medication therapy as well as regulatory compliance issues [at least monthly]. G. The consultant pharmacist documents activities performed and services provided on behalf of the residents and the facility. 1) A written or electronic report of the findings and recommendations resulting from the activities as described above is given to the, attending physician, director of nursing, medical director and others as may be appropriate (e.g. administrator, regional manager, etc.) [at least monthly]. The facility has a process to ensure that the findings are acted upon.
On 03/05/2020 at 2:30 p.m., during a briefing the Director of Nursing was made aware of finding. The Director of Nursing stated, It should have been addressed within 7 days. As soon as we get the recommendation we should go ahead and get them out to the doctor. No further information was presented about the finding.
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 general observations of the nursing facility and staff interview, the facility failed to ensure medications were labeled in accordance with currently accepted professional principles and stor...
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Based on general observations of the nursing facility and staff interview, the facility failed to ensure medications were labeled in accordance with currently accepted professional principles and stored according to manufacture guidelines in 3 out of 5 medication carts
The findings included:
1. The facility staff failed to ensure one Lantus (insulin) vial was dated once open for Resident #109. Resident #109 was originally admitted to the nursing facility on 04/20/15. Diagnosis for Resident #109 included but not limited to
Type 2 Diabetes.
On 3/02/20 at approximately 11:37 a.m., the medication cart on Unit 4 was inspected with Licensed Practical Nurse (LPN) #1. During the inspection of the insulins stored inside the medication cart, one Lantus vial was open with no open date. An interview was conducted with LPN #1 who stated, The Lantus insulin vial belongs to Resident #109 but does not have an open date; the insulin should have been dated once open. The Lantus insulin was removed from the medication cart by the nurse.
Review of Resident #109's February 2020 Physician Order Sheet revealed the following order:
-08/28/19 - Lantus - inject 35 units subcutaneously at bedtime for diabetes.
An interview was conducted with Director of Nursing (DON) on 03/02/20 at approximately 3:03 p.m. The DON stated, All insulins must be labeled and dated once opened.
2. The facility staff failed to ensure medication label (Ativan) was legible for Resident #75. Resident #75 was originally admitted to the nursing facility on 02/04/11. Diagnoses for Resident #75 included but not limited to Anxiety.
On 3/02/20 at approximately 11:37 a.m., the medication cart on Unit 4 was inspected with Licensed Practical Nurse (LPN) #1. During the inspection of the controlled medications stored inside the medication cart, a bottle of liquid Ativan was observed but the resident's name was not legible (most of the name was missing). An interview was conducted with LPN #1 who stated, The medication belongs to (Resident #75). The LPN was asked, How do you know who the Ativan belong to if most of the name on the bottle is missing she replied, I just know who the medication belong. The LPN stated, By looking at the Ativan bottle, I am unable to identify who this medication belong too; I am unable to ready the label.
An interview was conducted with Director of Nursing (DON) on 03/02/20 at approximately 3:03 p.m. The DON stated, If a label is not legible; the medication is not to be administered but a new label must be ordered from pharmacy first. The DON said Once the new label arrives, the nurse can administer the medication.
A briefing was held with the Administrator and Director of Nursing on 03/03/20 at approximately 4:00 p.m. The facility did not present any further information about the findings.
The facility policy titled Labeling of Medication Containers (Revised 2007).
Policy statement: All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations.
-Policy Interpretation and Implementation include but not limited to: Medication labels must be legible at all times.
3. The facility staff failed to ensure multi dose vials of liquid Ativan was stored according to manufacture guidelines on 3 of 5 medication carts. During the inspection of the controlled medications stored inside the medication cart, liquid Ativan bottles were observed. The label contain the following information: Store at cold temperature - refrigerate between 36-46 degrees. The following Residents multi dose vials of liquid Ativan (2 mg per ml) was observed on the medication carts:
-Resident #75's (Unit 4).
-Resident #83's (Unit 1).
-Resident #43's (Unit 2).
On 03/20/20 at approximately 11:37 a.m., an inventory of controlled medication was conducted on the medication cart located on Unit 4, assigned to Licensed Practical Nurse (LPN) #1. The LPN stated, The liquid Ativan for Resident #75 should be stored in the medication refrigerator and not on the medication cart.
On 03/20/20 at approximately 11:52 a.m., an inventory of controlled medication was conducted on the medication cart located on Unit 1, assigned to LPN #2. The LPN stated, The liquid Ativan should be stored in the refrigerator. The LPN was asked, What is the purpose for storing liquid Ativan in the refrigerator she replied, So the medication will not lose it potency.
On 03/20/20 at approximately 12:30 p.m., an inventory of controlled medication was conducted on the medication cart located on Unit 2, assigned to LPN #3. The LPN stated, The liquid Ativan for Resident #43 should be stored in the refrigerator after reviewing the label on the liquid Ativan.
An interview was conducted with Director of Nursing (DON) on 03/02/20 at approximately 3:03 p.m. The DON stated, Liquid (name of medication) should be stored in the refrigerator according to manufactures guidelines.
-Manufacture Guidelines: How should I store Ativan.
Store Ativan at a cold temperature. Refrigerate at 36 degrees to 46 degrees and protect from light.
Definition:
-Lantus is used to treat type 1 diabetes (condition in which the body does not produce insulin and therefore cannot control the amount of sugar in the blood). It is also used to treat people with type 2 diabetes (condition in which the body does not use insulin normally and, therefore, cannot control the amount of sugar in the blood) who need insulin to control their diabetes) (https://medlineplus.gov/ency/article/007365.htm).
-Ativan is used to relieve anxiety (www.nlm.nih.gov/medlineplus/drug).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations, staff interviews and facility document review the facility staff failed to store and prepare food in accordance with professional standards for food service safety.
The finding...
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Based on observations, staff interviews and facility document review the facility staff failed to store and prepare food in accordance with professional standards for food service safety.
The findings included:
On 3/2/20 at approximately 11:30 A.M. during the initial kitchen tour, the following observations were made:
Dry Storage Room:
1-25 pound bag of parboiled rice not sealed, open to air with no date.
1-10 pound bag of macaroni noodles not sealed, open to air.
1 bag of bowtie pasta not sealed, open to air.
Reach in Refrigerator #2:
1 gallon ziplock bag with a drink and a protein bar in it, which was immediately removed by the dietary aide that the food bag belonged to, stating it belonged to staff.
1 -2 pound package of smoked turkey breast sandwich meat not sealed, open to air.
1 open bag of boiled eggs with fluid leaking over other food contents in metal container.
Main kitchen area:
1-50 pound bag of potato starch on back kitchen table not sealed, open to air, not dated and a large scoop sitting on top of the bag.
1-2 pound bag of light brown cane sugar not sealed and open to air that was sitting on a shelf below a return air vent.
The return air vent was covered in a copious amount of dark gray sticky material.
1- 25 pound box of instant food thickener not sealed, open to air and a large scoop noted inside of the box lying on top of the food thickener.
Drain flies were observed flying around the steam table, the trash can and the handwashing sink. Three drains were inspected in the dishwashing area. All three drains were noted to have copious amounts of thick black grease build up. One drain was noted to have 3 fruit flies inside of it.
On 3/2/20 at 11:50 A.M. an interview was conducted with the Dietary Aide regarding fruit flies. The Dietary Aide stated, They are mainly in the dishwasher area.
The Dietary Manager was informed of all the above findings. On 3/2/20 at approximately 12:15 P.M. the Dietary Manager was asked about his expectations for the storage of food and pests in the kitchen. The Dietary Manager stated, When something is opened it should sealed so it is not open to air or pests and dated. Also scoops are single use and should be washed after each use. The drains need to be cleaned.
On 3/2/20 at approximately 12:25 P.M. the Director of Maintenance arrived in the kitchen and was shown the drains in the dishwasher area. The Director of Maintenance stated, I see the flies.
The facility policy titled Food Receiving and Storage revised July 2014 was reviewed and is documented in part, as follows:
Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices.
Policy Interpretation and Implementation:
1. Food Services, or other designated staff, will maintain clean food storage areas at all times.
4. Non-refrigerated foods, disposable dishware and napkins will be stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean.
6. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a first in-first out system.
7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date).
On 3/5/20 at 3:50 P.M. a pre-exit debriefing was held with the Administrator, the Director of Nursing and the Regional Director of Operations where the above information was discussed. Prior to exit no further information was provided.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation on 3/4/2020 at approximately 11:42 a.m., a live roach was seen swept by (Housekeeping) staff #12 on the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation on 3/4/2020 at approximately 11:42 a.m., a live roach was seen swept by (Housekeeping) staff #12 on the Unit 1 hallway near room [ROOM NUMBER].
On 3/5/2020 at approximately 9:35 a.m., an inspection of the Unit 1 hallway was conducted along with the Facility Maintenance Director. Surveyor pointed out areas of missing baseboards on the walls of the hallway. The Facility Maintenance Director responded, We will fix that today. It's an issue in controlling pests. We are in the process of repairing those to help control pests getting into the facility.
An interview held with Other (Housekeeping) staff #12 on 3/5/2020 at approximately 11:00 a.m. regarding sightings of roaches within the facility, Other #12 responded, I usually see roaches around two times per week and they are usually dead.
A review of Facility Pest Sighting/Evidence Logs revealed:
Unit 1:
Sightings of live roaches in the dining room on 10/9/2019.
Sightings of roaches in room [ROOM NUMBER] on 1/9/2020.
Unit 2:
Sightings of several roaches within the Social Services Office on 11/17/2019.
Sightings of roaches in room [ROOM NUMBER].
Sightings in room [ROOM NUMBER] (unspecified type).
Sightings of several roaches in the Social Services Office on 1/29/2020.
Unit 4:
Sightings of roaches on the main floors within rooms 115-123 on 1/28/2020.
Sightings of roaches on main floors by room [ROOM NUMBER] on 2/5/2020.
Unit 5:
Sightings of roaches within rooms 83, 85 and the Dining Room on 12/2/2019.
A review of Facility Vendor Customer Service Reports revealed, in part, the following:
1. A finding of floor tiles or baseboards loose/missing within resident rooms and kitchen area with a recommendation to repair to eliminate potential pest harborage/breeding site on 10/21/2019 and 11/21/2019.
2. A finding of spilled food material found on the floor, floor drains in need of cleaning and trash cans in need of cleaning, with a recommendation to clean to reduce pest attraction and source for breeding, on 1/24/2020.
3. A finding of hole/gap noted cracks and open areas around upper window frames and around air conditioner units allow for pest entry outside/inside, with a recommendation to seal to prevent pest entry or harborage on 2/20/2020.
The Facility policy on Pest Control (rev. 5/2008) included:
Our facility shall maintain an effective pest control program.
Policy Interpretation and Implementation
1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.
3. Windows are screened at all times.
4. Only approved FDA and EPA insecticides and rodenticides are permitted in the facility and all such supplies are stored in areas away from food storage areas.
5. Garbage and trash are not permitted to accumulate and are removed from the facility daily.
6. Maintenance services assist, when appropriate and necessary, in providing pest control services.
These findings were reviewed with the Facility Administrator, DON and Corporate Staff during a briefing held on 3/5/2020 at approximately 5:00 p.m. There was no additional information provided.
Based on observations, staff interviews and facility document review the facility staff failed to maintain an effective pest control program.
The findings included:
1. On 3/2/20 at approximately 1130 A.M. during the initial kitchen tour the following observations were made:
Drain flies were observed flying around the steam table, the trash can and the handwashing sink. Three drains were inspected in the dishwashing area. All three drains were noted to have copious amounts of thick black grease build up. One drain was noted to have 3 fruit flies inside of it.
On 3/2/20 at 11:50 A.M. an interview was conducted with the Dietary Aide regarding fruit flies. The Dietary Aide stated, They are mainly in the dishwasher area.
The Dietary Manager was informed of all the above findings. On 3/2/20 at approximately 12:15 P.M. the Dietary Manager was asked about his expectations for the storage of food and pests in the kitchen. The Dietary Manager stated, When something is opened it should sealed so it is not open to air or pests and dated .The drains need to be cleaned.
On 3/2/20 at approximately 12:25 P.M. the Director of Maintenance arrived in the kitchen and was shown the drains in the dishwasher area. The Director of Maintenance stated, I see the flies.
Throughout the survey gnats and fruit flies were also observed on Units 4 and 5.
On 3/5/20 at 9:40 A.M. an interview was conducted with the Director of Maintenance regarding the pest observed in the facility. The Director of Maintenance provided documentation to show on 1/24/20 that 1 box of [NAME] Fruit Fly Traps had been ordered. The Director of Maintenance was asked if the traps had been effective. The Director of Maintenance stated, It has slowed them down.
The facility policy titled Pest Control revised May 2008 was reviewed and is documented in part, as follows:
Policy Statement: Our facility shall maintain an effective pest control program.
Policy Interpretation and Implementation:
1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.
On 3/5/20 at 3:50 P.M. a pre-exit debriefing was held with the Administrator, the Director of Nursing and the Regional Director of Operations where the above information was discussed. Prior to exit no further information was provided.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "What safeguards are in place to prevent abuse and neglect?"
- "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: Federal abuse finding, 2 life-threatening violation(s), Special Focus Facility, 5 harm violation(s), $127,257 in fines. Review inspection reports carefully.
- • 114 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $127,257 in fines. Extremely high, among the most fined facilities in Virginia. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Birchwood Park Rehabilitation's CMS Rating?
CMS assigns BIRCHWOOD PARK 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 Birchwood Park Rehabilitation Staffed?
CMS rates BIRCHWOOD PARK REHABILITATION's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 55%, which is 9 percentage points above the Virginia average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Birchwood Park Rehabilitation?
State health inspectors documented 114 deficiencies at BIRCHWOOD PARK REHABILITATION during 2020 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 5 that caused actual resident harm, and 107 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 Birchwood Park Rehabilitation?
BIRCHWOOD PARK 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 EASTERN HEALTHCARE GROUP, a chain that manages multiple nursing homes. With 150 certified beds and approximately 136 residents (about 91% occupancy), it is a mid-sized facility located in VIRGINIA BEACH, Virginia.
How Does Birchwood Park Rehabilitation Compare to Other Virginia Nursing Homes?
Compared to the 100 nursing homes in Virginia, BIRCHWOOD PARK REHABILITATION's overall rating (1 stars) is below the state average of 3.0, staff turnover (55%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Birchwood Park 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?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "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?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, the facility's high staff turnover rate, and the below-average staffing rating.
Is Birchwood Park Rehabilitation Safe?
Based on CMS inspection data, BIRCHWOOD PARK REHABILITATION has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 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 Birchwood Park Rehabilitation Stick Around?
Staff turnover at BIRCHWOOD PARK REHABILITATION is high. At 55%, the facility is 9 percentage points above the Virginia average of 46%. 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 Birchwood Park Rehabilitation Ever Fined?
BIRCHWOOD PARK REHABILITATION has been fined $127,257 across 1 penalty action. This is 3.7x the Virginia average of $34,351. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Birchwood Park Rehabilitation on Any Federal Watch List?
BIRCHWOOD PARK REHABILITATION is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.