VIRGINIA BEACH HEALTHCARE AND REHAB CENTER
For profit - Limited Liability company
180 Beds
LIFEWORKS REHAB
Data: November 2025
Trust Grade
10/100
#279 of 285 in VA
Photo by Virginia Beach Healthcare and Rehabilitation Center
Photo by Virginia Beach Healthcare and Rehabilitation Center
Photo by Virginia Beach Healthcare and Rehabilitation Center
1 / 5 photos
Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Virginia Beach Healthcare and Rehab Center has received a Trust Grade of F, indicating significant concerns about the quality of care and overall conditions in the facility. Ranking #279 out of 285 in Virginia places it in the bottom half of nursing homes in the state, and it is the lowest-ranked option in Virginia Beach City County. Although the facility is on an improving trend, decreasing from 55 issues in 2024 to 2 in 2025, the staffing situation is concerning, with a turnover rate of 69%, well above the state average of 48%. Families should be aware that the center has incurred $131,313 in fines, which is higher than 94% of Virginia facilities, suggesting ongoing compliance problems. Specific incidents include a resident developing a serious pressure ulcer due to lack of proper care and another resident missing scheduled pain medication because there was no nurse on duty, leading to severe discomfort. While there are some improvements noted, these serious issues highlight the need for careful consideration.
- Trust Score
- F
- In Virginia
- #279/285
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 69% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $131,313 in fines. Lower than most Virginia facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 17 minutes of Registered Nurse (RN) attention daily — below average for Virginia. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 88 deficiencies on record. Higher than average. Multiple issues found across inspections.
10/100
Bottom 3%
Review needed
55 → 2 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 55 issues
2025: 2 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Virginia average (3.0)
Significant quality concerns identified by CMS
Staff Turnover: 69%
22pts above Virginia avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $131,313
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: LIFEWORKS REHAB
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (69%)
21 points above Virginia average of 48%
The Ugly 88 deficiencies on record
2 actual harm
Jan 2025
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
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 prevent the elopements for two (2) residents out of 24 residents. Resident #217 and Resident # 223, in the survey sample.
The findings included:
1.Resident #217 eloped from the facility on 1/21/25 at 11:03 PM., The facility staff failed to report the elopement within the required time frame of 2 hours to the State Survey Agency. This behavior could have put the resident at risk for death, hypothermia and or being hit by a moving vehicle. Resident # 217 was originally admitted to the facility 10/16/18 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Suicidal Ideations and Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety.
The admissions Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 9 out of a possible 15. This indicated Resident #217 cognitive abilities for daily decision making moderately impaired.
In sectionGG(Functional Abilities Goals) the resident was coded as being independent with eating, oral hygiene, requires supervision or touch assistance when walking 150 feet.
The Care Plan dated 12/30/24 read that Resident #217 is at risk for elopement. The goal for the resident was that he will not elope. The interventions for the resident were to check wander guard function, placement, elopement risk assessment.
The facility synopsis of events dated 1/21/25 read that Resident #217 was observed by staff in the parking lot. Returned to the building, no injuries noted. Resident #217 elopement was not reported until 1/22/25. The fax confirmation to the State Reporting Agency was dated 1/22/25 at 4:06 PM.,which was a total of 16 hours and 3 minutes after the elopement occurred.
According to the Health Status note and the Final Synopsis listed above. Resident #217's elopement wasn't reported to the State Agency and Adult Protective services until 16 hours and 3 minutes later.
On 1/22/25 an interview was conducted with Resident #217 at approximately 4:10 PM., concerning his elopement. Resident #217 said that he left the building to check on his home.
On 1/23/25 at approximately 4:30 PM., an interview was conducted with the DON concerning the above elopement. The DON said that the incident should have been reported within 2 hours, but it was reported later.
2. Resident #223. The facility staff failed to report his elopement to the State Survey Agency after resident eloped from the facility. Resident #223 was originally admitted to the facility 10/18/24 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Depression, Unspecified.
The 5-day Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/20/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #223 cognitive abilities for daily decision making were moderately impaired.
In sectionGG(Functional Abilities Goals) the resident was coded as requiring set-up assistance with eating and oral hygiene. Dependent with toileting hygiene and requires substantial maximal assistance with bathing/showering.
The Care Plan dated 12/30/24 read that Resident #223 is at risk for elopement. The goal for the resident was that he will not elope. The interventions for the resident were to check wander guard function, placement, elopement risk assessment.
A review of Resident #223's incident report completed on 12/29/24 at 2:00 PM., read that Resident #223's family observed resident sitting in his wheelchair in the parking lot. Resident said that he was going for a walk. No injuries were observed by staff. A Facility Synopsis of the event was not completed.
On 1/23/25 at approximately 6:30 PM., an interview was conducted with the DON. The DON said that the family informed the staff that the resident was in the parking lot. The DON also mentioned that a report (Facility Synopsis) was not completed but an elopement incident report was completed.
The Abuse/Neglect/Misappropriation/Crime Policy reads dated 10/17/23 reads: There is zero tolerance for abuse, neglect, misappropriation of property, or any crime against a patient of the Health and Rehabilitation Center. Procedure: Any suspected or witnessed incidents of patient abuse, neglect, theft against a patient should be reported to the administration, an internal investigation conducted, appropriate and timely reporting to the State Survey Agency and other legally designated agencies, as well as staff corrective action, suspension, and/or termination as necessary. Failure for an employee to report any suspected or witnessed incident of mistreatment, abuse, neglect against a patient will result in corrective action. Immediately upon notification of any alleged violations involving, abuse, neglect or exploitation the administrator will immediately report to the state agency, but no later than 2 hours after the allegation is made.
On 1/23/25 at approximately 7:30 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. The Regional Nurse Consultant (RNC) said that the staff was re-educated on resident elopements and investigating.
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
Accident Prevention
(Tag F0689)
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 provide the necessary supervision to prevent an elopement for two (2) out of 24 residents. Resident #217 and Resident # 223, in the survey sample.
The findings included:
1. Resident #217 eloped from the facility on 1/21/25 at 11:03 PM., in the snow to the facility parking lot where employees and visitors parked their vehicles. This behavior could have put the resident at risk for death, hypothermia and or being hit by a moving vehicle. Resident # 217 was originally admitted to the facility 10/16/18 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; suicidal Ideations and unspecified dementia, unspecified Severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety.
The admissions Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 9 out of a possible 15. This indicated Resident #217 cognitive abilities for daily decision making moderately impaired.
In sectionGG(Functional Abilities Goals) the resident was coded as being independent with eating, oral hygiene, requires supervision or touch assistance when walking 150 feet.
The Care Plan dated 12/30/24 read that Resident #217 is at risk for elopement. The goal for the resident was that he will not elope. The interventions for the resident were to check wander guard function, placement, elopement risk assessment.
The December 2024 Physician Order Summary (POS) read:
Check function of wander bracelet weekly every day shift every Monday for monitor placement. Active 12/29/2024.
Check Wander Prevention Patient Band every shift. every shift Verbal Active 12/29/2024.
A Health status noted dated 1/21/2025 at 11:03 PM., read that Resident #217 was found outside walking around the facility. Wander Guard did sound off and was alerted to the whole facility the Wander Guard was found on resident; door alarm did sound off and was alerted to the facility. No injuries found.
A Health status noted dated 1/21/25 at 12:08 AM., read that the Medical Doctor (MD) was notified. Vital signs taken. Temperature=97.9, Pulse=83, Blood Pressure =143/80, Respirations = 18, Oxygen = O2 sat's 96% on Room Air (RA). No noted distress, injuries, discomfort or complaints of pain, skin is intact.
The final synopsis of events dated 1/21/25 read that Resident #217 was observed by staff in the parking lot. Returned to the building, no injuries noted. Resident #217 elopement was not reported until 1/22/25. The fax confirmation to the state reporting agency was dated 1/22/25 at 4:06 PM.
According to the Health Status note and the Final Synopsis listed above. Resident #217's elopement wasn't reported to the State Agency and Adult Protective services until 16 hours and 3 minutes later.
On 1/22/25 an interview was conducted with Resident #217 at approximately 4:10 PM., concerning his elopement. Resident #217 said that he left the building to check on his home.
On 1/23/25 at approximately 11:00 AM., the Director of Nursing (DON) was given a list of three residents to check wander guard placement and function. Resident #217, Resident #218 and Resident #224.
On 1/23/25 at approximately 11:55 AM., the wander guards on the above three residents were observed and tested for function by Licensed Practical Nurse (LPN) # 4. No issues were found.
On 1/23/25 at approximately 4:30 PM., an interview was conducted with the DON concerning the above elopement. The DON said that the incident should have been reported within 2 hours, but it was reported later.
Elopement Scoring:
0 - 7 =Low Risk
8 - 9 =At Risk for elopement/exit seeking
10 - above =High Risk for elopement/exit seeking
The elopement Risk Tool assessment dated [DATE] at 8:38 PM., was reviewed. Resident #217 was assessed as scoring an 8 on the assessment which indicated that resident was at risk for elopement/exit seeking.
On 01/23/25 at approximately 6:30 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. The Corporate Regional Consultant said that whenever a resident leaves the building without the staff knowing is considered an elopement.
2.Resident #223. The facility staff failed to keep him from eloping from the facility. Resident #223 was originally admitted to the facility 10/18/24 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; depression, unspecified.
The 5-day Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/20/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #223 cognitive abilities for daily decision making were moderately impaired.
In sectionGG(Functional Abilities Goals) the resident was coded as requiring set-up assistance with eating and oral hygiene. Dependent with toileting hygiene and requires substantial maximal assistance with bathing/showering.
The Care Plan dated 12/30/24 read that Resident #223 is at risk for elopement. The goal for the resident was that he will not elope. The interventions for the resident were to check wander guard function, placement, elopement risk assessment.
Elopement Scoring:
0 - 7 =Low Risk
8 - 9 =At Risk for elopement/exit seeking
10 - above =High Risk for elopement/exit seeking
The elopement Risk Tool assessment dated [DATE] at 7:14 PM., was reviewed. Resident #223 was assessed as scoring 9 on the assessment which indicated that resident was at risk for elopement/exit seeking.
The December Physician Order Summary (POS) read:
Check function of wander bracelet weekly every day shift every Saturday. Active 12/30/2024.
Check Wander Prevention Patient Band every shift. every shift. Active 12/30/2024.
A review of Resident #223's incident report completed on 12/29/24 at 2:00 PM., read that Resident #223's family observed resident sitting in his wheelchair in the parking lot. Resident said that he was going for a walk. No injuries were observed by staff.
An interview was conducted on 1/22/25 at approximately 1:15 PM., with Resident #223. Resident #223 complained that the facility wouldn't let him leave at his own will by placing an ankle bracelet on his left ankle against his wishes. Resident #223 also said that he left Against Medical Advice (AMA) because he no longer wanted to stay at the facility.
An interview was conducted on 1/22/25 at approximately 4:35 PM., with Registered Nurse (RN) #2. RN #2 said that the facility staff tried to talk him out of leaving the facility. RN #2 also mentioned that the resident wore a wander guard because he was exit seeking. He never mentioned that staff wasn't treating him right. RN #2 also said that she removed his wander guard from his ankle on his day of discharge.
On 1/23/25 at approximately 6:30 PM., an interview was conducted with the Director of Nursing (DON). The DON said that the family informed the staff that the resident was in the parking lot. The DON also mentioned that a report (Facility Synopsis) was not completed but an elopement incident report was completed.
The facility's policy, Elopement/Exit Seeking Behaviors dated 1/29/24 read: The Elopement Risk Tool Assessment will be used to evaluate a patient's risk of elopement/exit seeking behaviors. Procedure: Upon admission to the center, each patient will be assessed for elopement/exit seeking history and or behaviors using the elopement Risk Tool Assessment. If a patient is determined to be at risk, a wander guard will be placed for intervention. An order will be obtained from the provider, the Responsible Party will be notified. If the resident begins demonstrating unsafe exit seeking behaviors after the initial admission, the Elopement Risk Tool Assessment will be utilized.
What is Nursing Home Elopement
In nursing homes and other long-term care facilities, an elopement is a form of unsupervised wandering that leads to the resident leaving the facility. Elopement risk refers to the potential danger when a patient, often deemed too ill or impaired to make sound decisions, leaves a healthcare facility unauthorized, posing immediate threats to their health or safety. This endangers the resident immediately and can result in serious injury, or even death, depending on circumstances such as the location of the facility, the time of year, how long it takes staff to recognize the resident is missing, and how long it takes to find the resident. https://www.bbga.com/practice-areas/nursing-home-abuse/nursing-home-elopement/
On 1/23/25 at approximately 7:30 p.m., the above findings were shared with the Administrator, DON and Corporate Consultant. The Regional Nurse Consultant (RNC) said that the staff was re-educated on resident elopements and investigating.
Oct 2024
43 deficiencies
2 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, 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, assess, identify and treat an avoidable pressure ulcer resulting in harm for one Resident (Resident #73) in a survey sample of 55 Residents.
The findings included:
Resident #73, with contracted fingers of the left hand, experienced a pressure sore injury from his fingernails pressing into his palm. The pressure sore became infected resulting in cellulitis, which led to the identification of the pressure sore injury in the facility. The pressure sore and resulting infection caused the Resident to be sent out to the hospital for treatment with IV (intravenous) antibiotics for 10 days. The facility staff were unaware of the wound prior to the infection, and had not been applying the Residents hand splint (palm guard) to prevent the wound. Further the Resident was suffering from significant weight loss and malnutrition, increasing debility, and inability to heal.
Resident #73 was originally admitted to the facility on [DATE], was hospitalized on [DATE] for a pressure sore injury with infection and cellulitis, and returned 10 days later on 6-1-24. Diagnoses included; acute infection/cellulitis of upper left limb, stroke with left hemiplegia, dementia, contractures of left side limbs, dysphagia, epilepsy, hypertension, hypernatremia, and vitamin D deficiency.
Resident #73's most recent Minimum Data Set assessment was a Significant change assessment with an assessment reference date of 7-29-24. Resident #73 had a Brief Interview of Mental Status score of 99 indicating severe cognitive impairment. He required extensive to total assistance with eating, bathing and personal hygiene. He was coded to have impaired Range of Motion on both upper extremities, and one lower extremity. He was coded with no behaviors, no swallowing difficulty, and had a mechanically altered regular pureed diet.
Before hospitalization and after hospitalization the Resident's diet remained the same. Regular diet, Dysphagia pureed texture, honey thick liquids consistency.
On 10-4-24 at approximately 12:00 PM, during continued tour of the facility, Resident #73 was observed eating lunch and being fed by a Certified Nursing Assistant (CNA). The Resident's hands were both contracted. He was not observed to be wearing a palm guard nor any other type of equipment in the upper extremities. The CNA was interviewed and stated Yes he eats really well, and usually finishes 100% of his meals. She was asked why the servings were so small, she stated yeah it doesn't look like enough, but it's pureed so that's what he gets. When asked why the items listed on the tray ticket were missing, she stated They must have missed the other stuff in the kitchen.
The Resident had just begun eating from 3 scoops of pureed food each scoop was approximately 2 inches long by 2 inches wide scoop circles (resembling a scoop of ice cream) and approximately 1 inch high. one scoop was gray and semi solid, one scoop was light tan/white and had a grainy pudding consistency, and the third scoop was a white smooth pudding consistency. There was also a clear plastic container with a lid containing approximately 90 milliliters of green liquefied gelatin which smelled like lime, and a cup with approximately 120 milliliters of thickened brown liquid described by the CNA as thickened tea. The Resident consumed all of the meal.
The tray ticket menu and preparation instructions for quantity was reviewed and revealed it should have contained; Pureed turkey meatloaf 6 ounces with brown gravy 2 ounces, Pureed buttered diced carrots 8 ounces, Mashed potatoes with gravy 1 cup, Pureed dinner roll with 1 margarine, Fortified pudding 8 ounces, Pureed soft peanut butter cookie 8 ounces, Hot coffee or hot tea, honey thick 16 ounces.
In American apothecary measurements and standardized metric medication measurements, 30 milliliters are equal to one ounce. One cup is equal to 8 fluid ounces. The 3 Pureed food servings on Resident #73's meal tray would have totaled approximately 3 ounces each, the gelatin was approximately 3 ounces, and thickened tea would have been approximately 4 ounces. There was half of the pureed meatloaf ordered, no gravy, no carrots, less than half of the potatoes, no gravy, no fortified pudding, no pureed cookie, and half of the thickened tea. The gelatin did not appear on the tray ticket. The meal did not contain all of the menu items nor was it quantity sufficient.
Resident #73 was addressed in greeting and did not respond. The CNA stated he's not verbal. 2 hand splints were noted on a chair in the room against the wall at the foot of the bed. The CNA was asked are those splints for this Resident or his room mate. The CNA replied I'm not sure I will check and get back to you. The CNA was asked if the Resident lashed out or refused care, and she stated no, he doesn't ever do any of that, he can't. The CNA was unaware of the splint use and did not apply them as a result.
On 10-4-24 at 1:30 PM, Kitchen staff were interviewed and told about the small quantity of food on Resident #73's tray, and the fact that all of the items were not on the tray and they responded that they were out of the pudding, and they didn't get magic cup in because it was too expensive so they substituted the Jello. They also stated that someone had made a mistake and left items off. When asked to see what the pureed cookie looked like, they stated all of the food was gone and they had none left.
On 10-7-24 at approximately 12:00 PM Resident #73 was again observed during the lunch meal being fed to him by a staff member. The tray portions were unchanged and insufficient as before, the Resident ate 100%, and no house fortified pudding was on the tray.
Resident #73's clinical record was reviewed. Weight documents all completed by mechanical Hoyer lift revealed the following;
5-01-24 - 118.0 pounds prior to the pressure sore injury and cellulitis.
5-20-24 - A nursing note documented Hoyer lift scale not working.
5-22-24 - The Resident went to the hospital with cellulitis after pressure sore injury.
6-10-24 - 125.2 pounds after hospitalization for cellulitis, after gaining 7 pounds in 10 days while hospitalized .
6-24-24 - 108.5 pounds
8-09-24 - 109.0 pounds
9-11-24 - 107.6 pounds
10-8-24 - 97.0 pounds taken during survey with 2 CNA's & surveyor.
On 10-8-24 Two CNA's on 3 PM-11 PM shift weighed the Resident at the request of the surveyor by way of the Hoyer mechanical lift correctly zeroing out the scale prior to lift. The Resident did not seem to mind the jostling and placing on the sling nor lifting in the sling and had no facial nor physical response to the experience. The Resident's weight was found to be 97.0 pounds. The CNA's were asked if he refused care or splinting and both stated no, he never fights me over anything.
Malnutrition Universal Screening (MUST) Tools were reviewed and revealed an assessment on 6-6-24 upon readmission after the 6-1-24 hospital discharge which documented low risk for malnutrition.
The same (MUST) assessment was completed again on 7-24-24 and documented high Risk for malnutrition, weight of 108.5 which had been obtained a month earlier on 6-24-24.
The 7-24-24 (MUST) assessment occurred after another full month of continued significant weight loss greater than 10% in less than 2 months. The downward trend continued through 9-11-24 which was the last facility obtained weight documented in the clinical record until the time of survey. On 10-8-24 when surveyors obtained a weight, no weight had been taken by facility staff for another month.
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. RD notes were reviewed and revealed continued weight loss until hospitalization, with no change in recommendations. While the Resident was hospitalized for the Pressure sore injury and cellulitis a 7 pound weight gain was experienced. Then after the readmission to the facility the weight loss began again, and continued through survey without any change to recommendations, with the exception of the 5 following items;
1. 7-25-24 Discontinuance of the vitamin C.
2. The Resident never received the magic cups.
3. 9-26-24 pro-stat liquid (protein for healing) for 3 days then discontinued 9-29-24.
4. 9-18-24 the Vitamin C restarted 2 months after discontinuance.
5. 10-4-24 the house fortified pudding was added, instead of the magic cup, which was observed as not received.
The weekly weights which were recommended by the RD were never obtained. The Resident did not receive meals in the quantity/caloric intake that was ordered, nor was the ordered diet followed.
Review of Physician's orders revealed only the following order for the left hand contracture and pressure wound injury with cellulitis;
1. Devices were ordered by the physician on 6-1-24 and again on 9-26-24. That device was Bean bag splints to left upper and left lower extremities as tolerated. No order for, nor directions for, use of palm guards was found in the clinical record.
Physician and Nursing progress notes were reviewed for information on the Resident's contractures, left palm pressure wound, and splint usage. That review revealed that From 5-1-24 through 5-19-24 the Resident had no skin wounds.
On 5-20-24 at 2:20 PM, the Physicians Assistant (PA) documented Patient seen today for nursing reports of wound to the left palm. Left hand is contracted. Drainage, erythema and swelling noted. Patient says ouch when I touch his hand. Comments; one centimeter wound to the left palm with surrounding erythema and swelling that extends into his middle finger. Hand is warm to touch. Hand is contracted so range of motion is limited. Pain states ouch when I move his hand. Assessment and plan; Cellulitis secondary to wound of the left hand. Wound appears to have been caused by (finger) nail of contracted hand being dug into his palm. Palm guard present at bedside but it is unclear how often it is actually being placed on the patient's hand. Swelling and erythema extends into middle finger and dorsal aspect of the hand. Wound cleaned with DWC (Dakin's wound Cleanser) and bandaged. Palm guard placed. Plan: Wound care - Left hand palm cleanse with wound cleanser, pat dry with gauze, then apply antibiotic ointment to wound bed, cover with dry dressing daily and as needed. Apply palm guard, only remove when eating. Start Keflex 500 mg 4 times per day for 7 days. Monitor closely, if wound worsens consider labs and additional antibiotics emergency room visit if warranted.
The Keflex order was changed later that same day to a renal dose of 500 mg twice per day instead of 4 times.
The Keflex antibiotic ordered on 5-20-24 at 2:20 PM was not obtained and administered until the afternoon of 5-21-24, which was 24 hours after the cellulitis was identified. It is notable to mention that the Keflex (Cefalexin 500 mg) 15 doses, was available for administration immediately in the facility, in the Omnicell stat box. The purpose of the Omnicell stat box is for staff to have on hand, and available, at all times, needed medications while waiting for the pharmacy to deliver the order, so as not to delay treatment. That was not done.
On 5-20-24 at 9:33 PM the Resident was again seen by the same PA, with no changes made.
On 5-21-24 at 1:38 AM nursing states notification received that the Resident will be starting the antibiotic treatment by mouth.
On 5-21-24 at 10:17 AM the PA documents seeing the Resident again for the cellulitis, stating the cellulitis resulted from the Resident's fingernail digging into his chronically contracted hand and it seemed that his palm guard had not been consistently applied daily, she had been made aware of the wound on 5-20-24, and was still waiting on the pharmacy to deliver the antibiotic to begin treatment.
On 5-22-24 at 8:47 AM the PA again assessed the Resident documenting worsening cellulitis. Further documenting only 3 doses of the oral antibiotic Keflex had been administered, and the hand continued to become more swollen and extended throughout the entire hand and into the wrist. Cellulitis progressing rapidly and has not responded to oral antibiotics, given the swift advancement of erythema and swelling she was sending the Resident to the hospital for evaluation and possible IV (intravenous) antibiotics.
There was concern by the PA that the tendon may have become infected, as a wound in the palm of the hand tissue which is shallow in depth, could reach underlying structures easily.
On 5-22-24 at 4:43 PM nursing notes indicate the order was received to send the Resident out to the hospital non-emergently, and at 5:08, that the Resident was sent non-emergently after 24 hours without antibiotics after the order, and 2 days after the infected pressure wound with symptoms was identified.
The Resident remained in the hospital for 10 days before returning with orders to continue Amoxicillin oral antibiotics twice per day for the cellulitis for 7 more days after receiving IV Zosyn, and IV Vancomycin in the hospital.
The Resident's care plan was reviewed and interventions revealed a focus for refusing to wear splint to (bilateral upper extremities/bilateral lower extremities - Bean Bag.) Cellulitis resolved 7-6-24. There was never a care plan devised for the palm guards.
Progress notes review revealed no refusals for splint nor bean bag placement, and no other aberrant behaviors nor refusals were documented for this Resident.
The Resident's [NAME] which is used by CNA's to guide specific care for each resident need was reviewed and revealed bean bag splints as tolerated with no other instruction on use, nor location of use, and no mention of the palm guards. Staff were unaware of the palm guard need.
Facility policies and procedures were reviewed. The policy titled Skin assessments stated that skin assessments would be conducted by nursing weekly and daily with ADL care.
Resident #73 experienced an avoidable pressure sore injury which was not identified until a cellulitis infection was present. The Resident was at risk for skin breakdown after a stroke and immobility with contractures, and was experiencing continued significant weight loss. The contracted left palm required palm guards to be implemented to protect the skin from wounds, however, they were not being used consistently. The pressure sore injury was identified only after it became infected requiring hospitalization. The pressure sore injury risk should have been identified during ADL care of the contracted hand prior to the actual wound opening and forming, which led to infection and hospitalization. The wound healed with care.
On 10-9-24 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.
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 F0697
(Tag F0697)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 10/1/24 at 7:00 PM an interview was conducted with Resident #47. Resident #47 stated that there was no nurse on unit 3 fro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 10/1/24 at 7:00 PM an interview was conducted with Resident #47. Resident #47 stated that there was no nurse on unit 3 from 3pm to 11pm and 11pm to 7am on 8/17/24. Resident #47 also stated that due to this, she did not receive the scheduled two (2) doses of Gabapentin on 8/17/24 and 8/18/24 and 1 scheduled dose of Tylenol on 8/18/24. Resident #47 voiced that due to not taking these medications, her pain level was a 9 out of 10, with 10 being the worst pain possible. Resident #47 further voiced that she experienced severe pain in her neck, head, and shaking of her hands.
The Care Plan with a revision date of 2/16/23 read that Resident #47 has a history of chronic pain related to cerebrovascular accident (CVA). The goal was the resident will not have discomfort related to side effects of analgesia. The intervention for Resident #47 was to administer analgesia per order. Give before treatments or care as needed.
The Physician's Order Summary (POS) for August 2024 read: Gabapentin Tablet 600 MG Give 1 tablet by mouth three times a day for Pain with a start date of 12/15/2021 and Tylenol (Acetaminophen) 8 Hour Oral Tablet Extended Release 650 MG Give 1 tablet by mouth every 8 hours for Chronic Pain with a start date of 9/27/2023.
A review of the Medication Administration Record (MAR) revealed that Resident #47 missed 2 doses of Gabapentin Tablet 600 MG Give 1 tablet by mouth three times a day on the following dates: 8/17/24-8/18/24 and missed 1 dose of Tylenol (Acetaminophen) 8 Hour Oral Tablet Extended Release 650 MG Give 1 tablet by mouth every 8 hours on the following date: 8/18/24.
Gabapentin is in a class of medications called anticonvulsants. Gabapentin treats seizures by decreasing abnormal excitement in the brain. Gabapentin relieves the pain of PHN by changing the way the body senses pain. It is not known exactly how gabapentin works to treat restless legs syndrome. https://medlineplus.gov/druginfo/meds/a694007.htm
Acetaminophen is in a class of medications called analgesics (pain relievers) and antipyretics (fever reducers). It works by changing the way the body senses pain and by cooling the body. https://medlineplus.gov/druginfo/meds/a681004.html
On 10/7/24 at 12:50 PM an interview was conducted with the two Regional Nurse Consultants. The Regional Nurse Consultants stated that the medications were available for Resident #47, and they could not explain why the resident was not administered these medications on 8/17/24 and 8/18/24. The two Regional Nurse Consultants also stated that no pain assessments were completed for Resident #47 on 8/17/24 and 8/18/24 regarding the missed doses of Gabapentin and the Tylenol.
On 10/9/24 at approximately 5:30 PM, a final interview was conducted with the Administrator, Assistant Administrator, Director of Nursing, and the two Regional Nursing Consultants. They had no further comments and voiced no concerns regarding the above resident issue.
Based on observation, resident, family and staff interview, clinical record review, and review of facility documents, the facility staff failed to administer analgesics to treat and manage pain which constituted harm for 2 of 55 residents (Resident #473 and Resident #325), in the survey sample.
The findings included:
1. The facility's staff failed to manage Resident #473 pain, which resulted in two emergency room visits to achieve relief and constituted harm.
Resident #473 was initially admitted to the facility on [DATE] and discharged home on 8/24/22. The resident's diagnoses at the time of his admission were lumbar spinal stenosis with lower back pain radiating to his feet, lumbar spinal fusion, and chronic musculoskeletal injuries from a motor vehicle accident.
The admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 8/8/22, coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated that Resident #473's cognitive abilities for daily decision-making were intact.
In section GG0130 (Self-Care) the resident was coded as independent with eating, oral care, upper body dressing, rolling left and right, sitting to lying, lying to sitting on the side of bed, and toilet transfer, requiring supervision or touching assistance with climbing four steps, and the ability to go up and down a curb, partial/moderate assistance with toileting hygiene, shower/bathe self, lower body dressing, walking 10 feet, setup or clean-up assistance sit to stand, and chair/bed-to-chair transfer.
The resident's care plan, dated 8/06/22, included a problem with Pain. The goal read that the resident would have no/decreased complaints of pain through the next review, 8/24/22. The interventions included medicating as ordered, positioning the resident for comfort, and notifying the physician/practitioner of pain not relieved with medication or of new complaints of pain.
On 10/9/24 at 11:25 AM, an interview was conducted with Family Member (FM) #1. FM #1 stated while her brother was a resident at the facility, he was transferred to the hospital because the facility's staff did not have the ordered pain medication Percocet Tablet 5-325 MG available for administration. FM #1 stated she brought twenty-seven Percocet Tablet 5-325 MG to the facility for staff administration to ensure Resident #473 would not be in pain.
An interview was conducted with the resident on 10/11/24 at 11:07 AM. The resident stated that most days, while a resident at the facility, he experienced excruciating pain. Pain so severe he did not want to move, walk, exercise, or eat. The resident stated the staff failed to inform him that it was his responsibility to request the pain medication, and when he learned that was the system, he followed it. The resident stated that most of the time, there was a long delay in administration after he requested the medication.
Resident #473 had multiple Percocet orders during his stay. They were:
8/05/22 - 8/16/22 2128 Percocet Tablet 5-325 MG, give 1 tablet by mouth every 4 hours as needed for pain and 8/05/22 - 8/16/22 1634 Percocet Tablet 5-325 MG, Give 2 tablet by mouth every 4 hours as needed for mild pain (1-3).
8/16/22 1227 Percocet Tablet 5-325 MG, give 2 tablets by mouth STAT for Pain. Pull from Omnicell.
8/16/22 - 8/22/22 1242 Percocet Tablet 5-325 MG, give 1 tablet by mouth every 4 hours as needed for mild to moderate pain (1-5) and 8/16/2022 - 8/22/22 Percocet Tablet 5-325 MG, Give 2 tablets by mouth every 4 hours as needed for severe pain (6-10)
8/22/2022 1034 -8/25/2022 Tylenol Tablet 325 MG, give 2 tablets by mouth every 4 hours as needed for pain or fever
8/23/22 - 8/25/2022 1155 Percocet Tablet 5-325 MG, give 2 tablets by mouth every 4 hours as needed for severe pain (1-5) and 8/23/22 - 8/25/2022 Percocet Tablet 5-325 MG, Give 2 tablet by mouth every 4 hours as needed for severe pain (6-10)
The resident stated he could not remember what occurred on 8/14/22 while he was a resident at (name of the facility), but he knew he had an enormous tolerance to pain, and if the pain was severe enough for him to request an ER visit, he was suffering unbearable pain.
A review of the nurse's note dated 8/14/22 at 14:46 revealed the resident complained of lower back pain that radiated to his feet. The on-call practitioner was notified and recommended that the resident wait until tomorrow to be assessed, but if he could not wait, the nurse would transfer the resident to the local ER. The nurse's note further stated near the end of the shift, the resident requested to go to ER because he was experiencing the worst pain he had ever suffered.
A review of the Medication Administration Record (MAR) revealed that when the resident was transferred to the ER on [DATE], he had not been administered the Percocet Tablet 5-325 MG since 8/12/24 at 14:44.
The ER's After Visit Summary dated 8/14/22 revealed that the resident arrived at the ER at 15:24, and his chief complaint was breakthrough pain to the lower back with tingling in his legs more constant and more severe over the last 3 days. The resident was treated with a Hydromorphone (Dilaudid) injection of 0.5 mg Intravenous (IV) Push at 16:35. and Dexamethasone (Decadron) 10 mg IV injection at 16:39. On 8/14/22 at 18:31, the resident was prepared to return to the long-term care facility with orders for Percocet 5-325 MG Tablets by mouth as ordered, and Prednisone 10 mg by mouth as ordered.
A nurse's note dated 8/16/22 at 01:40 read the resident requested to be sent to the ER for uncontrolled back pain. The nurse offered to administer his as-needed pain medication, but the resident had no more Percocet. The pharmacy authorized the removal of one Percocet from the Omnicell, but the resident refused to take the one Percocet and stated he wanted two Percocet tablets or to go to the ER. The Resident was transferred to the ER. The nurse failed to document an assessment of the resident's pain.
A review of the Medication Administration Record (MAR) revealed that when the resident was transferred to the ER on [DATE], he had not been administered the Percocet Tablet 5-325 MG since 8/14/22 at 23:50.
The ER's After Visit Summary dated 8/16/22 revealed that the resident arrived at the ER at 01:50, and his chief complaint was bilateral lower extremity pain and low back pain since approximately 20:00 8/15/22. The pain was suspected to be related to his recent surgery and known spinal seroma and spinal stenosis. The resident rated the pain as 7 out of 10 and described it as pounding pain to the posterior aspect of his calves and radiating to bilateral hips.
The summary revealed EMS administered two Percocet Tablets 5-325 MG to the resident before his arrival to the ER and during their assessment of his pain, the resident stated 7/10. The summary also revealed that Family Member #1 told the ER staff that she called the facility to arrange to obtain the Resident's Percocet Tablets 5-325 prescription at an outside pharmacy because the Resident requested not to return to the facility from the ER until it was confirmed the Percocet Tablets 5-325 would be available for administration. The resident described his experience to the ER staff regarding his pain on 8/14/22. He reaffirmed that he had suffered the worst pain he had ever endured and that his goal in coming to the ER on that day (8/16/22) was to get help before the unbearable pain returned.
The ER nurse contacted the long-term care facility, and the facility stated that the resident's Percocet tablets would arrive at the facility during the AM and the Prednisone ordered on 8/14/22 would be started at 09:00 on 8/16/22.
On 10/11/24 at approximately 8:15 PM, a final interview was conducted with the Administrator, Interim Administrator, Director of Nursing and two regional Nurse Consultants. They had no comments and voiced no concerns regarding the above information.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
Based on interview, clinical record review and facility documentation the facility staff has failed to determine that Residents are clinically appropriate to self-self-administer medication for 1 Resi...
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Based on interview, clinical record review and facility documentation the facility staff has failed to determine that Residents are clinically appropriate to self-self-administer medication for 1 Resident (#142) in a survey sample of 55 Residents.
The findings included:
For Resident #142 the facility staff allowed the Resident to self-administer the psychotropic medication, trazadone (an anti-depressant used to treat insomnia), without an assessment to determine if it was clinically appropriate for him to do so.
On 10/7/24 at approximately 12:00 p.m. an interview was conducted with Resident #142 who stated that they used to let him keep his trazadone by his bedside and take it when he wants to. He stated that he now has to ask for it and it Takes an act of God to get it.
When asked if he had any special lock box for it, he stated that he did not he used to keep it on his night table.
On 10/8/24 a review of the clinical record revealed the following orders for trazadone:
trazodone HCl Oral Tablet 100 MG Give 1.5 tablet by mouth at bedtime for insomnia MAY GIVE ANYHTIME BETWEEN 7PM AND 9PM -Order Date- 09/04/2024 -D/C Date-09/09/2024
trazodone HCl Oral Tablet 100 MG Give 1.5 tablet by mouth every 24 hours for insomnia unsupervised self-administration -Order Date-09/09/2024 -D/C Date-09/16/2024
trazodone HCl Oral Tablet 150 MG (Trazodone HCl) Give 1 tablet by mouth at bedtime related to INSOMNIA -Order Date-09/16/2024
-D/C Date-10/10/2024
A review of the MAR (Medication Administration Record) revealed that during the time from 9/9/24 through 9/16/24 the medication was signed in the MAR as SA (Self-Administer).
On 10/10/24 at approximately 2:00 p.m. LPN C was asked how it is determined if a Resident can self-administer medications, she stated that they must be screened for safety and cognitively able to do it, and they have to have a lock box for storage.
On 10/11/24 at approximately 10 a.m. an interview was conducted with the Clinical Nurse Consultant and the DON who both stated that Residents who are clinically appropriate to self-administer medications must be screened and have a lock box to store medications.
A review of the clinical record revealed that no screening was done for appropriateness of self - administration of meds was completed, and the order reverted back to facility administration on 9/16/24.
A review of the document entitled Medication Administration Policy revealed the following excerpt:
Page 5
13. Residents are permitted to self-administer medications when specifically authorized by the attending physician and in accordance with the procedures for self-administration of medications.
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 F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, Resident interview, staff interview and clinical record review, the facility staff failed to provide servi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, Resident interview, staff interview and clinical record review, the facility staff failed to provide services in the facility with reasonable accommodation of resident needs and preferences, for 2 Residents (# 161 and # 107) in a survey sample of 55 Residents.
The findings included:
1. For Resident # 161, the facility staff failed to ensure the clock on the bedroom wall was working.
Resident # 161 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, Primary Osteoarthritis of the Knee, Septic Arthritis of the Knee, Heart Failure, and edema.
The most recent Minimum Data Set (MDS) was an admission Assessment with an Assessment Reference Date (ARD) of 9/10/2024. Resident # 161's BIMS (Brief Interview for Mental Status) Score was a 14 out of 15, indicating no cognitive impairment.
Review of the clinical record was conducted on 10/92024-10/11/2024.
During rounds on 10/9/2024 at 1:15 p.m., Resident # 161 was observed lying in the bed and watching television. Resident # 161 was alert, oriented and able to converse with the surveyor. When asked about any concerns, Resident # 161 stated she had only one complaint about the facility. Resident # 161 pointed to a clock on the wall and stated that clock is wrong and it's been wrong the whole time. It is driving me crazy. The time on the clock in Resident # 161's room was observed to have the time of 11:50.
Resident # 161 stated she had told several people but it had not been corrected. Resident # 161 stated it was frustrating to see the clock was not working. She stated she would use the clock if it was correct. She stated she didn't want to keep complaining but she had told several staff members and it still wasn't fixed.
On 10/9/2024 at 2:10 p.m., the clock had the time of 11:50.
On 10/9/2024 at 2:45 p.m., the clock had the time of 11:50. Resident # 161 was observed sitting was up in bed watching television.
On 10/9/2024 at 3:10 p.m., the clock had the time of 11:50. Resident # 161 was lying in bed watching TV.
On 10/9/2024 at 3:11 p.m., an interview was conducted with the Certified Nursing Assistant (CNA)-2 who stated Resident # 161 was alert and oriented. CNA-2 stated she was aware that the clock was wrong. She stated hers needs a battery. We are waiting on maintenance. CNA-2 stated the battery was not working. CNA-2 stated she had put in two work orders previously to the Maintenance department but the clock had not been fixed. CNA-2 stated the clock had not been working for a long time.
On 10/9/2024 at 3:15 p.m., an interview was conducted with Licensed Practical Nurse (LPN)-4 who stated it was important for the time on the clocks to be correct. She stated the correct time helped with the orientation of the residents. LPN-4 stated she was an agency staff member and did not know how to put a maintenance request in the computer but would tell someone verbally if she noticed a problem with a clock not working. LPN-4 stated she had not noticed the clock in Resident # 161's room was incorrect since she was not working in that particular area. LPN-4 stated staff should respond to the requests/complaints of the residents.
The Regional Nurse Consultant (Corporate-1) went to Resident # 161's room with the surveyor, looked at the clock and stated the time showed 11:50. The Regional Nurse Consultant (Corporate-1)stated the clock in the room should have had the correct time because it was important for the orientation of the residents. She stated staff members should have observed the clock was wrong and should have corrected the issue.
During the end of day debriefing on 10/9/2024, the Facility Administrator, the Regional [NAME] President of Operations-Acting Administrator, two Regional Nurse Consultants (Corporate-1 and Corporate-2) and Director of Nursing were informed of the findings. They all stated the clocks in residents' rooms should be accurate.
No further information was provided.
2. For Resident # 107, the facility staff failed to ensure the clock on the bedroom wall was working.
Resident # 107 was admitted to the facility with the diagnoses of, but not limited to: Metabolic Encephalopathy, Hypertension, and Chronic Kidney Disease,
The most recent Minimum Data Set (MDS) was an admission Assessment with an Assessment Reference Date (ARD) of 10/3/2024. The MDS for Resident # 107 was coded with a BIMS (Brief Interview for Mental Status) Score of 6 out of 15 indicating severe cognitive impairment.
Review of the clinical record was conducted on 10/09/2024-10/10/2024.
During rounds on 10/9/2024 at 1:45 p.m., Resident # 107 was observed sitting up in bed, eating lunch and watching television. Resident # 107 was able to converse with the surveyor. When the surveyor asked what time he received his lunch, Resident # 107 stated he did not know for sure because the clock was wrong but he had not been eating too long. The clock on the wall near the dresser in Resident # 107's room was observed to have the time of 4:50. Resident # 107 stated the clock had been that time every since I've been here. Resident # 107 stated he informed the facility staff that the clock was not correct but it had not been fixed.
On 10/9/2024 at 2:40 p.m., the clock had the time of 4:50. The second hand was not moving.
Staff persons were observed in the room picking up food trays, and delivering ice and water. No staff person addressed the issue of the clock having the wrong time.
The Regional Nurse Consultant (Corporate-1) went to Resident # 107's room with the surveyor, looked at the clock and stated the time showed 4:50. The Regional Nurse Consultant (Corporate-1)stated the clock in the room should have had the correct time because it was important for the orientation of the residents. She stated staff members should have observed the clock was wrong and should have corrected the issue.
During the end of day debriefing on 10/9/2024, the Facility Administrator, the Regional [NAME] President of Operations-Acting Administrator, Administrator in Training, two Regional Nurse Consultants (Corporate-1 and Corporate-2) and Director of Nursing were informed of the findings. They all stated the clocks in residents' rooms should be accurate.
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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on family interview, a clinical record review and staff interviews, the facility staff failed to notify the resident's Emergency Contact of his transfers to the emergency room (ER) for 1 of 55 r...
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Based on family interview, a clinical record review and staff interviews, the facility staff failed to notify the resident's Emergency Contact of his transfers to the emergency room (ER) for 1 of 55 residents (Resident #473), in the survey sample.
The findings included:
Resident #473 was originally admitted to the facility 8/5/22 and he was discharged home on 8/24/22. The resident's diagnoses at the time of his admission were lumbar spinal stenosis with lower back pain radiating to his feet, lumbar spinal fusion and chronic musculoskeletal injuries from a motor vehicle accident.
The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/8/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #473's cognitive abilities for daily decision making were intact.
On 10/9/24 at 11:25 AM, an interview was conducted with Family Member (FM) #1. FM #1 stated while her brother was a resident at the facility he was transferred to the hospital because they facility's staff did not have the ordered pain medication Percocet Tablet 5-325 MG available for administration. FM #1 stated the resident was transferred to the ER two times and the facility's staff did not notify her. FM #1 stated she learned of the ER transfers from the resident notifying her both times that he was in the ER.
A review of the nurse's note dated 8/14/22 at 14:46 revealed the resident complained of lower back pain that radiated to his feet. The on-call Practitioner was notified and recommended that the resident wait until tomorrow to be assessed but if he could not wait, the nurse was to transfer the resident to the local ER. The nurse's note further stated near the end of the shift the resident requested to go to ER because he was experiencing the worst pain he had ever suffered. The nurse's note failed to have documentation that the emergency contact was notified of the resident's transfer to the ER.
A nurse's note dated 8/16/2022 at 01:40 read the resident requested to be sent to the ER for uncontrolled back pain. The Resident was transferred to ER. The nurse's note failed to have documentation that the emergency contact was notified of the resident's transfer to the ER.
On 10/11/24 at approximately 8:15 PM, a final interview was conducted with the Administrator, Interim Administrator, Director of Nursing and two regional Nurse Consultants. They had no comments and voiced no concerns regarding the above information.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
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 thoroughly and accurately complete the Preadm...
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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 thoroughly and accurately complete the Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability (PASARR) for 2 of 55 residents (Resident #56 and #28), in the survey sample.
The findings included:
1. The facility staff failed to code Resident #56's PASARR assessment for a current serious mental illness.
Resident #56 was originally admitted to the facility 6/1/24 and readmitted [DATE] after an acute care hospital stay. The resident's current diagnoses included Post Traumatic Stress Disorder (PTSD), an anxiety disorder, ODC, personality hysterical and a major depressive disorder with recurrent, severe psychotic symptoms.
The significant change 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 #56's cognitive abilities for daily decision making were intact.
The resident's current care plan had a problem which stated the resident has signs and symptoms of depression and is at risk for adverse reactions. The goal read the resident will not have any adverse effects from depressive symptoms through 12/16/24. The intervention included administer medications as ordered and referral to psych services.
The Physician's Order Summary included orders for Trazodone HCl Oral Tablet 150 MG - administer one (1) tablet by mouth at bedtime for a major depressive disorder, ordered 9/4/2024. Clomipramine HCl Oral Capsule 50 MG - administer three (3) capsule by mouth one time a day for a major depressive disorder, ordered 9/4/2024.
Resident #56 received mental health services on 9/27/24, 9/6/24, 8/16/24 and 7/29/24.
A review of Resident #56's PASAAR assessment completed on 9/4/24 revealed that she was not coded as having a current serious mental illness. A review of the resident's most recent mental health assessment dated [DATE] stated she was being treated for depression and an anxiety disorder and she continues to benefit without adverse effects from her current psychotropic medication regimen. The recommendation was to continue the medication regime as prescribed for the resident was stable at the current dose and a dose reduction attempt would cause decompensation of the resident.
On 10/9/24 at 1:40 PM an interview was conducted with the Social Worker (SW). The SW stated stated the PASARR was not coded for a serious major mental illness diagnosis because the resident had not been treated for a mental health disorder in two years. In July 2024 the resident PHQ-9 was positive for signs of depression and she continued to remain on a medication regimen for depression and an anxiety disorder.
An interview with Family Member (FM) #4 on 10/7/24 at 5:46 PM. FM #2 stated the resident had a long history of mental health concerns and she was followed in the community by the community services board. FM #4 stated that the resident's long history of mental health concerns was why she did not have children and it had impacted her entire life.
On 10/11/24 at approximately 8:15 PM, a final interview was conducted with the Administrator, Interim Administrator, Director of Nursing and two regional Nurse Consultants. They had no comments and voiced no concerns regarding the above information.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0660
(Tag F0660)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, staff interviews, and clinical record review, the facility staff failed to have an ongoing discharge ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, staff interviews, and clinical record review, the facility staff failed to have an ongoing discharge planning process which focused on the resident's/resident representative discharge goals for 1 of 31 residents (Resident #119), in the survey sample.
The findings included:
Resident #119 was originally admitted to the facility 2/17/23 and readmitted [DATE] after an acute care hospital stay. The resident's current diagnoses included intellectual disability, aphasia and a history of cancer of the colon which required a hemicolectomy and resulted in an ileostomy.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/3/24 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired daily decision making abilities.
The resident was admitted on [DATE] to the nursing facility after surgery for colon cancer. The resident was to receive rehabilitation services and surgical wound care while in the nursing facility because the Intermediate Care Facility (ICF) could not manage the surgical wound care. A review of the resident's person centered care plan dated 2/21/23, revealed the resident/resident representative preference was discharge from the facility and return to the ICF.
An interview was conducted on 12/4/24 at approximately 2:20 PM with the Family Member (FM) #2. FM #2 stated that it was always their goal for Resident #119 to return to the ICF. FM #2 stated the barrier was the staff inability to heal the residents skin around the ileostomy and the stoma. FM #2 stated the resident's skin problems continued because the nurses used the wrong size stoma wafer, they frequently allow the ileostomy bag to become too full before they emptied it and they don't provide ileostomy care as frequently as necessary. FM #2 further stated the facility's lack of proper care resulted in stoma and skin irritation which has prevented him from transitioning back into the community.
FM #2 stated the resident's skin has been healed approximately 2 months and the opportunity for the resident to transfer back into the community was now, but the staff is not working towards the goal of discharging him from the nursing facility to an ICF.
On 12/4/24 at approximately 2:55 PM, an interview was conducted with the Discharge Planner (DP). The DP stated the resident's medical record had a progress note which read after the surgical wound was healed the resident would be transferred back to the ICF. The DCP stated that Resident #119's last day of covered rehabilitation services was 5/27/23 and the wound was not healed therefore the ICF would not accept the resident because of the unhealed surgical wound. The DCP stated when the payer source changed on 5/28/23 the resident remained in the facility as a long term care resident and his discharge status changed to long term care (LTC) the discharge status also changed from discharge to the community to LTC.
On 12/5/24 at approximately 5:30 PM, a final interview was conducted with the Administrator, Director of Nursing and two regional Nurse Consultants. The Administrator stated they had begun seeking appropriate placement for Resident #119 in the community.
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
Based on family interviews, clinical record review, and staff interviews, the facility staff failed to provide a resident with a discharge summary at the time of discharge for 1 of 55 residents (Resid...
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Based on family interviews, clinical record review, and staff interviews, the facility staff failed to provide a resident with a discharge summary at the time of discharge for 1 of 55 residents (Resident #472), in the survey sample.
The findings included:
Resident #472 was originally admitted to the facility 8/7/24 and was discharged no return anticipated on 8/10/24 . The resident's diagnoses included diabetes, hypertension and recurrent urinary tract infections.
The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/10/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #472's cognitive abilities for daily decision making were intact.
On 10/9/24 at 12:40 PM an interview was conducted with Family member (FM) #2. FM #2 stated that Resident #472 was transferred to the long term care facility on 8/7/24 after a hospital stay. FM #2 stated upon arrival to the facility she and her sister were very dissatisfied because of the odors, pest, the appearance of their mother's room, the common areas and the lack of staff on duty.
An interview was conducted with FM #3 on 10/9/24 at 12:49. FM #3 stated she and her sister agreed the facility was not the best placement for their mother because the day after the resident's admission there was not a nurse on duty according to a response from a Certified Nursing Assistant (CNA) on duty. FM #3 stated the licensed nurse from another unit would come to that unit after the work was completed on the assigned unit. FM #1 stated her mother's blood sugar was not obtained timely and her diabetic and antihypertensive medications were not administered. FM #3 also stated the resident did not receive hygienic care timely.
FM #3 stated on 8/9/24 she contacted the Discharge Planner (DCP) and requested to have Resident #472 transferred from the facility to another facility on 8/10/24 because of their dissatisfaction with the facility. FM #3 stated she provided the DCP with the contact person at the new facility so they could complete coordination of the transfer.
FM #3 stated on 8/10/24 at the time the transfer was to take place the DCP refused to give her the resident's discharge summary which would provide the necessary information to the new facility to provide care without a delay in the resident's services. FM #3 stated as a result of the DCP failure to provide the discharge summary the new facility would not accept the resident unless she was re-evaluated at the hospital and orders were provided to them. FM #3 stated the resident was reassessed at the hospital and eventually discharge to the new facility at approximately 12:30 AM on 8/11/24.
A note written by the DCP dated 8/9/2024 at 16:16 stated that FM #3 came to the DCP's office requesting assistance to transfer the resident to (name of the facility). The DCP inquired the reason for the transfer and inquired if there was anything that could be done. FM #3 stated to the DCP that she did not like the facility and confirmed she had obtained a bed in the identified facility. The DCP stated she set up medical transportation and informed FM #3 that the discharge would be considered Against Medical Advice (AMA) and she would have to sign paperwork acknowledging the AMA status at the time of the discharge. The DCP stated the daughter stated she understood and agreed to sign the AMA document and the DCP scheduled transportation for 11:00 AM on Saturday 8/10/24.
On 10/11/24 at approximately 8:15 PM, a final interview was conducted with the Administrator, Interim Administrator, Director of Nursing and two regional Nurse Consultants. The Nurse Consultant stated the discharging nurse should have provided the resident with as much information as possible at the time of the discharge.
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
Accident Prevention
(Tag F0689)
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 provide the necessary supervision to prevent an elopement for two (2) out of 24 residents, Resident #217 and Resident # 223, in the survey sample.
The findings included:
1. Resident #217 eloped from the facility on 1/21/25 at 11:03 PM., in the snow to the facility parking lot where employees and visitors parked their vehicles. This behavior could have put the resident at risk for death, hypothermia and or being hit by a moving vehicle. Resident # 217 was originally admitted to the facility 10/16/18 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Suicidal Ideations and Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety.
The admissions Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 9 out of a possible 15. This indicated Resident #217 cognitive abilities for daily decision making moderately impaired.
In sectionGG(Functional Abilities Goals) the resident was coded as being independent with eating, oral hygiene, requires supervision or touch assistance when walking 150 feet.
The Care Plan dated 12/30/24 read that Resident #217 is at risk for elopement. The goal for the resident was that he will not elope. The interventions for the resident were to check wander guard function, placement, elopement risk assessment.
The December 2024 Physician Order Summary (POS) read:
Check function of wander bracelet weekly every day shift every Monday for monitor placement. Active 12/29/2024.
Check Wander Prevention Patient Band every shift. every shift Verbal Active 12/29/2024.
A Health status noted dated 1/21/2025 at 11:03 PM., read that Resident #217 was found outside walking around the facility. Wander Guard did sound off and was alerted to the whole facility the Wander Guard was found on resident; door alarm did sound off and was alerted to the facility. No injuries found.
A Health status noted dated 1/21/25 at 12:08 AM., read that the Medical Doctor (MD) was notified. Vital signs taken. Temperature=97.9, Pulse=83, Blood Pressure =143/80, Respirations = 18, Oxygen = O2 sat's 96% on Room Air (RA). No noted distress, injuries, discomfort or complaints of pain, skin is intact.
The final synopsis of events dated 1/21/25 read that Resident #217 was observed by staff in the parking lot. Returned to the building, no injuries noted. Resident #217 elopement was not reported until 1/22/25. The fax confirmation to the state reporting agency was dated 1/22/25 at 4:06 PM.
According to the Health Status note and the Final Synopsis listed above. Resident #217's elopement wasn't reported to the State Agency and Adult Protective services until 16 hours and 3 minutes later.
On 1/22/25 an interview was conducted with Resident #217 at approximately 4:10 PM., concerning his elopement. Resident #217 said that he left the building to check on his home.
On 1/23/25 at approximately 11:00 AM., the Director of Nursing (DON) was given a list of three residents to check wander guard placement and function. Resident #217, Resident #218 and Resident #224.
On 1/23/25 at approximately 11:55 AM., the wander guards on the above three residents were observed and tested for function by Licensed Practical Nurse (LPN) # 4. No issues were found.
On 1/23/25 at approximately 4:30 PM., an interview was conducted with the DON concerning the above elopement. The DON said that the incident should have been reported within 2 hours, but it was reported later.
Elopement Scoring:
0 - 7 =Low Risk
8 - 9 =At Risk for elopement/exit seeking
10 - above =High Risk for elopement/exit seeking
The elopement Risk Tool assessment dated [DATE] at 8:38 PM., was reviewed. Resident #217 was assessed as scoring an 8 on the assessment which indicated that resident was at risk for elopement/exit seeking.
On 01/23/25 at approximately 6:30 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. The Corporate Regional Consultant said that whenever a resident leaves the building without the staff knowing is considered an elopement.
2. Resident #223. The facility staff failed to keep him from eloping from the facility. Resident #223 was originally admitted to the facility 10/18/24 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Depression, Unspecified.
The 5-day Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/20/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #223 cognitive abilities for daily decision making were moderately impaired.
In sectionGG(Functional Abilities Goals) the resident was coded as requiring set-up assistance with eating and oral hygiene. Dependent with toileting hygiene and requires substantial maximal assistance with bathing/showering.
The Care Plan dated 12/30/24 read that Resident #223 is at risk for elopement. The goal for the resident was that he will not elope. The interventions for the resident were to check wander guard function, placement, elopement risk assessment.
Elopement Scoring:
0 - 7 =Low Risk
8 - 9 =At Risk for elopement/exit seeking
10 - above =High Risk for elopement/exit seeking
The elopement Risk Tool assessment dated [DATE] at 7:14 PM., was reviewed. Resident #223 was assessed as scoring 9 on the assessment which indicated that resident was at risk for elopement/exit seeking.
The December Physician Order Summary (POS) read:
Check function of wander bracelet weekly every day shift every Saturday. Active 12/30/2024.
Check Wander Prevention Patient Band every shift. every shift. Active 12/30/2024.
A review of Resident #223's incident report completed on 12/29/24 at 2:00 PM., read that Resident #223's family observed resident sitting in his wheelchair in the parking lot. Resident said that he was going for a walk. No injuries were observed by staff.
An interview was conducted on 1/22/25 at approximately 1:15 PM., with Resident #223. Resident #223 complained that the facility wouldn't let him leave at his own will by placing an ankle bracelet on his left ankle against his wishes. Resident #223 also said that he left Against Medical Advice (AMA) because he no longer wanted to stay at the facility.
An interview was conducted on 1/22/25 at approximately 4:35 PM., with Registered Nurse (RN) #2. RN #2 said that the facility staff tried to talk him out of leaving the facility. RN #2 also mentioned that the resident wore a wander guard because he was exit seeking. He never mentioned that staff wasn't treating him right. RN #2 also said that she removed his wander guard from his ankle on his day of discharge.
On 1/23/25 at approximately 6:30 PM., an interview was conducted with the DON. The DON said that the family informed the staff that the resident was in the parking lot. The DON also mentioned that a report (Facility Synopsis) was not completed but an elopement incident report was completed.
The facility's policy, Elopement/Exit Seeking Behaviors dated 1/29/24 read: The Elopement Risk Tool Assessment will be used to evaluate a patient's risk of elopement/exit seeking behaviors. Procedure: Upon admission to the center, each patient will be assessed for elopement/exit seeking history and or behaviors using the elopement Risk Tool Assessment. If a patient is determined to be at risk, a wander guard will be placed for intervention. An order will be obtained from the provider, the Responsible Party will be notified. If the resident begins demonstrating unsafe exit seeking behaviors after the initial admission, the Elopement Risk Tool Assessment will be utilized.
What is Nursing Home Elopement
In nursing homes and other long-term care facilities, an elopement is a form of unsupervised wandering that leads to the resident leaving the facility. Elopement risk refers to the potential danger when a patient, often deemed too ill or impaired to make sound decisions, leaves a healthcare facility unauthorized, posing immediate threats to their health or safety.
This endangers the resident immediately and can result in serious injury, or even death, depending on circumstances such as the location of the facility, the time of year, how long it takes staff to recognize the resident is missing, and how long it takes to find the resident ( https://www.bbga.com/practice-areas/nursing-home-abuse/nursing-home-elopement/).
On 1/23/25 at approximately 7:30 p.m., the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. The Regional Nurse Consultant (RNC) said that the staff was re-educated on resident elopements and investigating.
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 F0691
(Tag F0691)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, family interview, staff interview, clinical record review, and review of facility documents, the facility'...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, family interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to apply the correct size Ostomy appliance and failed to provide care to an ostomy according to the physician's order for 1 of 31 residents in the survey sample.
The findings included:
Resident #119 was originally admitted to the facility 02/17/23 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Ileostomy Status, Autistic Disorder and Malignant Neoplasm of Sigmoid Colon.
The quarterly Revision Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/03/24 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 for daily decision making.
In sectionGG(Functional Abilities Goal) the resident was coded as being independent with eating, Substantial/ maximal with toileting and personal hygiene. Resident was coded as refusing Tub/Shower transfers.
In section H (Bladder and Bowel) the resident was coded under Appliances as having an Ostomy to include an Ileostomy.
The December 2024 Physician's Order Summary (POS) reads:
Abdominal wound (near ostomy)
Gently cleanse wound with Dove
soap that was provided by family
Apply zinc oxide cream
Daily and PRN every day shift for wound
Treatment. -Order Date- 09/16/2024 3:23 PM.
discharged (DC) Date- 12/05/2024 11:08 AM.
Change Ostomy wafer and pouch.
Wafer 1 3/4 and prn every day shift every 3 day(s) for
ostomy change scheduled Q3 days & PRN
Order Date- 09/16/2024 3:45 PM
Check patient's colostomy bag q4h and
empty if it is more than 1/2 full. every 4 hours for reduce stool
exposure to adjacent open wound related to ILEOSTOMY STATUS
-Order Date- 07/16/2024 10:41 AM.
The person-centered Care Plan dated 07/22/24 read that Resident #119 has an Ileostomy of the Right Lower Quadrant. The Goals for the resident will be the Ostomy will be free from complications thru 1/05/25. The interventions will be to administer medications for loose stools, change bag as indicated, change wafer and provide site care as ordered, observed Ostomy and surrounding skin for signs of breakdown, irritation, infection or breakdown and notify MD as indicated and perform treatment as ordered to the surgical incision.
An ileostomy is an opening in the belly (abdominal wall) that's made during surgery. It's usually needed because a problem is causing the ileum to not work properly, or a disease is affecting that part of the colon and it needs to be removed. The end of the ileum (the lowest part of the small intestine) is brought through this opening to form a stoma, usually on the lower right side of the abdomen. An ileostomy may only be needed for a short time (temporary), maybe for 3 to 6 months, because that part of the colon needs time to rest and heal from a problem or disease. But sometimes a disease, such as cancer, is more serious and an ileostomy may be needed for the rest of a person's life (permanent). After the colon and rectum are removed or bypassed, waste no longer comes out of the body through the rectum and anus. Digestive contents now leave the body through the stoma. The drainage is collected in a pouch that sticks to the skin around the stoma. The pouch is fitted to you personally. It's worn at all times and can be emptied as needed. Ileostomy output will be liquid to pasty, depending on what you eat, your medicines, and other factors. Because the output is constant, you'll need to empty the pouch 5 to 8 times a day. https://www.cancer.org/cancer/managing-cancer/treatment-types/surgery/ostomies/ileostomy/what-is-ileostomy.html#:~:text=An%20ileostomy%20is%20an%20opening,it%20needs%20to%20be%20removed.
An interview was conducted on 12/04/24 at approximately 2:20 PM. With the Resident's Sister (Family Member/FM) #2. FM #2 said that the staff is using the wronged size wafer, It should be 1 ¾ cm. FM #2 also said that it used to take the staff up to 6 hours to change the resident's colostomy bag when it gets full which causes irritation to the resident's skin. Permission was received from FM #2 to observed Resident's stoma. The call bell was used by FM #2 to notify nurse.
On 12/04/24 at approximately 2:52 PM., Licensed Practical Nurse (LPN) #2 entered the resident's room to observed the resident's colostomy and stoma. LPN #2 removed the ostomy bag and said, This is the wrong size wafer. too much of the resident's skin was being exposed and the wafer was cut too large. FM #2 said it (wafer) should be 1 ¾ cm. LPN #2 said that she would return with supplies. The stoma was observed on the Resident's Right lower Abdomen, appeared, pinkish/reddish in color, no discharge or discoloration was observed. Shortly thereafter, resident was noted to have a moderate amount of yellow thin stool. LPN #2 said that the stoma was smaller but the wafer needed to be cut smaller. Ostomy care was provided by LPN #2 without difficulty. Resident tolerated procedure well.
A final interview was conducted on 12/04/24 at approximately 5:15 PM., with the Corporate Nurse Consultant (CNC), Director of Nursing and the Administrator. The CCN said that the Ostomy wafer size for Resident #119 should be 1 ¾ cm, the nursing staff have been educated.
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 significant weight loss and malnutrition for one Resident (Resident #73) in a survey sample of 55 Residents.
The findings included:
Resident #73, suffered significant weight loss and malnutrition, increasing debility, and promoting an inability to heal from a new pressure sore injury which became infected leading to cellulitis and required hospitalization.
Resident #73 was originally admitted to the facility on [DATE], was hospitalized on [DATE] for a pressure sore injury with infection and cellulitis and returned 10 days later on 6-1-24. Diagnoses included: Acute infection/cellulitis of upper left limb, stroke with left hemiplegia, dementia, contractures of left side limbs, dysphagia, epilepsy, hypertension, hypernatremia, and vitamin D deficiency.
Resident #73's most recent Minimum Data Set assessment was a significant change assessment with an assessment reference date of 7-29-24. Resident #73 had a Brief Interview of Mental Status score of 99 indicating severe cognitive impairment. He required extensive to total assistance with eating, bathing and personal hygiene. He was coded to have impaired Range of Motion on both upper extremities, and one lower extremity. He was coded with no behaviors, no swallowing difficulty, and had a mechanically altered regular pureed diet.
Before hospitalization and after hospitalization the Resident's diet remained the same. Regular diet, Dysphagia pureed texture, honey thick liquids consistency.
On 10-4-24 at approximately 12:00 PM, during continued tour of the facility, Resident #73 was observed eating lunch and being fed by a Certified Nursing Assistant (CNA). The Resident's hands were both contracted. He was not observed to be wearing a palm guard nor any other type of equipment in the upper extremities. The CNA was interviewed and stated Yes he eats really well, and usually finishes 100% of his meals. She was asked why the servings were so small, she stated yeah it doesn't look like enough, but it's pureed so that's what he gets. When asked why the items listed on the tray ticket were missing, she stated They must have missed the other stuff in the kitchen.
The Resident had just begun eating from 3 scoops of pureed food each scoop was approximately 2 inches long by 2 inches wide scoop circles (resembling a scoop of ice cream) and approximately 1 inch high. one scoop was gray and semi solid, one scoop was light tan/white and had a grainy pudding consistency, and the third scoop was a white smooth pudding consistency. There was also a clear plastic container with a lid containing approximately 90 milliliters of green liquefied gelatin which smelled like lime, and a cup with approximately 120 milliliters of thickened brown liquid described by the CNA as thickened tea. The Resident consumed all of the meal.
The tray ticket menu and preparation instructions for quantity was reviewed and revealed it should have contained; Pureed turkey meatloaf 6 ounces with brown gravy 2 ounces, Pureed buttered diced carrots 8 ounces, Mashed potatoes with gravy 1 cup, Pureed dinner roll with 1 margarine, Fortified pudding 8 ounces, Pureed soft peanut butter cookie 8 ounces, Hot coffee or hot tea, honey thick 16 ounces.
In American apothecary measurements and standardized metric medication measurements, 30 milliliters are equal to one ounce. One cup is equal to 8 fluid ounces. The 3 Pureed food servings on Resident #73's meal tray would have totaled approximately 3 ounces each, the gelatin was approximately 3 ounces, and thickened tea would have been approximately 4 ounces. There was half of the pureed meatloaf ordered, no gravy, no carrots, less than half of the potatoes, no gravy, no fortified pudding, no pureed cookie, and half of the thickened tea. The gelatin did not appear on the tray ticket. The meal did not contain all of the menu items nor was it quantity sufficient.
Resident #73 was addressed in greeting and did not respond. The CNA stated he's not verbal. 2 hand splints were noted on a chair in the room against the wall at the foot of the bed. The CNA was asked are those splints for this Resident or his roommate. The CNA replied I'm not sure I will check and get back to you. The CNA was asked if the Resident lashed out or refused care, and she stated no, he doesn't ever do any of that, he can't. The CNA was unaware of the splint use and did not apply them as a result.
On 10-4-24 at 1:30 PM, Kitchen staff were interviewed and talked about the small quantity of food on Resident #73's tray, and the fact that all of the items were not on the tray and they responded that they were out of the pudding, and they didn't get magic cup in because it was too expensive so they substituted the Jello. They also stated that someone had made a mistake and left items off. When asked to see what the pureed cookie looked like, they stated all of the food was gone and they had none left.
On 10-7-24 at approximately 12:00 PM Resident #73 was again observed during the lunch meal being fed to him by a staff member. The tray portions were unchanged and insufficient as before, the Resident ate 100%, and no house fortified pudding was on the tray.
Resident #73's clinical record was reviewed. Weight documents all completed by mechanical Hoyer lift revealed the following:
5-01-24 - 118.0 pounds prior to the pressure sore injury and cellulitis.
5-20-24 - A nursing note documented Hoyer lift scale not working.
5-22-24 - The Resident went to the hospital with cellulitis after pressure sore injury.
6-10-24 - 125.2 pounds after hospitalization for cellulitis, after gaining 7 pounds in 10 days while hospitalized .
6-24-24 - 108.5 pounds
8-09-24 - 109.0 pounds
9-11-24 - 107.6 pounds
10-8-24 - 97.0 pounds taken during survey with 2 CNA's & surveyor.
On 10-8-24 Two CNA's on 3 PM-11 PM shift weighed the Resident at the request of the surveyor by way of the Hoyer mechanical lift correctly zeroing out the scale prior to lift. The Resident did not seem to mind the jostling and placing on the sling nor lifting in the sling and had no facial nor physical response to the experience. The Resident's weight was found to be 97.0 pounds. The CNAs were asked if he refused care or splinting and both stated no, he never fights me over anything.
Malnutrition Universal Screening (MUST) Tools were reviewed and revealed an assessment on 6-6-24 upon readmission after the 6-1-24 hospital discharge which documented low risk for malnutrition.
The same (MUST) assessment was completed again on 7-24-24 and documented high Risk for malnutrition, weight of 108.5 which had been obtained a month earlier on 6-24-24.
The 7-24-24 (MUST) assessment occurred after another full month of continued significant weight loss greater than 10% in less than 2 months. The downward trend continued through 9-11-24 which was the last facility obtained weight documented in the clinical record until the time of survey. On 10-8-24 when surveyors obtained a weight, no weight had been taken by facility staff for another month.
Physician order reviews revealed only Vitamin C, a Multi vitamin, and 10 doses of Pro-stat for the Significant weight loss, those 3 follow below:
1. Ordered 9-18-24 Ascorbic Acid tablet (vit C) 500 mg (milligrams) 1 tablet at 9:00 AM for malnutrition and wound healing
2. Ordered 7-24-24 Multi vitamin 1 tablet at 9:00 Am for malnutrition and wound healing.
3. Ordered 9-26-24 - Pro-stat AWC oral liquid 30 ml (milliliters) by mouth 3 times per day for malnutrition and wound healing give at 9 AM, 2 PM, and 9 PM, discontinued 9-29-24 (only 10 doses given) in 3 days.
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. RD notes were reviewed and revealed that the RD evaluated the Resident on the following dates.
5-03-24 - Weight warning, weight change, 10% loss, large portions, magic cup with meals, intake 75-100%, clinically insignificant weight loss, 10.6% in 141 days, weigh weekly, RD to monitor.
6-06-24 - Malnutrition screening done, low risk, Weight warning, weight increase (after hospitalization).
6-10-24 - Weight warning, weight loss, reweigh and RD to follow up after reweighing.
6-28-24 - Weight warning, weight loss, weekly weight through 7-1-24, defer to nursing to determine baseline weight.
7-24-24 - Malnutrition screen done, high risk, weight loss, kept same orders, obtain updated weight.
8-09-24 - Weight warning, change note, weight loss, 99.2, do reweigh to verify.
8-14-24 - Significant weight change, weight loss, Vitamin C discontinued 7-25-24 by nursing, weigh weekly.
9-18-24 - Significant weight change, weight loss, restart Vitamin C, weigh weekly.
9-29-24 - Discontinue pro-stat secondary to it not being ordered to be honey thickened.
10-4-24 - was the last entry - Change magic cup (which was not provided) to house fortified pudding.
The RD notes reveal continued weight loss until hospitalization, with no change in recommendations. While the Resident was hospitalized a 7-pound weight gain was experienced, and then after the readmission to the facility the weight loss began again, and continued through survey without any change to recommendations, with the exception of the 5 following items;
1. 7-25-24 Discontinuance of the vitamin C.
2. The Resident never received the magic cups.
3. 9-26-24 pro-stat liquid (protein for healing) for 3 days then discontinued 9-29-24.
4. 9-18-24 the Vitamin C was discontinued, then restarted 2 months later.
5. 10-4-24 the house fortified pudding was added, instead of the magic cup, which was observed as not received.
The weekly weights which were recommended by the RD were never obtained. The Resident did not receive meals in the quantity/caloric intake that was ordered, nor was the ordered diet followed.
Review of Physician's orders revealed only the following order for the left-hand contracture and pressure wound injury with cellulitis.
1. Devices were ordered by the physician on 6-1-24 and again on 9-26-24. That device was Bean bag splints to left upper and left lower extremities as tolerated. No order for, nor directions for, use of palm guards was found in the clinical record.
Physician and Nursing progress notes were reviewed for information on the Resident's contractures, left palm pressure wound, and splint usage. That review revealed that from 5-1-24 through 5-19-24 the Resident had no skin wounds.
On 5-20-24 at 2:20 PM, the Physician's Assistant (PA) documented Patient seen today for nursing reports of wound to the left palm. Left hand is contracted. Drainage, erythema and swelling noted. Patient says ouch when I touch his hand. Comments; one centimeter wound to the left palm with surrounding erythema and swelling that extends into his middle finger. Hand is warm to touch. Hand is contracted so range of motion is limited. Pain states ouch when I move his hand. Assessment and plan; Cellulitis secondary to wound of the left hand. Wound appears to have been caused by (finger) nail of contracted hand being dug into his palm. Palm guard present at bedside but it is unclear how often it is actually being placed on the patient's hand. Swelling and erythema extends into middle finger and dorsal aspect of the hand. Wound cleaned with DWC (Dakin's wound Cleanser) and bandaged. Palm guard placed. Plan: Wound care - Left hand palm cleanse with wound cleanser, pat dry with gauze, then apply antibiotic ointment to wound bed, cover with dry dressing daily and as needed. Apply palm guard, only remove when eating. Start Keflex 500 mg 4 times per day for 7 days. Monitor closely, if wound worsens consider labs and additional antibiotics emergency room visit if warranted.
Resident #73 experienced continued significant weight loss and malnutrition without intervention and was not weighed weekly and monitored as recommended by the RD. The Resident did not receive the correct diet nor caloric intake need, and developed an avoidable pressure sore injury which was not identified until a cellulitis infection was present, and hospitalization was required.
On 10-9-24 at 11:15 a.m., the Administrator, Director of Nursing, and Corporate Nurse were notified of the above findings and given the opportunity to provide any further information or explanation. They stated they had no further information.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected 1 resident
Based on resident interview, staff interview, and review of facility documents, the facility staff failed to provide sufficient nursing staff to provide nursing and related services to meet the reside...
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Based on resident interview, staff interview, and review of facility documents, the facility staff failed to provide sufficient nursing staff to provide nursing and related services to meet the resident's needs for 2 of 55 residents (Resident #47, #472), in the survey sample.
The findings included:
1. On 10/1/24 at 7:00 PM an interview was conducted with Resident #47. Resident #47 stated that there was no nurse on unit 3 from 3pm to 11pm and 11pm to 7am on 8/17/24. Resident #47 also stated that due to this, she did not receive her Gabapentin, Tylenol, or Lisinopril.
On 10/2/24 at 12:15PM an interview was conducted with the two (2) Regional Nurse Consultants. The Regional Nurse Consultants stated that the expected staffing levels for all shifts is the following on all the nursing units: 2 Nurses for 7am - 3pm shift, 2 Nurses for 3pm - 11pm shift, and 1 Nurse for 11pm-7am shift. The Regional Nurse Consultants also stated that on 8/17/24 only 1 Nurse worked on Unit 3 from 3pm - 11pm and only 1 Nurse worked on Unit 4 from 3pm - 11pm. The Regional Nurse Consultants further stated that this did not meet the expected staffing levels for the 3pm-11pm shift on 8/17/24.
A review of the Working Nurse Schedule for the date of 8/17/24 read that 1 Nurse worked on Unit 3 from 3pm - 11pm and 1 Nurse worked on Unit 4 from 3pm - 11pm.
On 10/3/24 at 10:50AM an interview was conducted with LPN #9. LPN #9 stated that she worked on 8/17/24 from 7am-3pm and 3pm-11pm on unit 3. LPN #9 also stated that she was the only Nurse scheduled from 3pm-11pm on unit 3 and it was to many residents for her to provide care to and she voiced this to her supervisor at the agency and to the representatives of the facility however no assistance was provided . LPN #9 further stated that she did her best to provide important medications to the residents however if she missed administering any medications to a resident, it was due to having to many residents to provide care too. LPN #9 voiced that she felt it was not safe to have only one (1) Nurse working unit 3 from 3pm-11pm alone with no assistance.
On 10/9/24 at approximately 5:30 PM, a final interview was conducted with the Administrator, Assistant Administrator, Director of Nursing, and the two Regional Nursing Consultants. They had no further comments and voiced no concerns regarding the above allegation.
2. The facility's staff failed to have a licensed nurse assigned to Resident # 472 on 8/9/24 and 8/10/24.
Resident #472 was originally admitted to the facility 8/7/24 and was discharged no return anticipated on 8/10/24 . The resident's diagnoses included diabetes, hypertension and recurrent urinary tract infections.
The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/10/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. This indicated Resident #472's cognitive abilities for daily decision making were intact.
An interview was conducted with FM #3 on 10/9/24 at 12:49. FM #3 stated she and her sister agreed the facility was not the best placement for their mother because the day after the resident's admission there was not a nurse on duty according to a response from a Certified Nursing Assistant (CNA) on duty. FM #3 stated the CNA told her that the licensed nurse from another unit would come to the unit her mother resided on after the work was completed on the assigned unit. FM #3 stated her mother's blood sugar was not obtained and her diabetic and antihypertensive medications were not administered timely. FM #3 also stated the resident did not receive hygienic care timely.
A review of the staffing schedule and time punch records for 8/9/24 and 8/10/24 revealed there was not a nurse assigned to the unit on which Resident #472 resided on for the 3:00 PM - 11:00 PM shift. A review of the resident's Medication Administration Record (MAR) for her stay revealed medications were not signed out as administered for 8/9/24 and 8/10/24 during the 3:00 PM - 11:00 PM shift. Medications not signed as given included insulin, antihypertensives, pain medications, hyperlipidemia medication and the 4:00 PM and 9:00 PM blood sugar checks were not documented.
An interview was conducted with the Administrator-in-training (AIT) on 10/8/24 at approximately 1:40 PM. The stated they had a contract with only one agency and the agency's staff would accept shifts but not show up to work. The AIT stated therefore the facility added additional contract staffing and currently they are having less staffing concerns.
On 10/11/24 at approximately 8:15 PM, a final interview was conducted with the Administrator, Interim Administrator, Director of Nursing and two regional Nurse Consultants. They had no comments and voiced no concerns regarding the above information.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected 1 resident
Based on information obtained during the as worked nursing schedule nursing staff, the facility staff failed to staff a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week whic...
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Based on information obtained during the as worked nursing schedule nursing staff, the facility staff failed to staff a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week which could potentially affect all residents.
The facility staff failed to staff a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week.
The findings included;
A review of the as worked schedule from 11/19/24 through 12/05/24. The facility staff was unable to verify 8 consecutive hours a day of RN coverage for at least 2 days on the following dates: 11/30/24 and 12/01/24.
The above dates were verified by the Corporate Nurse Consultant (CNC) #2 on 12/03/24 at approximately 4:40 PM. The CNC #2 said there was no RN coverage, but there should have been coverage on 11/30/24 and 12/01/24.
A final interview was conducted on 12/04/24 at approximately 5:45 PM., with the Corporate Nurse Consultant (CNC) #2. The CNC #2 said that RN coverage should have been provided on the above dates.
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 F0742
(Tag F0742)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility record review, and clinical record review, the facility staff failed to provide specific and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility record review, and clinical record review, the facility staff failed to provide specific and adequate treatment services for mental health and psychosocial concerns for one Resident with depression, and anxiety (Resident #126) in a survey sample of 30 Residents.
Resident #126 did not receive adequate psychosocial, psychiatric, nor psychoactive medication care and services while in the facility after multiple falls, a hospitalization with fracture and head injury, and after return to the facility with behavioral issues complicated by new onset confusion. Further the facility failed to reinstitute long standing medication therapy for depression and anxiety after the hospitalization return.
The findings included:
Resident #126 was admitted to the facility on [DATE] and discharged back to the hospital on [DATE] for a fall with refracture of right hip, and head injury with acute subdural hematoma. He was readmitted on [DATE] after the 2-day hospital stay, and was transferred back to the hospital 11-28-24 for intractable pain and did not return until 11-29-24.
Resident #126's Diagnoses included but were not limited to; Cardiovascular disease, congestive heart failure, coronary heart disease, Atrial fibrillation, high cholesterol, chronic kidney disease, right hip & sacrum Fractures, major long standing depressive disorder, anxiety, long standing family history of psychiatric illness, heart disease, history of prostate cancer with resection, and chronic obstuctive pulmonary disease with nicotine dependency.
Resident #126's most recent Minimum Data Set (an assessment protocol) was a 5-day admission assessment with an Assessment Reference Date of 11-5-24 which coded Resident #126 with a BIMS (brief interview of mental status) score of 14, of a possible 15 points indicating no cognitive impairment. The Resident was documented as able to be understood and to understand others, and able to see and hear.
Resident #126 required limited assistance of 1 staff member according to the [NAME] care plan for the baseline care staff including Certified Nursing Assistant's (CNA's) dated 11-29-24. According to the ADL (activities of daily living) documentation, however, the Resident was totally dependant on staff for toileting. The resident was documented as always incontinent of bowel & bladder, and the Resident falls were linked to the Resident attempting to go unassisted to the bathroom.
On 12-4-24 at 12:30 p.m., Resident #126 was observed in bed lying flat on his back. The Resident was resting and refused interview stating he was tired. The surveyor asked him if he needed help and he replied no. Staff stated that the Resident was oriented to person, place, time, and could answer questions if he wanted to, but he would at times have behaviors and yell at staff. When asked what type of behaviors they stated he would yell, throw things, urinate on the floor if they didn't answer his call light immediately.
The entire clinical record was reviewed and revealed the following;
Review of behavior notes revealed that from 10-30-24 through 11-17-24 six notes were documented in the clinical record by nursing which revealed the following;
On 11-1-24 (3 notes) the Resident complained about going nuts and had no one to control him, yelling out, threw crackers at wife, shaking physically and stating he was going crazy and something needed to be done. The Resident requested that the thermostat be set automatically to alternate from hot to cold, and stated if he didn't get some type of sedative he would be a Bitch all night.
On 11-2-24 (2 notes) the behavior notes continued documenting that he was in bed naked stating he needed help and was locked in his room. The nurse documented that she placed an adult brief on the Resident and he calmed down. Later that day another note describes the Resident had removed his clothes and was continuously yelling for help, and complaining that nothing in the room worked. The note documented that nursing staff attempted to show him that things did work, however, no documentation was included on what those things were. The note goes on to describe that her intervention did not help and he continued yelling out for help.
On 11-17-24 (1 note) the document described that the Resident urinated on the floor, and when the nurse asked him why he had done that, he stated because he could not get out of bed. The note goes on to say that the Resident still had on an adult brief but refused to use it, indicating staff inconvenience, in that they wanted the Resident to use the incontinent brief rather than go to the bathroom.
It is notable to mention that if the resident refused to use the incontinence brief, and removed it to urinate on the floor then reapplied it, the Resident did so as a choice, with full knowledge of how to accomplish it, and not as an aberrant behavior. The behavior notes do indicate that the Resident willingly verbalized distress to staff, asked for help, and retaliated when help was not given. This is a reasonable person concept of reaction when needs are expected to be met in a facility, and necessary in the Resident's point of view, which went unfulfilled. The Resident was told not to go to the bathroom alone because of falls, yet could not get help in his point of view, and he found no alternatives.
The Resident was seen by psychiatric service providers only twice from admission on [DATE] until the time of survey on 12-5-24. No other psychiatric evaluations, nursing behavior notes, nor psychosocial treatments and or therapy were conducted and documented in the clinical record for review. The 2 Psychiatric provider notes indicated that the Resident was initially evaluated on 11-6-24, and seen a second time on 11-20-24. Those follow below;
On 11-6-24 - The Psychiatric Registered (NP) Nurse Practitioner documented that the Resident had a long standing family and personal psychiatric history, and described the individuals diagnoses and histories to included medications being used prior to hospitalization and admission to the facility with the Resident's spouse of 50 years at the bedside to corroborate. A PHQ-9 assessment was completed at the bedside which is an assessment of screening for and monitoring to include measurement of severity of depression, anxiety, sleep disorders and other psychological illness. The assessment tool indicated that a score of 5 or above is positive for requiring a follow up plan to include behavioral health consult, psychotherapy, and pharmacotherapy as indicated. The Resident scored a 10. The document goes on to describe the Residents current medications which were Trazadone, Ativan, Buspar, and Welbutrin.
On 11-20-24 - A second Psychiatric Registered (NP) Nurse Practitioner saw the Resident on this day and documented that another PHQ-9 was completed and positive again. The document indicated that the Buspar which the previous visit note indicated was to be discontinued, had not been discontinued as was ordered. The Ativan was discontinued on this day after 31 doses through 16 days of use without re-evaluation.
A Chronological change in the psychoactive medications received by Resident #126 follows below;
On 10-30-24 Wellbutrin 300 mg once per day antidepressant was ordered and discontinued 12-4-24.
On 11-1-24 Seroquel 25 mg at bedtime antipsychotic/antidepressant, was ordered for 5 days, then stopped after dosing on 11-5-24. This drug in concomittant use with wellbutrin is not advised due to increased risk of causing seizures, and use with trazadone may cause a potentially life threatening irregular heart rhythm.
On 11-5-24 Trazadone 100 mg antidepressant was ordered to be given at bedtime, and continued through out survey. This drug in concomittant use with Buspar is not advised due to increased risk of causing confusion, hallucination,and seizures.
On 11-6-24 the NP ordered Buspar 5 mg three times per day to be discontinued, and for Depakote 125 mg (milligrams) twice per day to be added.
On 11-15-24 the Depakote 125 mg twice per day anti seizure medication was discontinued, and increased to Depakote 250 mg three times per day. The Depakote was discontinued on 12-1-24
On 11-15-24 The Buspar 5 mg three times per day was discontinued finally, and was then increased to Buspar 10 mg three times per day. The medication was held for 3 doses between 11-19-24, and 11-20-24 for an unknown reason, and discontinued on 12-4-24.
On 11-15-24 Gabapentin 300 mg three times per day for neuropathy was ordered, and started on 11-16-24, and continued through survey.
On 12-4-24 Zyprexa 5 mg at bedtime for psychiatric disorder was ordered, however, not started at the time of exit on 12-5-24 due to Pending confirmation.
Long standing psychoactive medications at home prior to facility admission and according to hospital records were; Wellbutrin, Buspar, Depakote, Gabapentin, and trazadone.
At the time of survey exit on 12-5-24 psychoactive medications were: Trazadone and Gabapentin.
The National Institutes of Health, and National Institutes of Mental Health, were referenced for the administration of Psychotropic medications. That guidance includes that psychoactive medications take time to work. Psychoactive medications should be adjusted slowly and safely to avoid serious harmful side effects including confusion and hallucination. Those with cardiovascular disease are more at risk for serious life threatening side effects of psychoactive medications.
On 11-26-24 the Resident was sent out to the hospital after having fallen multiple times with serious injuries. Those injuries included a Subdural hematoma from striking his head, and he had refractured the hip which had been recently surgically repaired.
The Resident had exhibited and expressed psychological distress, and according to Psychiatric NP documentation had experienced falls and hallucinations as reported by facility staff. The rapidly changing cocktail of concomittant administration of numerous psychoactive medications to include; rapid introductions of new medications, withdrawals of long standing medications, and increases of medications over a 3 week period could have contributed to Resident #126's distress and statements of going crazy.
These medication changes coupled with 3 hospitalizations and entrance into a skilled nursing facility, with the known transfer trauma effect which is a medically recognized syndrome and typically care planned by healthcare providers was not assessed for nor care planned by the facility staff.
On 11-28-24 the Resident returned to the facility and on the same day was returned to the hospital for unrelieved pain due to unavailable pain medication at the facility according to hospital records. The Resident was then readmitted to the facility on [DATE].
The Resident was not seen by the Psychiatric NP's from 11-20-24 to the time of survey exit on 12-5-24, however the facility Administrator assured surveyors that the Resident would be seen that day. It was stated that outside of the orders previously issued by the Psychiatric NP on 11-6-24, and 11-20-24, the facility Medical Director would have been responsible for issuing any of the other orders that were made for Resident #126.
On 12-4-24 Olanzipine/Zyprexa 5 mg at bedtime for Bipolar disorder was ordered. It is notable to mention that the Resident did not have a diagnosis of Bipolar Disorder. Zyprexa also has a black box warning of increased risk of death in older adults.
On 12-4-24 after surveyor concerns were made known to the facility, the medications Wellbutrin, and Buspar were discontinued and Zyprexa was ordered, however, had not yet been administered at the time of survey exit on 12-5-24.
All discipline progress notes from 11-4-24 through 12-4-24 were reviewed. The prog notes revealed the following;
The Medical doctor saw the Resident only one time on 11-9-24 through the time of survey. That note described the Resident as Sedated and normal participated in conversation, coherent.
The Psychiatric NP's saw him, on 11-6-24, and nursing documented that the Resident's room was changed to be closer to the nursing station for observation due to falls, and was seen on 11-20-24 as stated above.
On 11-15-24 a computerized auto generated pharmacy system identified and alerted staff to medication concerns for use of Trazadone and buspar being combined with a potential severe reaction of increased possibility of Serotonin syndrome which can be life threatening, and Trazadone could increase the effects of Ativan if used together causing confusion and sedation.
On 12-19-24 Nurses notes indicated that the Resident's spouse complained that the Ativan was causing the Resident's confusion and requested it be stopped. It was held on 11-19-24, and on 11-20-24 the Ativan was discontinued
The Family practice NP also saw him on 11-20-24.
Nursing notes indicated that on 11-26-24 the Resident was sent to the hospital after a fall as requested by the Resident and his spouse with no indication that he was seen by facility physician staff.
On 11-28-24 the NP and Third Eye a computer generated telehealth company, sent the Resident back to the hospital.
On all nursing skilled notes the area for Non-pharmacy interventions was blank, with none were used, nor specified for use.
Review of the current care plan derived 10-30-24 upon discharge from the hospital, revealed only 3 care planned problem areas that could be related to psychiatric needs. The first focus was repeated in the document so not mentioned twice. Those follow below;
1. FOCUS. Antipsychotics (medications): The Resident is at risk for adverse reactions related to the use of antipsychotics secondary to a diagnosis of : (no diagnosis given, left blank.)
GOAL. The resident will be free from adverse effects related to antipsychotic use through review period.
INTERVENTIONS. Administer medications as ordered. Aims assessment as indicated (abnormal involuntary movement scale) (never completed). Labs as ordered, Monitor for behaviors related to medication use (none specified). Pharmacy review as indicated (none in clinical record), PHQ-9 mood screening as indicated, psyche services as needed/indicated, observe for signs and syptoms of adverse side effects related to medication use and notify MD (doctor) as indicated (no signs or symptoms specified), nonpharmacological interventions: (SPECIFY), (none were specified).
2. FOCUS. The resident has a level 2 PASARR.
GOAL. The resident will communicate feelings related to emotional state by review date.
INTERVENTIONS. Administer medications as ordered, monitor document for side effects, psychological/psychiatric interventions/consultation as ordered, If reasonable, discuss the resident's behavior, explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. (no behaviors specified).
3. FOCUS. The resident will continuously get out of bed and put himself on floor related to depressive disorder, yells and screams, throws items, removes clothing.
GOAL. The resident's behaviors will not cause them or other residents distress through the review period.
INTERVENTIONS. Administer medications as ordered, assure the resident they are safe if they become distressed, listen to the resident and try to calm, physician review of medications as needed, psyche services referral as needed, take the resident to a quiet place if they become overstimulated.
In the first careplan focus no diagnosis was listed, no AIM's assessment was conducted, and appeared unnecessary as the Resident was never documented as having abnormal involuntary movements, no pharmacy evaluation was conducted, no adverse behaviors, signs, nor symptoms were listed for medication side effects, and no non-pharmacologic interventions for distress were listed.
In the second focus no inappropriate or unacceptable behaviors were specified.
In the third focus of putting self on floor, yelling, screaming, throwing things, and removing clothes are not causes of distress, they are expressions of distress. The Resident did not put himself on the floor, he fell, which is well documented in the clinical record as he was trying to go to the bathroom. He also complained of being uncomfortable and asked for the thermostat in the room to be reset, and the Resident was obese.
It is notable to mention that during the most recent fall and hospitalization the Resident experienced a head injury with resultant subdural hematoma. The Resident did not receive a CT (computed tomography) scan of his head after hospitalization, and so it was unclear if the medication changes or a worsening head injury was at fault for causing the Resident's psychological distress, as it was not exhibited upon initial admission. On 12-5-24 The Corporate RN (Registered Nurse) consultant stated she had obtained an order for the follow up CT for the Resident and that it would be completed on 12-6-24 at 9:00 AM.
On 12-5-24 at 1:15 PM multiple staff members to include CNA's and Licensed Practical Nurses (LPN's) were interviewed in the conference room by surveyors. All agreed that psychiatric and behavioral health training had not been received by them.
On 12-4-24 an interview with the Discharge planner was conducted in the conference room with surveyors. That interview revealed that only she and the Activities Director had been attending care plan meetings for Residents. The care planning was not interdisciplinary, and neither of the attendees were trained in healthcare. When asked what should be in a Care Plan for patients with psychiatric concerns, she stated she would have to find out, and there should be non-pharmacological interventions for specific behaviors and activities specific to Resident's needs. When asked what those would be, she replied I'll have to find out.
On 12-4-24 at a morning meeting, and on 12-5-24 at an end of day debriefing, the Corporate RN, Administrator and Director of Nursing (DON) were made aware of the findings. At the time of exit they stated there was no further information available to submit to 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
Deficiency F0745
(Tag F0745)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews, staff interview, clinical record review, and facility document review, it was determined that the ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews, staff interview, clinical record review, and facility document review, it was determined that the facility social worker failed to provide services for one resident (Resident #521) in the survey sample of 55 Residents
The findings included;
For Resident #521, the facility Social worker failed to provide medically related social services to meet the Resident's needs for a strictly Spanish speaking Resident who had signs of frustration, and aggression.
Resident #521 abused 3 Residents in the facility and exhibited aggressive behaviors and signs of distress which were never assessed and care planned, and not evaluated by medical social work.
For Resident #521 the facility staff failed to obtain a physician ordered psychiatric consult timely, failed to conduct behavior monitoring, failed to provide a comprehensive care plan for emotion regulation, failed to identify stressors and responses such as language barrier and supervision, to those stressors, which resulted in aggressive behaviors aimed at and impacting other residents.
The facility failures described above resulted in the willful abuse of Residents #68, #20, and a third unknown Resident victim as perpetrated by Resident #521.
Resident #521 was not receiving any psychotropic medications, to include antidepressants.
Resident #68 (victim 1)was admitted to the facility on [DATE]. Diagnoses included but were not limited to: heart failure, hypertension, high cholesterol, malnutrition, peripheral venous insufficiency, hypothyroidism, rheumatoid arthritis, scoliosis, rhabdomyolysis, and foot pain.
Resident #68's most recent Minimum Data Set with an Assessment Reference Date of 8-2-24 was coded as a quarterly assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicates no cognitive impairment. The Resident was cognitively intact, and her own responsible party. The Resident required extensive assistance from one staff member for hygiene and bathing. The Resident had no aberrant behaviors documented, and had no complaints against any other staff or situations since her admission on [DATE].
Resident #20 (victim 2) was admitted to the facility on [DATE]. Diagnoses included but were not limited to chronic ischemic heart disease, stroke with hemiplegia right side, anemia, diabetes, chronic hepatic failure, neck fracture, chronic kidney disease, depression, and femur fracture.
Resident #20's most recent Minimum Data Set was a quarterly assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicates no cognitive impairment. The Resident was cognitively intact, and her own responsible party. The Resident was independent for transferring and used a motorized wheel chair to leave the building for shopping trips to walmart using a van. The Resident had no aberrant behaviors documented, and had no complaints against any other staff or situations since her admission on [DATE].
Resident #521 (perpetrator of 1 and 2) was admitted to the facility on [DATE], went back out to the hospital for syncope on 9-5-24, and returned on 9-8-24. Hospital discharge records indicated that the Resident was alert and oriented to person, place and time, and was ambulatory at the time of discharge. Diagnoses included but were not limited to: Heart failure, hypertension, Gastro Esophageal reflux disease, renal insufficiency, diabetes, thyroid disorder, dementia, malnutrition, and asthma.
Resident #521's most recent Minimum Data Set with an Assessment Reference Date of 9-5-24 after one day in the facility was coded as an admission assessment. The Brief Interview for Mental Status was coded as 12 out of a possible 15 points which indicated mild cognitive impairment, however, the language barrier may have contributed to a false lower score. The Resident was her own responsible party. The Resident spoke only Spanish. The Resident required extensive assistance from one staff member for hygiene and bathing.
On 10-1-24, the first day of survey, Resident #521 went out to a medical appointment and lost consciousness while there. She was sent directly to the hospital, and did not return during the remainder of the survey.
While on continued tour of the facility on 10-4-24, Resident #68 was interviewed and asked if any person in the facility had abused her or if she had ever witnessed abuse. She stated yes that her former room mate (Resident #521) had kicked her, thrown fruit at her, hit her, and had spit on her. She stated that Resident #521 had also cursed and yelled at her, gotten in her bed, held her wheel chair so she could not leave the room for help, and had stood over her while she was laying in bed menacing her. She stated that she had been bruised by the kick and punch, but luckily suffered no other injuries. She further stated that she had complained to staff repeatedly but they did nothing until 9-20-24 when Resident #521 punched her in the arm and the Assistant Director of Nursing saw it. She went on to say that they moved her that day. The Resident was asked if she was still afraid and she stated no, she's gone now.
On 10-7-24 the clinical records of Resident's #68, and #521 were reviewed. Those reviews contained the following information in chronological order;
On 9-20-24 at 3:42 PM the records indicated that Resident #521 had been moved to another room for Safety. No other descriptions about the allegations of abuse on Resident #68 were documented.
On 9-20-24 Resident #521's progress notes documented she was moved to the room containing Resident #20.
On 9-21-24 at 12:47 AM (7.5 hours later) after the move, progress note review indicated that Resident #521 was observed to throw a cup of water across the room and spit on her new room mates charger for her electric wheel chair.
On 9-21-24 at 8:41 PM, Later the same day, documents record Resident #521 hit Resident #20 and it was witnessed by staff. There was no mention of the scratches to Resident #20 inflicted by Resident #521.
On 9-22-24 at 1:34 AM (5 hours later) progress notes go on to describe that Resident #521 was moved to a private room.
(Victim #3 unknown name) On 9-22-24 at 2:54 AM, (1.5 hours after move) another note describes Resident #521 as standing next to her neighbors bed (unknown which neighboring room to the private room or which Resident this involved) staring at her (the neighbor of Resident #521) while sleeping and threatened anger aggressive behavior.
On 9-23-24 a psychiatric consultation was ordered. It was never obtained.
On 9-25-24 the Physician's Assistant (PA) described in a note that (Resident #521) Patient assault on room mate multiple times, resident denied, on alternate location at this time.
On 10-7-24 Resident #20 was interviewed and stated that Resident #521 was placed in her room and almost immediately began to yell at her, spit at her, and throw things at her. She went on to state that Resident #521 finally came over to her side of the room after dinner sometime and lashed out at her hitting her, causing several small scratches on her hand. She stated she was fending off the blows with her arm raised. and Resident #521's fingernails scratched her. She went on to state that the staff saw it and moved her out of the room until they could find a place for Resident #521. She stated that Resident #521 was moved Sometime late that night around midnight. Resident #20 was asked if she was afraid of Resident #521, and she stated no, she went to the hospital and I don't think she's ever coming back.
Nursing staff on the units where Resident #521 was housed were interviewed and stated they remembered Resident #521, and her aggressive behaviors, however, those working during survey interviews were not present during the abuses. They stated they were aware of the incidents, however, most of the staff were from a staffing agency and did not work there every day.
During interview and review of the clinical record, it was found that the Social Worker/Discharge Planner (SWDP) was only involved with Resident #521 on 3 occasions. Those instances follow below:
1. Nine days after admission on [DATE] for a Trauma Informed Care assessment which was negative for trauma experienced by the Resident.
2. After the first abuse on 9-20-24 to Resident #68, to notify Resident #521's son of the first room change.
3. Finally, at the first Interdisciplinary care plan meeting on 9-26-24 with only the SWDP and the Activity Assistant present.
The facility staff provided a copy of their Abuse policy, and the policy review revealed that all allegations of abuse will be investigated, Residents will be protected and prevented from further abuse, reports will be sent initially to the State agency VDH/OLC (and other agencies) within 24 hours or within 2 hours if serious injury occurs, and a follow up report will be sent in 5 days to include findings and corrections.
Resident #68 reported abuse for days before staff observed the abuse and moved Resident #521.
Resident #521 was then placed with Resident #20 who was not protected and was abused.
Resident #521 was moved again and went to a third unknown Resident's room to abuse.
The allegations of abuse were never reported to the state agency. Residents were not protected from a known abuser. Abuse was not investigated fully, and the facility policy was not implemented for the protections of Residents from abuse. Further, there was never any added staff supervision for Resident #521 to prevent the abuse from continuing.
No staff ever noted the suspicion of a crime, so no police report was ever filed. The first alleged report by the Administrator was never signed and had errors in information giving the appearance of a severely demented alleged abuser to APS in a single occurrence resulting in no investigation opened by them.
Resident #521's nursing and physician progress notes were reviewed and revealed the following:
9-8-24 nurses documented Resident with language barrier (speaks only Spanish) states frustration with interpreter.
9-11-24 the physician documented Plan: - The patient has had a diagnosis of depression or has had a diagnosis of Bipolar Disorder.
9-12-24 nurses documented refused, wants to be left alone to therapy, refused weight yelling in Spanish
9-19-24 nurses documented Google translater only means of translation in the facility.
9-20-24 nurses documented room change for safety.
9-21-24 12:47 AM nurses documented woke from nap anxious, stating dead bodies everywhere, resident extremely restless and gestures for sleep but will not stay in bed more than 15-20 minutes at a time.
9-21-24 10:41 PM nurses documented Aggression and hitting roommate, removed from room.
9-22-24 1:34 AM nursing notes documented another room change to a private room.
9-22-24 2:54 AM nursing notes Aggressive behavior standing over sleeping neighbor threatening neighbor room.
9-23-24 2:45 PM nursing note Psyche consult placed in psyche referral book.
9-23-24 11:12 PM nursing note difficulty communicating with Resident.
9-25-24 physician documented resident's roommate spoke up about Resident #521 laying hands on her multiple times. Staff made aware, management involved, room changed. That reveals that the physician was only aware of one abuse victim, and not the other two.
Resident #521's frustration was identified on day 1, and no plan was implemented to improve communication between staff and residents for this Resident.
The psychiatric evaluation was put in a book at the nursing station awaiting the next visit from psyche professionals to see other residents before they knew Resident #521 needed services. This was revealed during interview at the nursing station when the consult book was requested, on 10-7-24 they stated that's our procedure.
From 9-4-24 through 10-1-24 (28 days), no psychosocial nor behavioral services were ever afforded a disturbed Resident #521 even after 3 abuses of other Residents and aggression toward staff.
Resident #521's care plan was reviewed and revealed no focus nor interventions for dementia, language barrier, nor behaviors was ever derived nor implemented before or after the abuses occurred.
Resident #521's physician's orders and progress notes were reviewed and revealed On 9-8-24 Geriatric psyche consult (as needed) PRN. No other assessments nor orders for behavioral health support were ever obtained.
Resident #521's Social Work/Discharge Planning (SW/DP) notes were reviewed and only 4 existed in the clinical record. They are as follows:
1. 9-13-24 Trauma informed screening completed . Resident has experienced none at this time. Resident has no reported trauma indicators.
2. 9-13-24 Psychosocial, medical and behavioral health related needs explained. None, Patient is alert and oriented times 2. Patient is long term care, and has no advanced directive.
3. 9-20-24 (name) Resident notified of room change. Family/responsible party notified of room change. Reason for room change: Safety.
4. 9-26-24 IDT (interdisciplinary team) met for the patients care plan meeting. Members in attendance were the Activities assistant and Discharge planner (DCP), aka (SW/DP), DCP called the patients son and left a voicemail regarding the care planning meeting. The patient declined to participate in the meeting.
The SW/DP was interviewed on 10-8-24 and was asked why no social work notes existed for this Resident's distressed behavior, and she stated she had not known as none of the staff alerted her to the issues. She stated she was aware of the single first altercation with her roommate, and that she had been moved, but she was not further updated after that or she would have documented those moves as well.
On 10-9-24 at approximately 5:30 p.m., the facility Administrator, Corporate Registered Nurse, and Corporate Administrator were notified of the findings. They stated they had no further information or documentation to offer.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, the facility staff failed to procure routine medications as ordered by ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, the facility staff failed to procure routine medications as ordered by the physician for 2 Residents (#142, #161) in the survey sample of 55 residents and establish a system of records of receipt and disposition of all controlled drugs.
The findings included:
1. For Resident #142 the facility staff failed to sign off administration of all 9 a.m. medications on 9/1/24 as well as failing to document why the medications were not given.
On 10/10/24 during clinical record review it was discovered that Resident #142 did not receive any of his 9 a.m. medications on 9/1/24. Those medications included vitamins, iron, aspirin (given for dx. of Atrial Fibrillation, a cardiac arrhythmia) and Namenda (a medication given to slow the progression of dementia). The record contained no skilled charting for 9/1/24 and none of the ordered vital signs for that shift.
On 10/10/24 at approximately 2 p.m. an interview with the DON and the Clinical Nurse Consultant was conducted, and the DON stated, If it wasn't documented it wasn't done. She indicated that the nurse should have done the vital signs and documented if the medication was refused or held and the reason why and notification of the physician. She stated that as it stands it gives the appearance that nothing was done.
A review of the document entitled Medication Administration Policy revealed the following excerpt:
Page 4
II Administration
2. Medications are administered in accordance with written orders of the prescriber.
Page 5
16. For residents not in their rooms or otherwise unavailable to receive medications on the pass, the MAR is 'flagged.' After completing the medication pass, the nurse returns to the missed resident to administer the medication.
On 10/10/24 during the end of day meeting the Administrator was made aware of the findings and don further information was
provided.
2. For the Facility, the facility staff failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation.
DHP presented concrete evidence that too many count narcotics were observed in an unlocked file cabinet.
On 10/10/24 at approximately 9:00 a.m. the following nurses on each unit were interviewed about the facility process for destroying narcotics.
Unit 1 - LPN (Licensed Practical Nurse) # 3 was asked the process for disposal of narcotic medications no longer in use and she stated that the card of meds and the narc sheet were kept locked in the narc box on the cart until the DON came to collect them for disposal. When asked how many nurses were required to waste narcotics, she stated 2 and both must sign the narc sheet after verifying the count and witnessing the disposal.
Unit 2- LPN #6 was asked the process for disposal of narcotic medications no longer in use and she stated that the meds and the narc sheet were kept locked in the narc box on the cart until the DON came to collect them for disposal. When asked how many nurses were required to waste narcotics, she stated 2 and both must sign the narc sheet after verifying the count and witnessing the disposal. She added that the narcotics must continue to be counted every shift change until they were destroyed.
Unit 3- LPN #5 was asked the process for disposal of narcotic medications no longer in use and she stated that the meds and the narc sheet were to be counted every shift and left locked in the narc drawer until the DON came to collect them for disposal. When asked how many nurses were required to waste narcotics, she stated 2 and both must sign the narc sheet after verifying the count and witnessing the disposal.
Unit 4 - RN #1 was asked the process for disposal of narcotic medications no longer in use and she stated that the DON and another nurse will come and get the unused narcotics and take them for disposal. She stated until then they are kept locked in the cart and counted as usual shift to shift. When asked how many nurses are required to waste narcotics, she stated always 2 nurses.
On 10/10/24 at approximately 11 a.m. the current DON and the Corporate Nurse Consultant were shown the evidence submitted by the DHP (Dept. of Health Professions). The DON stated that, though that might have been the process in the past the current process for narcotic destruction is that the medications and the count sheets stay locked on the cart until the DON picks them up then if she has no one to witness destruction she will lock them in the safe in her office until another Nurse is available to witness and countersign the form. The DON demonstrated use of the safe.
On 10/10/24 during the end of day meeting the Administrator was made aware of the findings and don further information was provided.
3. For Resident # 161, the facility staff failed to ensure that oral antibiotics were available for administration as per physician's orders.
Resident # 161 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, Primary Osteoarthritis of the Knee, Septic Arthritis of the Knee, Heart Failure, and edema.
The most recent Minimum Data Set (MDS) was an admission Assessment with an Assessment Reference Date (ARD) of 9/10/2024. Resident # 161's BIMS (Brief Interview for Mental Status) Score was a 14 out of 15, indicating no cognitive impairment.
Review of the clinical record was conducted on 10/9/2024-10/11/2024.
Review of the clinical record revealed the following order:
Amoxicillin Oral Capsule 500 mg (milligrams) Give 2 capsules by mouth three times a day related to Arthritis due to other bacteria, left knee, for 14 Days. Give with food. Order Date-09/18/2024 0833 The medication was scheduled for administration at 9:00 a.m., 2:00 p.m., and 9:00 p.m. and to stop on 10/1/2024 at 9:00 p.m.
Review of the September 2024 Medication Administration Record revealed documentation that the antibiotic (Amoxicillin) was started on 9/18/2024 at 9:00 a.m. and was not available for administration 6 times during the two week course of treatment, including four consecutive missed doses on 9/28/2024-9/29/2024. The dates of missed doses were:
Amoxicillin was not administered on:
9/21/2024 at 9:00 p.m.
9/28/2024 at 9:00 p.m.
9/29/2024 at 9:00 a.m.
9/29/2024 at 2:00 p.m.
9/29/2024 at 9:00 p.m.
10/1/2024 at 9:00 a.m.
Review of the Progress Notes revealed documentation that the Amoxicillin was not administered because it was on order.
On 10/9/2024 at 2:05 p.m., inspection of the B cart on Unit 4 was conducted with LPN (Licensed Practical Nurse)- 4. LPN-4 stated the medications come on a blister pack for each resident. The blister pack should have the medications for each scheduled dose. LPN-4 stated if medication was not available, the nurse was expected to check the Omnicell 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.
On 10/11/2024 at 11 a.m.,, an interview was conducted with the Regional Nurse Consultant (Corporate-2) who stated medications should be available for administration as ordered by the physician. Corporate-2 stated the Pharmacy should have ensured the medication was available for administration. She also stated the nurses should have checked the Omnicell (in house Stat box) for an available supply of the medication. Corporate-2 stated she did not understand why a blister pack of medications from the Pharmacy would not have been available for the nurses to have administered the medications. Corporate-2 explained that on the first day the order was written, the Pharmacy would have sent a blister pack with the entire 14 day course of medication. The nurses would have had access to the medications for each time of scheduled administration.
During the end of day debriefing on 10/11/2024, the Facility's Acting Administrator, Administrator in Training, Regional Nurse Consultant (Corporate-2) and Director of Nursing were informed of the findings.
No further information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation, interview, and facility documentation the facility staff failed to ensure food was prepared, in accordance with professional standards for food service safety for 1 of 4 kitchen ...
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Based on observation, interview, and facility documentation the facility staff failed to ensure food was prepared, in accordance with professional standards for food service safety for 1 of 4 kitchen staff.
The findings included:
The preparing the evening meal on 10/7/24 failed to ensure the beard guard was sufficient to cover his large amount of facial hair.
On 10/7/24 at approximately 5:00 PM a staff member who identified himself as the cook (Other Employee #9) was observed preparing food with a beard guard that only halfway covered his facial hair. When asked about it he stated, It's the only one the facility provides, and it doesn't fit right.
A review of the facility policy entitled Staff Attire read:
Policy Statement: It the center policy that all Dining Services employees wear approved attire for the performance of their duties.
Action Steps:
1. The Dining Services Director ensures that all staff members have their hair off their shoulders confined in a hair net or cap and facial hair properly restrained.
On 10/7/24 at approximately 5:30 p.m. Corporate employee #1 went to kitchen with surveyor and observed employee #9 and she stated that it was the expectation of the facility and the facility policy that facial hair is fully covered.
On 10/11/24 during the end of day meeting the Administrator was made aware 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
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 and clinical record review, the facility staff failed to provide requested medical records for 1 of 55 ...
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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 provide requested medical records for 1 of 55 residents (Resident #171), in the survey sample.
The findings included:
Resident #171 was no longer a resident of the facility; therefore, a closed record review was conducted. Resident #171 was admitted to the facility on [DATE] and the resident was discharged home on [DATE]. The resident's diagnoses included acute respiratory failure with hypoxia, cystic fibrosis with pulmonary manifestations, muscle weakness, and chronic obstructive pulmonary disease.
The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/31/19 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #171's cognitive abilities for daily decision making were intact.
On 10/8/24 at 10:45 AM an interview was conducted with the Regional Nursing Consultant. The Regional Nursing Consultant stated that due to the company change in ownership, a copy of the monthly Medication Administration Records for Resident #171 could not be provided. The Regional Nursing Consultant voiced that she is not able to retrieve these records. The Regional Nursing Consultant also stated that a request has been forwarded to the company Information Technology (IT) Department to retrieve these records.
On 10/9/24 at 2:45 PM an interview was conducted with the Regional Nursing Consultant. The Regional Nursing Consultant stated that the company Information Technology (IT) Department is unable to retrieve the Medication Administration Records for Resident #171, and these records are not able to be obtained at this time.
On 10/9/24 at approximately 5:30 PM, a final interview was conducted with the Administrator, Assistant Administrator, Director of Nursing, and the two Regional Nursing Consultants. They had no further comments and voiced no concerns regarding the above issue.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
Based on observation, interview, clinical record review and facility documentation the facility staff failed to Maintain all mechanical, electrical, and patient care equipment in safe operating condit...
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Based on observation, interview, clinical record review and facility documentation the facility staff failed to Maintain all mechanical, electrical, and patient care equipment in safe operating condition
The findings included:
For the facility, the facility staff failed to ensure the dishwasher, and 2 washing machines were functional and available for use by staff.
On 10/7/24 during the kitchen inspection the kitchen staff were noted to be using Styrofoam take out containers for food service during the lunch and dinner meals. When questioned Other Employee #9 stated the dishwasher has been broke for weeks now. He stated we have a new one it's just not hooked up yet.
On 10/8/24 an interview was conducted with Other Employee #5 who stated that he wasn't exactly sure how long the dishwasher had been down. He was asked to research and provide a timeline.
8/6/24 - dishwasher was purchased (evidenced by email from corporate purchasing office to maintenance).
9/24/24 - dishwasher arrived at facility (as evidenced by email between maintenance and supplier).
10/10/24 - during the current survey, the dishwasher was installed and running as of breakfast meal.
On 10/11/24 at 3:00 pm, an interview was conducted with the director of housekeeping who was asked why there was a shortage of linens, and the laundry was not getting done in a timely manner. She stated that they are doing the best they can with 1 washing machine. When asked if that is all the facility has for 180 beds, she stated that the other 2 washers are broken. She stated that they are working 7 days a week with the one washer they have to try and keep up with all the linens and facility laundry as well as Resident personal clothing.
9/30/24 - Washer 1&2 down and waiting on replacement for #1. As of close of survey, 10/11/24, the washers had still not been repaired or replaced.
On 10/11/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected multiple residents
Based on information obtained during the Resident Group interview, observations, staff interviews, and Resident Group meeting minutes, the facility staff failed to demonstrate their response, action a...
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Based on information obtained during the Resident Group interview, observations, staff interviews, and Resident Group meeting minutes, the facility staff failed to demonstrate their response, action and/or a rationale for not taking action to the Resident Group grievances.
The findings included:
On 10/7/24 at 2:00 PM a Resident Group meeting was held with the President, [NAME] President, four resident who attends the group meeting regularly and one who does not attend the regularly. It was a consensus of all attending the meeting that their grievances are not acted upon even when they had been voiced multiple times. The groups stated they had never received communication from the administrative staff regarding any of their grievances.
The group's President stated that the Activity's Director (AD) assists with the meeting and she ensures the departments are aware of their grievances but she has her assistant act as a liaison between the residents and the staff.
A review of six months of the Resident Group minutes revealed that the residents voiced the following concerns multiple times; medication are not administration as ordered, linen are not changed as needed, unprofessional of nursing staff, a desire for a variety of foods for meals, meal portions are too small, resident shopping trips are desired, rooms/floors not getting cleaned, trash not removed from the rooms on the weekends, toilet paper not replenished, call bells not answered or just turned off, water bugs in rooms, ceiling tiles over resident beds wet as well as their personal belongings, showers not given, dinner in the dining room wanted, personal laundry not returned but receiving others persons laundry, and episodes of having only 1-2 Certified Nursing Assistants on the unit.
An interview was conducted with the AD on 10/10/24 at approximately 12: 48 PM. The AD stated she does present the group grievances to the department heads during the morning meetings but she has never received feedback to their grievances to report back to the group. The AD also stated she was not aware a response, action and/or a rationale if applicable were requirements.
On 10/11/24 at approximately 8:15 PM, a final interview was conducted with the Administrator, Interim Administrator, Director of Nursing and two regional Nurse Consultants. They had no comments and voiced no concerns regarding the above information.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff failed to prevent repeated willful abuse and neglect, failed to report the abuse to the state agency, failed to fully investigate the abuse, failed to protect the victims during the investigation, and further failed to implement their abuse and neglect policies for four known Residents (Residents #68, #20 and #521, ) in a survey sample size of 55 residents.
The findings included:
The facility failures described above resulted in the willful abuse of Residents #68, #20, and a third unknown Resident victim as perpetrated by Resident #521.
Resident #68 (victim 1)was admitted to the facility on [DATE]. Diagnoses included but were not limited to: heart failure, hypertension, high cholesterol, malnutrition, peripheral venous insufficiency, hypothyroidism, rheumatoid arthritis, scoliosis, rhabdomyolysis, and foot pain.
Resident #68's most recent Minimum Data Set with an Assessment Reference Date of 8-2-24 was coded as a quarterly assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicates no cognitive impairment. The Resident was cognitively intact, and her own responsible party. The Resident required extensive assistance from one staff member for hygiene and bathing. The Resident had no aberrant behaviors documented, and had no complaints against any other staff or situations since her admission on [DATE].
Resident #20 (victim 2) was admitted to the facility on [DATE]. Diagnoses included but were not limited to chronic ischemic heart disease, stroke with hemiplegia right side, anemia, diabetes, chronic hepatic failure, neck fracture, chronic kidney disease, depression, and femur fracture.
Resident #20's most recent Minimum Data Set was a quarterly assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicates no cognitive impairment. The Resident was cognitively intact, and her own responsible party. The Resident was independent for transferring and used a motorized wheel chair to leave the building for shopping trips to walmart using a van. The Resident had no aberrant behaviors documented, and had no complaints against any other staff or situations since her admission on [DATE].
Resident #521 (perpetrator of 1 and 2) was admitted to the facility on [DATE]. Hospital discharge records indicated that the Resident was alert and oriented to person, place and time, and was ambulatory at the time of discharge. Diagnoses included but were not limited to: Heart failure, hypertension, Gastro Esophageal reflux disease, renal insufficiency, diabetes, thyroid disorder, dementia, malnutrition, and asthma.
Resident #521's most recent Minimum Data Set with an Assessment Reference Date of 9-5-24 after one day in the facility was coded as an admission assessment. The Brief Interview for Mental Status was coded as 12 out of a possible 15 points which indicated mild cognitive impairment, however, the language barrier may have contributed to a false lower score. The Resident was her own responsible party. The Resident spoke only Spanish. The Resident required extensive assistance from one staff member for hygiene and bathing.
On 10-1-24, the first day of survey, Resident #521 went out to a medical appointment and lost consciousness while there. She was sent directly to the hospital, and did not return during the remainder of the survey.
While on continued tour of the facility on 10-4-24, Resident #68 was interviewed and asked if any person in the facility had abused her or if she had ever witnessed abuse. She stated yes that her former room mate (Resident #521) had kicked her, thrown fruit at her, hit her, and had spit on her. She stated that Resident #521 had also cursed and yelled at her, gotten in her bed, held her wheel chair so she could not leave the room for help, and had stood over her while she was laying in bed menacing her. She stated that she had been bruised by the kick and punch, but luckily suffered no other injuries. She further stated that she had complained to staff repeatedly but they did nothing until 9-20-24 when Resident #521 punched her in the arm and the Assistant Director of Nursing saw it. She went on to say that they moved her that day. The Resident was asked if she was still afraid and she stated no, she's gone now.
On 10-7-24 the clinical records of Resident's #68, and #521 were reviewed. Those reviews contained the following information in chronological order;
On 9-20-24 at 3:42 PM the records indicated that Resident #521 had been moved to another room for Safety. No other descriptions about the allegations of abuse on Resident #68 were documented.
On 9-20-24 Resident #521's progress notes documented she was moved to the room containing Resident #20.
On 9-21-24 at 12:47 AM (7.5 hours later) after the move, progress note review indicated that Resident #521 was observed to throw a cup of water across the room and spit on her new room mates charger for her electric wheel chair.
On 9-21-24 at 8:41 PM, Later the same day, documents record Resident #521 hit Resident #20 and it was witnessed by staff. There was no mention of the scratches to Resident #20 inflicted by Resident #521.
On 9-22-24 at 1:34 AM (5 hours later) progress notes go on to describe that Resident #521 was moved to a private room.
(Victim #3 unknown name) On 9-22-24 at 2:54 AM, (1.5 hours after move) another note describes Resident #521 as standing next to her neighbors bed (unknown which neighboring room to the private room or which Resident this involved) staring at her (the neighbor of Resident #521) while sleeping and threatened anger aggressive behavior.
On 9-23-24 a psychiatric consultation was ordered. It was never obtained.
On 9-25-24 the Physician's Assistant (PA) described in a note that (Resident #521) Patient assault on room mate multiple times, resident denied, on alternate location at this time.
On 10-7-24 Resident #20 was interviewed and stated that Resident #521 was placed in her room and almost immediately began to yell at her, spit at her, and throw things at her. She went on to state that Resident #521 finally came over to her side of the room after dinner sometime and lashed out at her hitting her, causing several small scratches on her hand. She stated she was fending off the blows with her arm raised. and Resident #521's fingernails scratched her. She went on to state that the staff saw it and moved her out of the room until they could find a place for Resident #521. She stated that Resident #521 was moved Sometime late that night around midnight. Resident #20 was asked if she was afraid of Resident #521, and she stated no, she went to the hospital and I don't think she's ever coming back.
Nursing staff on the units where Resident #521 was housed were interviewed and stated they remembered Resident #521, and her aggressive behaviors, however, those working during survey interviews were not present during the abuses. They stated they were aware of the incidents, however, most of the staff were from a staffing agency and did not work there every day.
During interview and review of the clinical record, it was found that the Social Worker/Discharge Planner (SWDP) was only involved with Resident #521 on 3 occasions. Those instances follow below:
1. Nine days after admission on [DATE] for a Trauma Informed Care assessment which was negative for trauma experienced by the Resident.
2. After the first abuse on 9-20-24 to Resident #68, to notify Resident #521's son of the first room change.
3. Finally, at the first Interdisciplinary care plan meeting on 9-26-24 with only the SWDP and the Activity Assistant present.
A copy of all Facility Reported Incidents (FRI's) for the prior 6 months were requested. 10 were provided by the Administrator, and 9 of the 10 followed the standardized format and documentation was provided for notification of the state agency the Virginia Department of Health Office of Licensure and Certification (VDH/OLC), the state Long Term Care Ombudsman, and Adult Protective Services (APS). The 9 completed FRI's were all prior to 9-20-24.
The tenth alleged FRI involving Resident #68, and Resident #521 was incomplete and contained 7 documents. The documents included four statements from staff alleging abuse to Resident #68. One of the staff statements alleged repeated abuse allegations documented from 9-17-24 through 9-20-24 and for over a week. Also included was a fifth documented statement from the Resident alleging verbal and physical abuse. The sixth document was a written synopsis by the Administrator which was not signed, and only described the initial abuse allegation for Resident #68. It did not include Resident #20's abuse by Resident #521, the room changes, nor the incident with the unknown neighbor after being installed in the third room. The seventh document was a response from APS stating that the report to them did not meet validity criteria required to initiate an APS investigation.
The Administrator's synopsis stated that Resident #68 was asked what was triggering Resident #521's behavior, which implies that the victim is the causative factor, or that the victim is able to psychologically assess her room mate who only spoke Spanish, and Resident #68 only spoke English. The synopsis also stated that Resident #521 would be moved to a room with someone more compatible.
The Administrator's synopsis goes on to describe Resident #521 as having a BIMS score of 3 points out of a possible 15 points indicating severe dementia, which was incorrect. The Resident's BIMS score was 12. The state agency VDH/OLC did not receive the fax sent by the Administrator and review of the fax number revealed it to be in error. All of the documents were completed on 9-20-24, the initial day of assault reporting on Resident #68, and #521. There was no report, investigation, nor protections for Resident #20 after her multiple assaults on 9-21-24, nor for the unknown Resident on 9-22-24 after a third room was inhabited by Resident #521 in less than 48 hours.
The Administrator was interviewed on 10-8-24, and was asked why the document from 9-20-24 was not completed as the other FRI's were, his response was that he had only been here 4 weeks, and I am not required by law to use the FRI document, and I have all of the investigation, and here it is, this is the initial and 5 day follow up all in one.
The synopsis was simple typed document on a clean white unlined sheet of copy paper, and did not state that it was an initial FRI, nor a 5 day follow up, and it was not signed. Included in the packet were 3 copies of a fax cover sheet To: VDH/APS/Willie From: (first name & last name first letter only) the Administrator, documenting that the fax contained 2 pages. The fax was sent on 9-20-24, at 2:24 PM, 2:26 PM, 2:27 PM respectively.
The Administrator stated he wrote the synopsis, and sent the fax, and that in error he didn't sign it. This indicates the only 2 sheets allegedly sent were the fax cover sheet and the synopsis which was not signed, and did not state it was an initial FRI, nor a 5 day follow up.
At that time the Administrator was informed that the investigation was incomplete as no FRI was ever received at the state agency VDH/OLC for the first allegation of abuse. The other 2 Resident's who were later involved were not protected from abuse and added to the initial investigation, and a 5 day follow up as required by law would have captured them as well. The Administrator was made aware that no second FRI and investigation was ever conducted after further abuse from Resident #521 on Resident #20, and the unknown Resident. Residents were not protected from a known abuser. Further they had not implemented their policies on abuse.
The facility staff provided a copy of their Abuse policy, and the policy review revealed that all allegations of abuse will be investigated, Residents will be protected and prevented from further abuse, reports will be sent initially to the State agency VDH/OLC (and other agencies) within 24 hours or within 2 hours if serious injury occurs, and a follow up report will be sent in 5 days to include findings and corrections.
Resident #68 reported abuse for days before staff observed the abuse and moved Resident #521.
Resident #521 was then placed with Resident #20 who was not protected and was abused.
Resident #521 was moved again and went to a third unknown Resident's room to abuse.
The allegations were never reported to the state agency. Residents were not protected from a known abuser. Abuse was not investigated fully, and the facility policy was not implemented for the protections of Residents from abuse. Further, there was never any added staff supervision for Resident #521 to prevent the abuse from continuing.
No staff ever noted the suspicion of a crime, so no police report was ever filed. The first alleged report by the Administrator was never signed and had errors in information giving the appearance of a severely demented alleged abuser to APS in a single occurrence resulting in no investigation opened by them.
On 10-9-24 at approximately 5:30 p.m., the facility Administrator, Corporate Registered Nurse, and Corporate Administrator were notified of the findings. They stated they had no further information or documentation to offer.
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
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff failed to implement their abuse policies to prevent repeated willful abuse and neglect, in so doing, failed to report the abuse to the state agency, failed to fully investigate the abuse,and further failed to protect the victims during the investigation, for four known Residents (Residents #68, #20, #521, and #325) in a survey sample size of 55 residents.
The findings included:
The facility failures described above resulted in the willful abuse of Residents #68, #20, and a third unknown Resident victim as perpetrated by Resident #521.
Resident #68 (victim 1)was admitted to the facility on [DATE]. Diagnoses included but were not limited to: heart failure, hypertension, high cholesterol, malnutrition, peripheral venous insufficiency, hypothyroidism, rheumatoid arthritis, scoliosis, rhabdomyolysis, and foot pain.
Resident #68's most recent Minimum Data Set with an Assessment Reference Date of 8-2-24 was coded as a quarterly assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicates no cognitive impairment. The Resident was cognitively intact, and her own responsible party. The Resident required extensive assistance from one staff member for hygiene and bathing. The Resident had no aberrant behaviors documented, and had no complaints against any other staff or situations since her admission on [DATE].
Resident #20 (victim 2) was admitted to the facility on [DATE]. Diagnoses included but were not limited to chronic ischemic heart disease, stroke with hemiplegia right side, anemia, diabetes, chronic hepatic failure, neck fracture, chronic kidney disease, depression, and femur fracture.
Resident #20's most recent Minimum Data Set was a quarterly assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicates no cognitive impairment. The Resident was cognitively intact, and her own responsible party. The Resident was independent for transferring and used a motorized wheel chair to leave the building for shopping trips to walmart using a van. The Resident had no aberrant behaviors documented, and had no complaints against any other staff or situations since her admission on [DATE].
Resident #521 (perpetrator of 1 and 2) was admitted to the facility on [DATE]. Hospital discharge records indicated that the Resident was alert and oriented to person, place and time, and was ambulatory at the time of discharge. Diagnoses included but were not limited to: Heart failure, hypertension, Gastro Esophageal reflux disease, renal insufficiency, diabetes, thyroid disorder, dementia, malnutrition, and asthma.
Resident #521's most recent Minimum Data Set with an Assessment Reference Date of 9-5-24 after one day in the facility was coded as an admission assessment. The Brief Interview for Mental Status was coded as 12 out of a possible 15 points which indicated mild cognitive impairment, however, the language barrier may have contributed to a false lower score. The Resident was her own responsible party. The Resident spoke only Spanish. The Resident required extensive assistance from one staff member for hygiene and bathing.
On 10-1-24, the first day of survey, Resident #521 went out to a medical appointment and lost consciousness while there. She was sent directly to the hospital, and did not return during the remainder of the survey.
While on continued tour of the facility on 10-4-24, Resident #68 was interviewed and asked if any person in the facility had abused her or if she had ever witnessed abuse. She stated yes that her former room mate (Resident #521) had kicked her, thrown fruit at her, hit her, and had spit on her. She stated that Resident #521 had also cursed and yelled at her, gotten in her bed, held her wheel chair so she could not leave the room for help, and had stood over her while she was laying in bed menacing her. She stated that she had been bruised by the kick and punch, but luckily suffered no other injuries. She further stated that she had complained to staff repeatedly but they did nothing until 9-20-24 when Resident #521 punched her in the arm and the Assistant Director of Nursing saw it. She went on to say that they moved her that day. The Resident was asked if she was still afraid and she stated no, she's gone now.
On 10-7-24 the clinical records of Resident's #68, and #521 were reviewed. Those reviews contained the following information in chronological order;
On 9-20-24 at 3:42 PM the records indicated that Resident #521 had been moved to another room for Safety. No other descriptions about the allegations of abuse on Resident #68 were documented.
On 9-20-24 Resident #521's progress notes documented she was moved to the room containing Resident #20.
On 9-21-24 at 12:47 AM (7.5 hours later) after the move, progress note review indicated that Resident #521 was observed to throw a cup of water across the room and spit on her new room mates charger for her electric wheel chair.
On 9-21-24 at 8:41 PM, Later the same day, documents record Resident #521 hit Resident #20 and it was witnessed by staff. There was no mention of the scratches to Resident #20 inflicted by Resident #521.
On 9-22-24 at 1:34 AM (5 hours later) progress notes go on to describe that Resident #521 was moved to a private room.
(Victim #3 unknown name) On 9-22-24 at 2:54 AM, (1.5 hours after move) another note describes Resident #521 as standing next to her neighbors bed (unknown which neighboring room to the private room or which Resident this involved) staring at her (the neighbor of Resident #521) while sleeping and threatened anger aggressive behavior.
On 9-23-24 a psychiatric consultation was ordered. It was never obtained.
On 9-25-24 the Physician's Assistant (PA) described in a note that (Resident #521) Patient assault on room mate multiple times, resident denied, on alternate location at this time.
On 10-7-24 Resident #20 was interviewed and stated that Resident #521 was placed in her room and almost immediately began to yell at her, spit at her, and throw things at her. She went on to state that Resident #521 finally came over to her side of the room after dinner sometime and lashed out at her hitting her, causing several small scratches on her hand. She stated she was fending off the blows with her arm raised. and Resident #521's fingernails scratched her. She went on to state that the staff saw it and moved her out of the room until they could find a place for Resident #521. She stated that Resident #521 was moved Sometime late that night around midnight. Resident #20 was asked if she was afraid of Resident #521, and she stated no, she went to the hospital and I don't think she's ever coming back.
Nursing staff on the units where Resident #521 was housed were interviewed and stated they remembered Resident #521, and her aggressive behaviors, however, those working during survey interviews were not present during the abuses. They stated they were aware of the incidents, however, most of the staff were from a staffing agency and did not work there every day.
During interview and review of the clinical record, it was found that the Social Worker/Discharge Planner (SWDP) was only involved with Resident #521 on 3 occasions. Those instances follow below:
1. Nine days after admission on [DATE] for a Trauma Informed Care assessment which was negative for trauma experienced by the Resident.
2. After the first abuse on 9-20-24 to Resident #68, to notify Resident #521's son of the first room change.
3. Finally, at the first Interdisciplinary care plan meeting on 9-26-24 with only the SWDP and the Activity Assistant present.
A copy of all Facility Reported Incidents (FRI's) for the prior 6 months were requested. 10 were provided by the Administrator, and 9 of the 10 followed the standardized format and documentation was provided for notification of the state agency the Virginia Department of Health Office of Licensure and Certification (VDH/OLC), the state Long Term Care Ombudsman, and Adult Protective Services (APS). The 9 completed FRI's were all prior to 9-20-24.
The tenth alleged FRI involving Resident #68, and Resident #521 was incomplete and contained 7 documents. The documents included four statements from staff alleging abuse to Resident #68. One of the staff statements alleged repeated abuse allegations documented from 9-17-24 through 9-20-24 and for over a week. Also included was a fifth documented statement from the Resident alleging verbal and physical abuse. The sixth document was a written synopsis by the Administrator which was not signed, and only described the initial abuse allegation for Resident #68. It did not include Resident #20's abuse by Resident #521, the room changes, nor the incident with the unknown neighbor after being installed in the third room. The seventh document was a response from APS stating that the report to them did not meet validity criteria required to initiate an APS investigation.
The Administrator's synopsis stated that Resident #68 was asked what was triggering Resident #521's behavior, which implies that the victim is the causative factor, or that the victim is able to psychologically assess her room mate who only spoke Spanish, and Resident #68 only spoke English. The synopsis also stated that Resident #521 would be moved to a room with someone more compatible.
The Administrator's synopsis goes on to describe Resident #521 as having a BIMS score of 3 points out of a possible 15 points indicating severe dementia, which was incorrect. The Resident's BIMS score was 12. The state agency VDH/OLC did not receive the fax sent by the Administrator and review of the fax number revealed it to be in error. All of the documents were completed on 9-20-24, the initial day of assault reporting on Resident #68, and #521. There was no report, investigation, nor protections for Resident #20 after her multiple assaults on 9-21-24, nor for the unknown Resident on 9-22-24 after a third room was inhabited by Resident #521 in less than 48 hours.
The Administrator was interviewed on 10-8-24, and was asked why the document from 9-20-24 was not completed as the other FRI's were, his response was that he had only been here 4 weeks, and I am not required by law to use the FRI document, and I have all of the investigation, and here it is, this is the initial and 5 day follow up all in one.
The synopsis was simple typed document on a clean white unlined sheet of copy paper, and did not state that it was an initial FRI, nor a 5 day follow up, and it was not signed. Included in the packet were 3 copies of a fax cover sheet To: VDH/APS/Willie From: (first name & last name first letter only) the Administrator, documenting that the fax contained 2 pages. The fax was sent on 9-20-24, at 2:24 PM, 2:26 PM, 2:27 PM respectively.
The Administrator stated he wrote the synopsis, and sent the fax, and that in error he didn't sign it. This indicates the only 2 sheets allegedly sent were the fax cover sheet and the synopsis which was not signed, and did not state it was an initial FRI, nor a 5 day follow up.
At that time the Administrator was informed that the investigation was incomplete as no FRI was ever received at the state agency VDH/OLC for the first allegation of abuse. The other 2 Resident's who were later involved were not protected from abuse and added to the initial investigation, and a 5 day follow up as required by law would have captured them as well. The Administrator was made aware that no second FRI and investigation was ever conducted after further abuse from Resident #521 on Resident #20, and the unknown Resident. Residents were not protected from a known abuser. Further they had not implemented their policies on abuse.
The facility staff provided a copy of their Abuse policy, and the policy review revealed that all allegations of abuse will be investigated, Residents will be protected and prevented from further abuse, reports will be sent initially to the State agency VDH/OLC (and other agencies) within 24 hours or within 2 hours if serious injury occurs, and a follow up report will be sent in 5 days to include findings and corrections.
Resident #68 reported abuse for days before staff observed the abuse and moved Resident #521.
Resident #521 was then placed with Resident #20 who was not protected and was abused.
Resident #521 was moved again and went to a third unknown Resident's room to abuse.
The allegations were never reported to the state agency. Residents were not protected from a known abuser. Abuse was not investigated fully, and the facility policy was not implemented for the protections of Residents from abuse. Further, there was never any added staff supervision for Resident #521 to prevent the abuse from continuing.
No staff ever noted the suspicion of a crime, so no police report was ever filed. The first alleged report by the Administrator was never signed and had errors in information giving the appearance of a severely demented alleged abuser to APS in a single occurrence resulting in no investigation opened by them.
On 10-9-24 at approximately 5:30 p.m., the facility Administrator, Corporate Registered Nurse, and Corporate Administrator were notified of the findings. They stated they had no further information or documentation to offer.
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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff f...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff failed to prevent repeated willful abuse and neglect, failed to report the abuse to the state agency, failed to fully investigate the abuse, failed to protect the victims during the investigation, and further failed to implement their abuse and neglect policies for four known Residents (Residents #68, #20, #521, and #325) in a survey sample size of 55 residents.
The findings included:
The facility failures described above resulted in the willful abuse of Residents #68, #20, and a third unknown Resident victim as perpetrated by Resident #521.
Resident #68 (victim 1)was admitted to the facility on [DATE]. Diagnoses included but were not limited to: heart failure, hypertension, high cholesterol, malnutrition, peripheral venous insufficiency, hypothyroidism, rheumatoid arthritis, scoliosis, rhabdomyolysis, and foot pain.
Resident #68's most recent Minimum Data Set with an Assessment Reference Date of 8-2-24 was coded as a quarterly assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicates no cognitive impairment. The Resident was cognitively intact, and her own responsible party. The Resident required extensive assistance from one staff member for hygiene and bathing. The Resident had no aberrant behaviors documented, and had no complaints against any other staff or situations since her admission on [DATE].
Resident #20 (victim 2) was admitted to the facility on [DATE]. Diagnoses included but were not limited to chronic ischemic heart disease, stroke with hemiplegia right side, anemia, diabetes, chronic hepatic failure, neck fracture, chronic kidney disease, depression, and femur fracture.
Resident #20's most recent Minimum Data Set was a quarterly assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicates no cognitive impairment. The Resident was cognitively intact, and her own responsible party. The Resident was independent for transferring and used a motorized wheel chair to leave the building for shopping trips to walmart using a van. The Resident had no aberrant behaviors documented, and had no complaints against any other staff or situations since her admission on [DATE].
Resident #521 (perpetrator of 1 and 2) was admitted to the facility on [DATE]. Hospital discharge records indicated that the Resident was alert and oriented to person, place and time, and was ambulatory at the time of discharge. Diagnoses included but were not limited to: Heart failure, hypertension, Gastro Esophageal reflux disease, renal insufficiency, diabetes, thyroid disorder, dementia, malnutrition, and asthma.
Resident #521's most recent Minimum Data Set with an Assessment Reference Date of 9-5-24 after one day in the facility was coded as an admission assessment. The Brief Interview for Mental Status was coded as 12 out of a possible 15 points which indicated mild cognitive impairment, however, the language barrier may have contributed to a false lower score. The Resident was her own responsible party. The Resident spoke only Spanish. The Resident required extensive assistance from one staff member for hygiene and bathing.
On 10-1-24, the first day of survey, Resident #521 went out to a medical appointment and lost consciousness while there. She was sent directly to the hospital, and did not return during the remainder of the survey.
While on continued tour of the facility on 10-4-24, Resident #68 was interviewed and asked if any person in the facility had abused her or if she had ever witnessed abuse. She stated yes that her former room mate (Resident #521) had kicked her, thrown fruit at her, hit her, and had spit on her. She stated that Resident #521 had also cursed and yelled at her, gotten in her bed, held her wheel chair so she could not leave the room for help, and had stood over her while she was laying in bed menacing her. She stated that she had been bruised by the kick and punch, but luckily suffered no other injuries. She further stated that she had complained to staff repeatedly but they did nothing until 9-20-24 when Resident #521 punched her in the arm and the Assistant Director of Nursing saw it. She went on to say that they moved her that day. The Resident was asked if she was still afraid and she stated no, she's gone now.
On 10-7-24 the clinical records of Resident's #68, and #521 were reviewed. Those reviews contained the following information in chronological order;
On 9-20-24 at 3:42 PM the records indicated that Resident #521 had been moved to another room for Safety. No other descriptions about the allegations of abuse on Resident #68 were documented.
On 9-20-24 Resident #521's progress notes documented she was moved to the room containing Resident #20.
On 9-21-24 at 12:47 AM (7.5 hours later) after the move, progress note review indicated that Resident #521 was observed to throw a cup of water across the room and spit on her new room mates charger for her electric wheel chair.
On 9-21-24 at 8:41 PM, Later the same day, documents record Resident #521 hit Resident #20 and it was witnessed by staff. There was no mention of the scratches to Resident #20 inflicted by Resident #521.
On 9-22-24 at 1:34 AM (5 hours later) progress notes go on to describe that Resident #521 was moved to a private room.
(Victim #3 unknown name) On 9-22-24 at 2:54 AM, (1.5 hours after move) another note describes Resident #521 as standing next to her neighbors bed (unknown which neighboring room to the private room or which Resident this involved) staring at her (the neighbor of Resident #521) while sleeping and threatened anger aggressive behavior.
On 9-23-24 a psychiatric consultation was ordered. It was never obtained.
On 9-25-24 the Physician's Assistant (PA) described in a note that (Resident #521) Patient assault on room mate multiple times, resident denied, on alternate location at this time.
On 10-7-24 Resident #20 was interviewed and stated that Resident #521 was placed in her room and almost immediately began to yell at her, spit at her, and throw things at her. She went on to state that Resident #521 finally came over to her side of the room after dinner sometime and lashed out at her hitting her, causing several small scratches on her hand. She stated she was fending off the blows with her arm raised. and Resident #521's fingernails scratched her. She went on to state that the staff saw it and moved her out of the room until they could find a place for Resident #521. She stated that Resident #521 was moved Sometime late that night around midnight. Resident #20 was asked if she was afraid of Resident #521, and she stated no, she went to the hospital and I don't think she's ever coming back.
Nursing staff on the units where Resident #521 was housed were interviewed and stated they remembered Resident #521, and her aggressive behaviors, however, those working during survey interviews were not present during the abuses. They stated they were aware of the incidents, however, most of the staff were from a staffing agency and did not work there every day.
During interview and review of the clinical record, it was found that the Social Worker/Discharge Planner (SWDP) was only involved with Resident #521 on 3 occasions. Those instances follow below:
1. Nine days after admission on [DATE] for a Trauma Informed Care assessment which was negative for trauma experienced by the Resident.
2. After the first abuse on 9-20-24 to Resident #68, to notify Resident #521's son of the first room change.
3. Finally, at the first Interdisciplinary care plan meeting on 9-26-24 with only the SWDP and the Activity Assistant present.
A copy of all Facility Reported Incidents (FRI's) for the prior 6 months were requested. 10 were provided by the Administrator, and 9 of the 10 followed the standardized format and documentation was provided for notification of the state agency the Virginia Department of Health Office of Licensure and Certification (VDH/OLC), the state Long Term Care Ombudsman, and Adult Protective Services (APS). The 9 completed FRI's were all prior to 9-20-24.
The tenth alleged FRI involving Resident #68, and Resident #521 was incomplete and contained 7 documents. The documents included four statements from staff alleging abuse to Resident #68. One of the staff statements alleged repeated abuse allegations documented from 9-17-24 through 9-20-24 and for over a week. Also included was a fifth documented statement from the Resident alleging verbal and physical abuse. The sixth document was a written synopsis by the Administrator which was not signed, and only described the initial abuse allegation for Resident #68. It did not include Resident #20's abuse by Resident #521, the room changes, nor the incident with the unknown neighbor after being installed in the third room. The seventh document was a response from APS stating that the report to them did not meet validity criteria required to initiate an APS investigation.
The Administrator's synopsis stated that Resident #68 was asked what was triggering Resident #521's behavior, which implies that the victim is the causative factor, or that the victim is able to psychologically assess her room mate who only spoke Spanish, and Resident #68 only spoke English. The synopsis also stated that Resident #521 would be moved to a room with someone more compatible.
The Administrator's synopsis goes on to describe Resident #521 as having a BIMS score of 3 points out of a possible 15 points indicating severe dementia, which was incorrect. The Resident's BIMS score was 12. The state agency VDH/OLC did not receive the fax sent by the Administrator and review of the fax number revealed it to be in error. All of the documents were completed on 9-20-24, the initial day of assault reporting on Resident #68, and #521. There was no report, investigation, nor protections for Resident #20 after her multiple assaults on 9-21-24, nor for the unknown Resident on 9-22-24 after a third room was inhabited by Resident #521 in less than 48 hours.
The Administrator was interviewed on 10-8-24, and was asked why the document from 9-20-24 was not completed as the other FRI's were, his response was that he had only been here 4 weeks, and I am not required by law to use the FRI document, and I have all of the investigation, and here it is, this is the initial and 5 day follow up all in one.
The synopsis was simple typed document on a clean white unlined sheet of copy paper, and did not state that it was an initial FRI, nor a 5 day follow up, and it was not signed. Included in the packet were 3 copies of a fax cover sheet To: VDH/APS/Willie From: (first name & last name first letter only) the Administrator, documenting that the fax contained 2 pages. The fax was sent on 9-20-24, at 2:24 PM, 2:26 PM, 2:27 PM respectively.
The Administrator stated he wrote the synopsis, and sent the fax, and that in error he didn't sign it. This indicates the only 2 sheets allegedly sent were the fax cover sheet and the synopsis which was not signed, and did not state it was an initial FRI, nor a 5 day follow up.
At that time the Administrator was informed that the investigation was incomplete as no FRI was ever received at the state agency VDH/OLC for the first allegation of abuse. The other 2 Resident's who were later involved were not protected from abuse and added to the initial investigation, and a 5 day follow up as required by law would have captured them as well. The Administrator was made aware that no second FRI and investigation was ever conducted after further abuse from Resident #521 on Resident #20, and the unknown Resident. Residents were not protected from a known abuser. Further they had not implemented their policies on abuse.
The facility staff provided a copy of their Abuse policy, and the policy review revealed that all allegations of abuse will be investigated, Residents will be protected and prevented from further abuse, reports will be sent initially to the State agency VDH/OLC (and other agencies) within 24 hours or within 2 hours if serious injury occurs, and a follow up report will be sent in 5 days to include findings and corrections.
Resident #68 reported abuse for days before staff observed the abuse and moved Resident #521.
Resident #521 was then placed with Resident #20 who was not protected and was abused.
Resident #521 was moved again and went to a third unknown Resident's room to abuse.
The allegations were never reported to the state agency. Residents were not protected from a known abuser. Abuse was not investigated fully, and the facility policy was not implemented for the protections of Residents from abuse. Further, there was never any added staff supervision for Resident #521 to prevent the abuse from continuing.
No staff ever noted the suspicion of a crime, so no police report was ever filed. The first alleged report by the Administrator was never signed and had errors in information giving the appearance of a severely demented alleged abuser to APS in a single occurrence resulting in no investigation opened by them.
On 10-9-24 at approximately 5:30 p.m., the facility Administrator, Corporate Registered Nurse, and Corporate Administrator were notified of the findings. They stated they had no further information or documentation to offer.
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
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff f...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, Resident interviews, clinical record reviews, and facility documentation review, the facility staff failed to prevent repeated willful abuse and neglect, failed to fully investigate the abuse, failed to report the abuse to the state agency, failed to protect the victims during the investigation, and further failed to implement their abuse and neglect policies for four known Residents (Residents #68, #20, #521, and #325) in a survey sample size of 55 residents.
The findings included:
The facility failures described above resulted in the willful abuse of Residents #68, #20, and a third unknown Resident victim as perpetrated by Resident #521.
Resident #68 (victim 1)was admitted to the facility on [DATE]. Diagnoses included but were not limited to: heart failure, hypertension, high cholesterol, malnutrition, peripheral venous insufficiency, hypothyroidism, rheumatoid arthritis, scoliosis, rhabdomyolysis, and foot pain.
Resident #68's most recent Minimum Data Set with an Assessment Reference Date of 8-2-24 was coded as a quarterly assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicates no cognitive impairment. The Resident was cognitively intact, and her own responsible party. The Resident required extensive assistance from one staff member for hygiene and bathing. The Resident had no aberrant behaviors documented, and had no complaints against any other staff or situations since her admission on [DATE].
Resident #20 (victim 2) was admitted to the facility on [DATE]. Diagnoses included but were not limited to chronic ischemic heart disease, stroke with hemiplegia right side, anemia, diabetes, chronic hepatic failure, neck fracture, chronic kidney disease, depression, and femur fracture.
Resident #20's most recent Minimum Data Set was a quarterly assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicates no cognitive impairment. The Resident was cognitively intact, and her own responsible party. The Resident was independent for transferring and used a motorized wheel chair to leave the building for shopping trips to walmart using a van. The Resident had no aberrant behaviors documented, and had no complaints against any other staff or situations since her admission on [DATE].
Resident #521 (perpetrator of 1 and 2) was admitted to the facility on [DATE]. Hospital discharge records indicated that the Resident was alert and oriented to person, place and time, and was ambulatory at the time of discharge. Diagnoses included but were not limited to: Heart failure, hypertension, Gastro Esophageal reflux disease, renal insufficiency, diabetes, thyroid disorder, dementia, malnutrition, and asthma.
Resident #521's most recent Minimum Data Set with an Assessment Reference Date of 9-5-24 after one day in the facility was coded as an admission assessment. The Brief Interview for Mental Status was coded as 12 out of a possible 15 points which indicated mild cognitive impairment, however, the language barrier may have contributed to a false lower score. The Resident was her own responsible party. The Resident spoke only Spanish. The Resident required extensive assistance from one staff member for hygiene and bathing.
On 10-1-24, the first day of survey, Resident #521 went out to a medical appointment and lost consciousness while there. She was sent directly to the hospital, and did not return during the remainder of the survey.
While on continued tour of the facility on 10-4-24, Resident #68 was interviewed and asked if any person in the facility had abused her or if she had ever witnessed abuse. She stated yes that her former room mate (Resident #521) had kicked her, thrown fruit at her, hit her, and had spit on her. She stated that Resident #521 had also cursed and yelled at her, gotten in her bed, held her wheel chair so she could not leave the room for help, and had stood over her while she was laying in bed menacing her. She stated that she had been bruised by the kick and punch, but luckily suffered no other injuries. She further stated that she had complained to staff repeatedly but they did nothing until 9-20-24 when Resident #521 punched her in the arm and the Assistant Director of Nursing saw it. She went on to say that they moved her that day. The Resident was asked if she was still afraid and she stated no, she's gone now.
On 10-7-24 the clinical records of Resident's #68, and #521 were reviewed. Those reviews contained the following information in chronological order;
On 9-20-24 at 3:42 PM the records indicated that Resident #521 had been moved to another room for Safety. No other descriptions about the allegations of abuse on Resident #68 were documented.
On 9-20-24 Resident #521's progress notes documented she was moved to the room containing Resident #20.
On 9-21-24 at 12:47 AM (7.5 hours later) after the move, progress note review indicated that Resident #521 was observed to throw a cup of water across the room and spit on her new room mates charger for her electric wheel chair.
On 9-21-24 at 8:41 PM, Later the same day, documents record Resident #521 hit Resident #20 and it was witnessed by staff. There was no mention of the scratches to Resident #20 inflicted by Resident #521.
On 9-22-24 at 1:34 AM (5 hours later) progress notes go on to describe that Resident #521 was moved to a private room.
(Victim #3 unknown name) On 9-22-24 at 2:54 AM, (1.5 hours after move) another note describes Resident #521 as standing next to her neighbors bed (unknown which neighboring room to the private room or which Resident this involved) staring at her (the neighbor of Resident #521) while sleeping and threatened anger aggressive behavior.
On 9-23-24 a psychiatric consultation was ordered. It was never obtained.
On 9-25-24 the Physician's Assistant (PA) described in a note that (Resident #521) Patient assault on room mate multiple times, resident denied, on alternate location at this time.
On 10-7-24 Resident #20 was interviewed and stated that Resident #521 was placed in her room and almost immediately began to yell at her, spit at her, and throw things at her. She went on to state that Resident #521 finally came over to her side of the room after dinner sometime and lashed out at her hitting her, causing several small scratches on her hand. She stated she was fending off the blows with her arm raised. and Resident #521's fingernails scratched her. She went on to state that the staff saw it and moved her out of the room until they could find a place for Resident #521. She stated that Resident #521 was moved Sometime late that night around midnight. Resident #20 was asked if she was afraid of Resident #521, and she stated no, she went to the hospital and I don't think she's ever coming back.
Nursing staff on the units where Resident #521 was housed were interviewed and stated they remembered Resident #521, and her aggressive behaviors, however, those working during survey interviews were not present during the abuses. They stated they were aware of the incidents, however, most of the staff were from a staffing agency and did not work there every day.
During interview and review of the clinical record, it was found that the Social Worker/Discharge Planner (SWDP) was only involved with Resident #521 on 3 occasions. Those instances follow below:
1. Nine days after admission on [DATE] for a Trauma Informed Care assessment which was negative for trauma experienced by the Resident.
2. After the first abuse on 9-20-24 to Resident #68, to notify Resident #521's son of the first room change.
3. Finally, at the first Interdisciplinary care plan meeting on 9-26-24 with only the SWDP and the Activity Assistant present.
A copy of all Facility Reported Incidents (FRI's) for the prior 6 months were requested. 10 were provided by the Administrator, and 9 of the 10 followed the standardized format and documentation was provided for notification of the state agency the Virginia Department of Health Office of Licensure and Certification (VDH/OLC), the state Long Term Care Ombudsman, and Adult Protective Services (APS). The 9 completed FRI's were all prior to 9-20-24.
The tenth alleged FRI involving Resident #68, and Resident #521 was incomplete and contained 7 documents. The documents included four statements from staff alleging abuse to Resident #68. One of the staff statements alleged repeated abuse allegations documented from 9-17-24 through 9-20-24 and for over a week. Also included was a fifth documented statement from the Resident alleging verbal and physical abuse. The sixth document was a written synopsis by the Administrator which was not signed, and only described the initial abuse allegation for Resident #68. It did not include Resident #20's abuse by Resident #521, the room changes, nor the incident with the unknown neighbor after being installed in the third room. The seventh document was a response from APS stating that the report to them did not meet validity criteria required to initiate an APS investigation.
The Administrator's synopsis stated that Resident #68 was asked what was triggering Resident #521's behavior, which implies that the victim is the causative factor, or that the victim is able to psychologically assess her room mate who only spoke Spanish, and Resident #68 only spoke English. The synopsis also stated that Resident #521 would be moved to a room with someone more compatible.
The Administrator's synopsis goes on to describe Resident #521 as having a BIMS score of 3 points out of a possible 15 points indicating severe dementia, which was incorrect. The Resident's BIMS score was 12. The state agency VDH/OLC did not receive the fax sent by the Administrator and review of the fax number revealed it to be in error. All of the documents were completed on 9-20-24, the initial day of assault reporting on Resident #68, and #521. There was no report, investigation, nor protections for Resident #20 after her multiple assaults on 9-21-24, nor for the unknown Resident on 9-22-24 after a third room was inhabited by Resident #521 in less than 48 hours.
The Administrator was interviewed on 10-8-24, and was asked why the document from 9-20-24 was not completed as the other FRI's were, his response was that he had only been here 4 weeks, and I am not required by law to use the FRI document, and I have all of the investigation, and here it is, this is the initial and 5 day follow up all in one.
The synopsis was simple typed document on a clean white unlined sheet of copy paper, and did not state that it was an initial FRI, nor a 5 day follow up, and it was not signed. Included in the packet were 3 copies of a fax cover sheet To: VDH/APS/Willie From: (first name & last name first letter only) the Administrator, documenting that the fax contained 2 pages. The fax was sent on 9-20-24, at 2:24 PM, 2:26 PM, 2:27 PM respectively.
The Administrator stated he wrote the synopsis, and sent the fax, and that in error he didn't sign it. This indicates the only 2 sheets allegedly sent were the fax cover sheet and the synopsis which was not signed, and did not state it was an initial FRI, nor a 5 day follow up.
At that time the Administrator was informed that the investigation was incomplete as no FRI was ever received at the state agency VDH/OLC for the first allegation of abuse. The other 2 Resident's who were later involved were not protected from abuse and added to the initial investigation, and a 5 day follow up as required by law would have captured them as well. The Administrator was made aware that no second FRI and investigation was ever conducted after further abuse from Resident #521 on Resident #20, and the unknown Resident. Residents were not protected from a known abuser. Further they had not implemented their policies on abuse.
The facility staff provided a copy of their Abuse policy, and the policy review revealed that all allegations of abuse will be investigated, Residents will be protected and prevented from further abuse, reports will be sent initially to the State agency VDH/OLC (and other agencies) within 24 hours or within 2 hours if serious injury occurs, and a follow up report will be sent in 5 days to include findings and corrections.
Resident #68 reported abuse for days before staff observed the abuse and moved Resident #521.
Resident #521 was then placed with Resident #20 who was not protected and was abused.
Resident #521 was moved again and went to a third unknown Resident's room to abuse.
The allegations were never reported to the state agency. Residents were not protected from a known abuser. Abuse was not investigated fully, and the facility policy was not implemented for the protections of Residents from abuse. Further, there was never any added staff supervision for Resident #521 to prevent the abuse from continuing.
No staff ever noted the suspicion of a crime, so no police report was ever filed. The first alleged report by the Administrator was never signed and had errors in information giving the appearance of a severely demented alleged abuser to APS in a single occurrence resulting in no investigation opened by them.
On 10-9-24 at approximately 5:30 p.m., the facility Administrator, Corporate Registered Nurse, and Corporate Administrator were notified of the findings. They stated they had no further information or documentation to offer.
CONCERN
(E)
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** Based on Resident staff interview, facility documentation review, and clinical record review, the facility staff failed to provi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Resident staff interview, facility documentation review, and clinical record review, the facility staff failed to provide a comprehensive care plan for care and services to maintain the highest practicable well being for two residents, (Resident #73, and #521) in a survey sample of 55 residents.
The findings included:
1. Resident #73 had contractures with splints and palm guards required to prevent further contracture and maintain skin integrity. No care plan was ever devised for the palm guards and the splinting care plan was not individualized nor Resident centered.
Resident #73, with contracted fingers of the left hand, experienced a pressure sore injury from his fingernails pressing into his palm. The pressure sore became infected resulting in cellulitis, which led to the identification of the pressure sore injury in the facility. The pressure sore and resulting infection caused the Resident to be sent out to the hospital for treatment with IV (intravenous) antibiotics for 10 days.
The facility staff were unaware of the wound prior to the infection, and had not been applying the Residents hand splint (palm guard) to prevent the wound.
Resident #73 was originally admitted to the facility on [DATE], was hospitalized on [DATE] for a pressure sore injury with infection and cellulitis, and returned 10 days later on 6-1-24. Diagnoses included; acute infection/cellulitis of upper left limb, stroke with left hemiplegia, dementia, contractures of left side limbs, dysphagia, epilepsy, hypertension, hypernatremia, and vitamin D deficiency.
Resident #73's most recent Minimum Data Set assessment was a Significant change assessment with an assessment reference date of 7-29-24. Resident #73 had a Brief Interview of Mental Status score of 99 indicating severe cognitive impairment. He required extensive to total assistance with eating, bathing and personal hygiene. He was coded to have impaired Range of Motion on both upper extremities, and one lower extremity. He was coded with no behaviors, no swallowing difficulty, and had a mechanically altered regular pureed diet.
On 10-4-24 at approximately 12:00 PM, during continued tour of the facility, Resident #73 was observed eating lunch and being fed by a Certified Nursing Assistant (CNA). The Resident's hands were both contracted. He was not observed to be wearing a palm guard nor any other type of equipment in the upper extremities.
Physician and Nursing progress notes were reviewed for information on the Resident's contractures, left palm pressure wound, and splint usage. That review revealed that From 5-1-24 through 5-19-24 the Resident had no skin wounds.
On 5-20-24 at 2:20 PM, the Physicians Assistant (PA) documented Patient seen today for nursing reports of wound to the left palm. Left hand is contracted. Drainage, erythema and swelling noted. Patient says ouch when I touch his hand. Comments; one centimeter wound to the left palm with surrounding erythema and swelling that extends into his middle finger. Hand is warm to touch. Hand is contracted so range of motion is limited. Pain states ouch when I move his hand. Assessment and plan; Cellulitis secondary to wound of the left hand. Wound appears to have been caused by (finger) nail of contracted hand being dug into his palm. Palm guard present at bedside but it is unclear how often it is actually being placed on the patient's hand. Swelling and erythema extends into middle finger and dorsal aspect of the hand. Wound cleaned with DWC (Dakin's wound Cleanser) and bandaged. Palm guard placed. Plan: Wound care - Left hand palm cleanse with wound cleanser, pat dry with gauze, then apply antibiotic ointment to wound bed, cover with dry dressing daily and as needed. Apply palm guard, only remove when eating. Start Keflex 500 mg 4 times per day for 7 days. Monitor closely, if wound worsens consider labs and additional antibiotics emergency room visit if warranted.
The Resident's care plan was reviewed and interventions revealed a focus for refusing to wear splint to (bilateral upper extremities/bilateral lower extremities - Bean Bag.) Cellulitis resolved 7-6-24. There was never a care plan devised for the application of palm guards.
Progress notes review revealed no refusals for splint (palm guards) nor bean bag placement, and no other aberrant behaviors nor refusals were documented for this Resident.
The Resident's [NAME] which is used by CNA's as a care plan to guide specific care for each resident need, was reviewed and revealed bean bag splints as tolerated with no other instruction on use, nor location of use, and no mention of the palm guards.
Staff were unaware of the palm guard need. Palm guards were not used consistently, which resulted in a pressure sore injury to the Resident's left palm.
2. Resident #521 abused 3 Residents in the facility and exhibited aggressive behaviors and signs of distress which were never assessed and care planned.
For Resident #521 the facility staff failed to obtain a physician ordered psychiatric consult timely, failed to conduct behavior monitoring, failed to provide a comprehensive care plan for emotion regulation, failed to identify stressors and responses such as language barrier and supervision, to those stressors, which resulted in aggressive behaviors aimed at and impacting other residents.
The facility failures described above resulted in the willful abuse of Residents #68, #20, and a third unknown Resident victim as perpetrated by Resident #521.
Resident #521 was not receiving any psychotropic medications, to include antidepressants.
Resident #68 (victim 1)was admitted to the facility on [DATE]. Diagnoses included but were not limited to: heart failure, hypertension, high cholesterol, malnutrition, peripheral venous insufficiency, hypothyroidism, rheumatoid arthritis, scoliosis, rhabdomyolysis, and foot pain.
Resident #68's most recent Minimum Data Set with an Assessment Reference Date of 8-2-24 was coded as a quarterly assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicates no cognitive impairment. The Resident was cognitively intact, and her own responsible party. The Resident required extensive assistance from one staff member for hygiene and bathing. The Resident had no aberrant behaviors documented, and had no complaints against any other staff or situations since her admission on [DATE].
Resident #20 (victim 2) was admitted to the facility on [DATE]. Diagnoses included but were not limited to chronic ischemic heart disease, stroke with hemiplegia right side, anemia, diabetes, chronic hepatic failure, neck fracture, chronic kidney disease, depression, and femur fracture.
Resident #20's most recent Minimum Data Set was a quarterly assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicates no cognitive impairment. The Resident was cognitively intact, and her own responsible party. The Resident was independent for transferring and used a motorized wheel chair to leave the building for shopping trips to walmart using a van. The Resident had no aberrant behaviors documented, and had no complaints against any other staff or situations since her admission on [DATE].
Resident #521 (perpetrator of 1 and 2) was admitted to the facility on [DATE], went back out to the hospital for syncope on 9-5-24, and returned on 9-8-24. Hospital discharge records indicated that the Resident was alert and oriented to person, place and time, and was ambulatory at the time of discharge. Diagnoses included but were not limited to: Heart failure, hypertension, Gastro Esophageal reflux disease, renal insufficiency, diabetes, thyroid disorder, dementia, malnutrition, and asthma.
Resident #521's most recent Minimum Data Set with an Assessment Reference Date of 9-5-24 after one day in the facility was coded as an admission assessment. The Brief Interview for Mental Status was coded as 12 out of a possible 15 points which indicated mild cognitive impairment, however, the language barrier may have contributed to a false lower score. The Resident was her own responsible party. The Resident spoke only Spanish. The Resident required extensive assistance from one staff member for hygiene and bathing.
On 10-1-24, the first day of survey, Resident #521 went out to a medical appointment and lost consciousness while there. She was sent directly to the hospital, and did not return during the remainder of the survey.
While on continued tour of the facility on 10-4-24, Resident #68 was interviewed and asked if any person in the facility had abused her or if she had ever witnessed abuse. She stated yes that her former room mate (Resident #521) had kicked her, thrown fruit at her, hit her, and had spit on her. She stated that Resident #521 had also cursed and yelled at her, gotten in her bed, held her wheel chair so she could not leave the room for help, and had stood over her while she was laying in bed menacing her. She stated that she had been bruised by the kick and punch, but luckily suffered no other injuries. She further stated that she had complained to staff repeatedly but they did nothing until 9-20-24 when Resident #521 punched her in the arm and the Assistant Director of Nursing saw it. She went on to say that they moved her that day. The Resident was asked if she was still afraid and she stated no, she's gone now.
On 10-7-24 the clinical records of Resident's #68, and #521 were reviewed. Those reviews contained the following information in chronological order;
On 9-20-24 at 3:42 PM the records indicated that Resident #521 had been moved to another room for Safety. No other descriptions about the allegations of abuse on Resident #68 were documented.
On 9-20-24 Resident #521's progress notes documented she was moved to the room containing Resident #20.
On 9-21-24 at 12:47 AM (7.5 hours later) after the move, progress note review indicated that Resident #521 was observed to throw a cup of water across the room and spit on her new room mates charger for her electric wheel chair.
On 9-21-24 at 8:41 PM, Later the same day, documents record Resident #521 hit Resident #20 and it was witnessed by staff. There was no mention of the scratches to Resident #20 inflicted by Resident #521.
On 9-22-24 at 1:34 AM (5 hours later) progress notes go on to describe that Resident #521 was moved to a private room.
(Victim #3 unknown name) On 9-22-24 at 2:54 AM, (1.5 hours after move) another note describes Resident #521 as standing next to her neighbors bed (unknown which neighboring room to the private room or which Resident this involved) staring at her (the neighbor of Resident #521) while sleeping and threatened anger aggressive behavior.
On 9-23-24 a psychiatric consultation was ordered. It was never obtained.
On 9-25-24 the Physician's Assistant (PA) described in a note that (Resident #521) Patient assault on room mate multiple times, resident denied, on alternate location at this time.
On 10-7-24 Resident #20 was interviewed and stated that Resident #521 was placed in her room and almost immediately began to yell at her, spit at her, and throw things at her. She went on to state that Resident #521 finally came over to her side of the room after dinner sometime and lashed out at her hitting her, causing several small scratches on her hand. She stated she was fending off the blows with her arm raised. and Resident #521's fingernails scratched her. She went on to state that the staff saw it and moved her out of the room until they could find a place for Resident #521. She stated that Resident #521 was moved Sometime late that night around midnight. Resident #20 was asked if she was afraid of Resident #521, and she stated no, she went to the hospital and I don't think she's ever coming back.
Nursing staff on the units where Resident #521 was housed were interviewed and stated they remembered Resident #521, and her aggressive behaviors, however, those working during survey interviews were not present during the abuses. They stated they were aware of the incidents, however, most of the staff were from a staffing agency and did not work there every day.
During interview and review of the clinical record, it was found that the Social Worker/Discharge Planner (SWDP) was only involved with Resident #521 on 3 occasions. Those instances follow below:
1. Nine days after admission on [DATE] for a Trauma Informed Care assessment which was negative for trauma experienced by the Resident.
2. After the first abuse on 9-20-24 to Resident #68, to notify Resident #521's son of the first room change.
3. Finally, at the first Interdisciplinary care plan meeting on 9-26-24 with only the SWDP and the Activity Assistant present.
The facility staff provided a copy of their Abuse policy, and the policy review revealed that all allegations of abuse will be investigated, Residents will be protected and prevented from further abuse, reports will be sent initially to the State agency VDH/OLC (and other agencies) within 24 hours or within 2 hours if serious injury occurs, and a follow up report will be sent in 5 days to include findings and corrections.
Resident #68 reported abuse for days before staff observed the abuse and moved Resident #521.
Resident #521 was then placed with Resident #20 who was not protected and was abused.
Resident #521 was moved again and went to a third unknown Resident's room to abuse.
The allegations of abuse were never reported to the state agency. Residents were not protected from a known abuser. Abuse was not investigated fully, and the facility policy was not implemented for the protections of Residents from abuse. Further, there was never any added staff supervision for Resident #521 to prevent the abuse from continuing.
No staff ever noted the suspicion of a crime, so no police report was ever filed. The first alleged report by the Administrator was never signed and had errors in information giving the appearance of a severely demented alleged abuser to APS in a single occurrence resulting in no investigation opened by them.
Resident #521's nursing and physician progress notes were reviewed and revealed the following:
9-8-24 nurses documented Resident with language barrier (speaks only Spanish) states frustration with interpreter.
9-11-24 the physician documented Plan: - The patient has had a diagnosis of depression or has had a diagnosis of Bipolar Disorder.
9-12-24 nurses documented refused, wants to be left alone to therapy, refused weight yelling in Spanish
9-19-24 nurses documented Google translater only means of translation in the facility.
9-20-24 nurses documented room change for safety.
9-21-24 12:47 AM nurses documented woke from nap anxious, stating dead bodies everywhere, resident extremely restless and gestures for sleep but will not stay in bed more than 15-20 minutes at a time.
9-21-24 10:41 PM nurses documented Aggression and hitting roommate, removed from room.
9-22-24 1:34 AM nursing notes documented another room change to a private room.
9-22-24 2:54 AM nursing notes Aggressive behavior standing over sleeping neighbor threatening neighbor room.
9-23-24 2:45 PM nursing note Psyche consult placed in psyche referral book.
9-23-24 11:12 PM nursing note difficulty communicating with Resident.
9-25-24 physician documented resident's roommate spoke up about Resident #521 laying hands on her multiple times. Staff made aware, management involved, room changed. That reveals that the physician was only aware of one abuse victim, and not the other two.
Resident #521's frustration was identified on day 1, and no plan was implemented to improve communication between staff and residents for this Resident.
The psychiatric evaluation was put in a book at the nursing station awaiting the next visit from psyche professionals to see other residents before they knew Resident #521 needed services. This was revealed during interview at the nursing station when the consult book was requested, on 10-7-24 they stated that's our procedure.
From 9-4-24 through 10-1-24 (28 days), no psychosocial nor behavioral services were ever afforded a disturbed Resident #521 even after 3 abuses of other Residents and aggression toward staff.
Resident #521's care plan was reviewed and revealed no focus nor interventions for dementia, language barrier, nor behaviors was ever derived nor implemented before or after the abuses occurred.
Resident #521's physician's orders and progress notes were reviewed and revealed On 9-8-24 Geriatric psyche consult (as needed) PRN. No other assessments nor orders for behavioral health support were ever obtained.
On 10-9-24 at approximately 5:30 p.m., the facility Administrator, Corporate Registered Nurse, and Corporate Administrator were notified of the findings. They stated they had no further information or documentation to offer.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident # 161. the facility staff failed to ensure antibiotics were administered as ordered by the physician.
Resident #...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. For Resident # 161. the facility staff failed to ensure antibiotics were administered as ordered by the physician.
Resident # 161 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, Primary Osteoarthritis of the Knee, Septic Arthritis of the Knee, Heart Failure, and Edema.
The most recent Minimum Data Set (MDS) was an admission Assessment with an Assessment Reference Date (ARD) of 9/10/2024. Resident # 161's BIMS (Brief Interview for Mental Status) Score was a 14 out of 15, indicating no cognitive impairment.
Review of the clinical record was conducted on 10/9/2024-10/11/2024.
Review revealed that on admission, Resident # 161 had a PICC (Peripherally inserted Central Catheter) and an order for Cephalexin Intravenously for 17 days and was being followed by an Infectious Disease Physician. Resident # 161 was seen by the Infectious Disease Physician on 9/18/2024 and the antibiotic was changed to an oral antibiotic to be given for 14 days.
Review of the Physicians Orders revealed an order for:
Amoxicillin Oral Capsule 500 mg (milligrams) Give 2 capsules by mouth three times a day related to Arthritis due to other bacteria, left knee, for 14 Days. Give with food. Order Date-09/18/2024 0833
Review of the September 2024 Medication Administration Record revealed he medication was scheduled for administration at 9:00 a.m., 2:00 p.m., and 9:00 p.m. and to stop on 10/1/2024 at 9:00 p.m.
Further review revealed there were six doses not administered during the course of treatment.
Amoxicillin was not administered on:
9/21/2024 at 9:00 p.m.
9/28/2024 at 9:00 p.m. -medication on order
9/29/2024 at 9:00 a.m. -on order ok to hold per provider
9/29/2024 at 2:00 p.m. -on order ok to hold per provider
9/29/2024 at 9:00 p.m. -on order
10/1/2024 at 9:00 a.m.-NONE AVAILABLE, PA (Physician Assistant) MADE AWARE. RX-(Pharmacy) CONTACTED
On 10/11/2024 during clinical record review, it was noted that Resident # 161's order for Amoxicillin was supposed to be administered for 14 days. The Medication Administration Record revealed there had been 6 doses missed during the prescribed course of treatment. Four consecutive doses were missed from 9/28/2024 at 9:00 p.m. to 9/29/2024 at 9:00 p.m. The six missed doses equated to a total of two full days of missed doses. There was no indication that the antibiotic was extended to additional days to cover the missed doses. There was no documentation that the Infectious Disease Physician was notified of the missed doses.
On 10/11/2024 at 1:10 p.m., an interview was conducted with the Regional Nurse Consultant (Corporate-2). She was asked if antibiotics should be continued as ordered. She stated it was very important. When asked why it was important to continue the antibiotics as prescribed, Corporate-2 stated that it was important because the antibiotics were prescribed to kill the bacteria. She also stated that taking all of the antibiotic as prescribed would prevent the bacteria from growing and becoming antibiotic resistant. Corporate -2 stated she had reviewed Resident # 161's record and noted the resident was seen by the Infectious Disease Physician who discontinued the IV antibiotics and changed to oral Amoxicillin 500 milligrams two capsules by mouth three times per day for 14 days. Corporate-2 stated the nurses should have administered the Antibiotic to Resident # 161 as ordered.
On 10/11/2024 at approximately 3:20 p.m.,, another interview was conducted with the Regional Nurse Consultant (Corporate-2) who stated the Pharmacy was responsible for delivery of medications. Corporate-2 stated the nurses had access to medications that were delivered to the facility. If a medication was not available at the time of scheduled administration, the nurses should go to the Omnicell (on-site Stat box) to see if the medication was available in that stock. Corporate-2 stated if the medication was not in the Omnicell, the nurse was expected to inform the physician to see if there was another medication order or if the doctor would give the approval for the medication to be started later when available from the Pharmacy. Corporate-2 stated Resident # 161 should not have had any missed doses since the blister pack should have been received on the first day the medication was ordered. Corporate-2 also stated it was important for the antibiotics to be given timely and four consecutive doses should not have been missed.
Review of the Omnicell STAT box contents revealed the medication, Amoxicillin 250 milligrams, was on hand. There was a quantity of 10 tablets in the box. The nurses could have retrieved the medication from the Omnicell STAT box.
According to the Mayo Clinic, antibiotics are important drugs that can successfully treat infections caused by bacteria. Antibiotics can prevent the spread of disease. The way drugs are used affects how quickly and to what degree resistance occurs.
It also stated:
You need to to take the full treatment to kill the disease-causing bacteria. If you do not take an antibiotic as prescribed, you may need to start treatment again later. If you stop taking it, it can also promote the spread of antibiotic-resistant properties among harmful bacteria.
The article also stated that Drug resistant infections can cause many problems including: More-serious illness, longer recovery, more-frequent or longer hospital stays, more health care provider visits and more- expensive treatments.
Complete the entire treatment.
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 10/15/2024.
During the end of day debriefing on 10/11/2024, the Facility's Acting Administrator, Administrator in Training, Regional Nurse Consultant (Corporate-2) and Director of Nursing were informed of the findings. The nurses failed to ensure the antibiotics were administered as prescribed by the Physician.
No further information was provided.
Based on observations, Resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to follow the professional standards of nursing practice for 2 residents, (Residents #89, and #161) in a survey sample of 55 residents.
The Findings Included:
1. For resident #89 the facility staff failed to apply a Cardiac Monitor, to the Resident for the required time frame to capture and diagnose the cause of repeated syncopal episodes from suspected heart arrythmias (irregular heart beats).
Resident #89 was admitted to the facility on [DATE], and readmitted on [DATE], after a 6 day hospitalization. Diagnoses included; Chronic Kidney disease, sick sinus syndrome after syncope and collapse on 7-12-24, dementia, hypertension, malnutrition, stroke, and anemia.
Resident #89's most recent Minimum Data set assessment was a quarterly assessment with an assessment reference date (ARD) of 8-1-24. Resident #89 was coded with a Brief Interview of Mental Status score of 3 indicating severe cognitive impairment. Resident #89 required extensive to total assistance from one to two staff members, with all activities of daily living.
Resident #89's clinical record was reviewed on 10-7-24. The Resident's Medication Administration and Treatment Administration Records (MAR's/TAR's) and Physician's Orders revealed an order for Change cardiac monitor patch every 7 days starting 7-25-24. Discontinue patch and mail back (monitor) on 8-18-24 at 11:59 PM.
Clinical hospital records indicate that the Cardiac monitoring was initiated in the hospital just prior to discharge on [DATE]. The first change for the patch would have been completed 7 days later on 7-25-24, and then every 7 days after that on: 8-1-24, 8-8-24, 8-15-24, and finally removed on 8-18-24 after monitoring for 30 days (4 weeks). The monitor would have then been mailed back to the physician who ordered it, or the company which supplied it who would provide a report to the cardiology doctor.
The TAR review revealed that the monitor/patches were not signed off as completed as ordered, and the monitor was discontinued 14 days early on 8-4-24, after only 2 weeks. Review of nursing and physician progress notes do not indicate a reason for the early discontinuance.
On 8-19-24 (2 weeks after early discontinuance) the Physician's Assistant (PA) documented the following in the Physician progress notes;
In the past 60 days the treatment plan has been closely monitored and adjusted when necessary to provide the patient with the best optimal health possible to prevent injury, prevent hospitalization, and improve quality of life. Cardiac monitor end date 8-18-24. Need to follow up with nursing to ensure this was mailed back.
The above note written by the PA revealed that the physicians treating in the facility were unaware that the monitor had been discontinued halfway through the ordered monitoring.
The Resident's care plan was reviewed and documented an intervention for the cardiac monitoring to end on 8-18-24 and send the patch monitor by mail as ordered.
On 10-8-24 at 11:00 a.m., 11:30 a.m., and 1:30 p.m., observations of Resident #89 were conducted. The Resident was alert, pleasant, talkative, and oriented to person, place, and time of day. The Resident stated she had enjoyed her lunch and her food tray was noted to be empty with only smears of what she had eaten 100% of for the meal. She stated I'm still hungry it wasn't much, can you get me a sandwich or something. The Resident was asked if she remembered going to the hospital and wearing the patch on her chest which was a heart monitor. She stated she did not remember it.
On 10-8-24 at 3:00 PM, the current Assistant Director of Nursing ADON was interviewed, and stated that the Administrator had only been in the building for a month, the Director of Nursing had just started this week, and she (ADON) had no recollection of the cardiac monitor for that Resident. The PA which had been involved in the Resident's care was called via cellular phone, however, could not be contacted. Nursing staff on the Resident's nursing unit were interviewed and only 1 of 3 stated they did remember the monitor, however, the nurse was from an agency and worked there sporadically so had little contact with the Resident stating maybe twice during August.
On 10-9-24 at 4:30 p.m., in the conference room with surveyors, the Administrator stated he was not in the building during that time, and they had 4 Directors of Nursing (DON's) in less than 1 year. He was made aware by surveyors that the Resident did not receive the cardiac monitoring as ordered for Resident #89, and also that the constant turn over in facility staff, and the daily presence of off site agency nursing staff, has been known to result in poor continuity of care.
The Registered Nurse Corporate Consultant stated [NAME] as their nursing reference for their standards of practice.
[NAME] Fundamentals of Nursing, provides the following guidance regarding physicians' orders, Nurses are obligated to follow physicians' orders unless they believe the orders are in error or would harm the clients.
The facility Administrator and DON stated that they had no further information 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
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility documentation and clinical record review, the facility staff failed to ensure tw...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility documentation and clinical record review, the facility staff failed to ensure two Residents (Resident #89 and #68) received ADL (activities of daily living) care to include hygiene and showers in a survey sample of 55 residents.
The findings included:
1. For Resident #89 her fingernails were long and dirty/encrusted with a brown substance, and the resident did not receive twice weekly showers.
Resident #89 was admitted to the facility on [DATE], and readmitted on [DATE], after a 6 day hospitalization. Diagnoses included; Chronic Kidney disease, sick sinus syndrome after syncope and collapse on 7-12-24, dementia, hypertension, malnutrition, stroke, and anemia.
Resident #89's most recent Minimum Data set assessment was a quarterly assessment with an assessment reference date (ARD) of 8-1-24. Resident #89 was coded with a Brief Interview of Mental Status score of 3 indicating severe cognitive impairment. Resident #89 required extensive to total assistance from one to two staff members, with all activities of daily living.
Resident #89's clinical record was reviewed on 10-8-24. ADL (Activities of Daily Living) care records revealed from 9-8-24 through 10-7-24 (30 days) the Resident received only 2 baths. The record indicated a refusal one day, however, it was the only refusal in 30 days.
Review of the facility's policy regarding general ADL care included the fact that nursing personnel would provide basic nursing care and services following accepted standards of practice guidelines, and the fact that resident specific care activities will be reflected in the resident plan of care.
The Resident's care plan was reviewed and revealed no bathing care plan for this Resident who was completely dependant on staff.
On 10-8-24 at 11:00 a.m., 11:30 a.m., and 1:30 p.m., observations of Resident #89 were conducted. The Resident was alert, pleasant, talkative, and oriented to person, place, and time of day. The Resident was in a reclined side sitting position facing the window and stated she had enjoyed her lunch and her food tray was noted to be empty with only smears of what she had eaten 100% of, for the meal. She stated I'm still hungry it wasn't much, can you get me a sandwich or something. The Resident's finger nails were approximately 1/2 inch long, jagged and completely encrusted underneath with a hard dry tan substance. The surveyor told her she might need to wipe her hands that she had what looked like food under her nails, and she stated she had a stroke and could not do it. She was asked if she would enjoy having a bath and her nails cleaned and groomed, and she replied oh! that sounds wonderful.
On 10-8-24 at 2:00 PM, the nursing staff on the Resident's nursing unit were interviewed and only 1 of 3 stated they knew her, however, the nurse was from an agency and worked there sporadically so had little contact with the Resident stating she had taken care of the Resident maybe twice during August. An interview with CNA (certified nursing assistant) on the hall of the Resident stated I work mostly on the other unit but I am just helping get someone else up with the hoyer lift. She went on to state she knew Resident #89 and stated, On shower days, she is gotten up with a Hoyer lift. We do look at their nails while they are being bathed. Both staff members stated the expectation for baths is 2 per week or more if necessary and nail care every day.
On 10-9-24 at 12:00 PM the Director of Nursing (DON) was interviewed and asked what the expectation was for bathing residents and she stated 2 times per week minimum and more as needed. She was made aware at that time that Resident #89 had only had two baths in 30 days.
On 10-9-24 at 4:30 p.m., in the conference room with surveyors, the Administrator stated he had only been in the building for 4 weeks, and they had 5 Directors of Nursing (DON's) in less than 1 year. He was made aware by surveyors that the Resident had only received bathing twice in the last 30 days, and that she had not been afforded sufficient hygiene/nail care. A discussion ensued regarding the fact that the constant turn over in facility staff, and the daily presence of off site agency nursing staff, has been known to result in poor continuity of care.
The facility Administrator and DON stated that they had no further information to provide.
2. For Resident #68 the resident complained of not receiving twice weekly showers, even after requesting them.
Resident #68 was admitted to the facility on [DATE]. Diagnoses included but were not limited to: heart failure, hypertension, high cholesterol, malnutrition, peripheral venous insufficiency, hypothyroidism, rheumatoid arthritis, scoliosis, rhabdomyolysis, and foot pain.
Resident #68's most recent Minimum Data Set with an Assessment Reference Date of 8-2-24 was coded as a quarterly assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicates no cognitive impairment. The Resident was cognitively intact, and her own responsible party. The Resident required extensive assistance from one staff member for hygiene and bathing. The Resident had no aberrant behaviors documented.
While on continued tour of the facility on 10-4-24, Resident #68 was interviewed and had several areas of concern reported to the surveyor. The area of greatest concern was the fact that she could not get baths twice per week. She stated staff constantly told her they were short when she asked for a bath, and she stated it helped her back pain from a spinal fracture and scoliosis. She went on to say staff is always out with smokers and didn't ask her until 9 PM or 10 PM, after she was in bed, on one occasion. She stated she had only one bath in the last month.
Bathing records were reviewed on 10-9-24 at 11:00 AM and revealed that the Resident's bathing schedule was to be on Mondays and Thursdays, on the 3:00 PM to 11:00 PM shift. Documentation by staff indicated that from 9-8-24 she received a bath on Thursday 9-19-24. The Resident had no other baths through 10-9-24.
Certified Nursing Assistants (CNA's) on the Resident's unit were interviewed and stated that the Resident was a 3-11 PM bath, and no one had told them that her bath had been skipped, or they would have helped her on the 7:00 AM -3:00 PM shift.
On 10-9-24 at 12:00 PM the Director of Nursing (DON) was interviewed and asked what the expectation was for bathing residents and she stated 2 times per week minimum and more as needed. She was made aware at that time that Resident #68 had only had one bath in 30 days.
On 10-9-24 at 4:30 p.m., in the conference room with surveyors, the Administrator stated he had only been in the building for 4 weeks, and they had 5 Directors of Nursing (DON's) in less than 1 year. He was made aware by surveyors that the Resident had only received bathing once in the last 30 days, and that she had not been afforded sufficient ADL care. A discussion ensued regarding the fact that the constant turn over in facility staff, and the daily presence of off site agency nursing staff, has been known to result in poor continuity of care.
The facility Administrator and DON stated that they had no further information to provide.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to identify and address necessary behavioral health services, and failed to devise and implement a comprehensive person centered care plan for identified responses to stressors for one Resident with non-Alzheimer's type dementia with a language barrier (Resident #521) in a survey sample of 55 Residents.
The findings included:
For Resident #521 the facility staff failed to obtain a physician ordered psychiatric consult timely, failed to conduct behavior monitoring, failed to provide a comprehensive care plan for emotion regulation, failed to identify stressors and responses such as language barrier and supervision, to those stressors, which resulted in aggressive behaviors aimed at and impacting other residents.
The facility failures described above resulted in the willful abuse of Residents #68, #20, and a third unknown Resident victim as perpetrated by Resident #521.
Resident #521 was not receiving any psychotropic medications, to include antidepressants.
Resident #68 (victim 1)was admitted to the facility on [DATE]. Diagnoses included but were not limited to: heart failure, hypertension, high cholesterol, malnutrition, peripheral venous insufficiency, hypothyroidism, rheumatoid arthritis, scoliosis, rhabdomyolysis, and foot pain.
Resident #68's most recent Minimum Data Set with an Assessment Reference Date of 8-2-24 was coded as a quarterly assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicates no cognitive impairment. The Resident was cognitively intact, and her own responsible party. The Resident required extensive assistance from one staff member for hygiene and bathing. The Resident had no aberrant behaviors documented, and had no complaints against any other staff or situations since her admission on [DATE].
Resident #20 (victim 2) was admitted to the facility on [DATE]. Diagnoses included but were not limited to chronic ischemic heart disease, stroke with hemiplegia right side, anemia, diabetes, chronic hepatic failure, neck fracture, chronic kidney disease, depression, and femur fracture.
Resident #20's most recent Minimum Data Set was a quarterly assessment. The Brief Interview for Mental Status was coded as 15 out of a possible 15 points which indicates no cognitive impairment. The Resident was cognitively intact, and her own responsible party. The Resident was independent for transferring and used a motorized wheel chair to leave the building for shopping trips to walmart using a van. The Resident had no aberrant behaviors documented, and had no complaints against any other staff or situations since her admission on [DATE].
Resident #521 (perpetrator of 1 and 2) was admitted to the facility on [DATE], went back out to the hospital for syncope on 9-5-24, and returned on 9-8-24. Hospital discharge records indicated that the Resident was alert and oriented to person, place and time, and was ambulatory at the time of discharge. Diagnoses included but were not limited to: Heart failure, hypertension, Gastro Esophageal reflux disease, renal insufficiency, diabetes, thyroid disorder, dementia, malnutrition, and asthma.
Resident #521's most recent Minimum Data Set with an Assessment Reference Date of 9-5-24 after one day in the facility was coded as an admission assessment. The Brief Interview for Mental Status was coded as 12 out of a possible 15 points which indicated mild cognitive impairment, however, the language barrier may have contributed to a false lower score. The Resident was her own responsible party. The Resident spoke only Spanish. The Resident required extensive assistance from one staff member for hygiene and bathing.
On 10-1-24, the first day of survey, Resident #521 went out to a medical appointment and lost consciousness while there. She was sent directly to the hospital, and did not return during the remainder of the survey.
While on continued tour of the facility on 10-4-24, Resident #68 was interviewed and asked if any person in the facility had abused her or if she had ever witnessed abuse. She stated yes that her former room mate (Resident #521) had kicked her, thrown fruit at her, hit her, and had spit on her. She stated that Resident #521 had also cursed and yelled at her, gotten in her bed, held her wheel chair so she could not leave the room for help, and had stood over her while she was laying in bed menacing her. She stated that she had been bruised by the kick and punch, but luckily suffered no other injuries. She further stated that she had complained to staff repeatedly but they did nothing until 9-20-24 when Resident #521 punched her in the arm and the Assistant Director of Nursing saw it. She went on to say that they moved her that day. The Resident was asked if she was still afraid and she stated no, she's gone now.
On 10-7-24 the clinical records of Resident's #68, and #521 were reviewed. Those reviews contained the following information in chronological order;
On 9-20-24 at 3:42 PM the records indicated that Resident #521 had been moved to another room for Safety. No other descriptions about the allegations of abuse on Resident #68 were documented.
On 9-20-24 Resident #521's progress notes documented she was moved to the room containing Resident #20.
On 9-21-24 at 12:47 AM (7.5 hours later) after the move, progress note review indicated that Resident #521 was observed to throw a cup of water across the room and spit on her new room mates charger for her electric wheel chair.
On 9-21-24 at 8:41 PM, Later the same day, documents record Resident #521 hit Resident #20 and it was witnessed by staff. There was no mention of the scratches to Resident #20 inflicted by Resident #521.
On 9-22-24 at 1:34 AM (5 hours later) progress notes go on to describe that Resident #521 was moved to a private room.
(Victim #3 unknown name) On 9-22-24 at 2:54 AM, (1.5 hours after move) another note describes Resident #521 as standing next to her neighbors bed (unknown which neighboring room to the private room or which Resident this involved) staring at her (the neighbor of Resident #521) while sleeping and threatened anger aggressive behavior.
On 9-23-24 a psychiatric consultation was ordered. It was never obtained.
On 9-25-24 the Physician's Assistant (PA) described in a note that (Resident #521) Patient assault on room mate multiple times, resident denied, on alternate location at this time.
On 10-7-24 Resident #20 was interviewed and stated that Resident #521 was placed in her room and almost immediately began to yell at her, spit at her, and throw things at her. She went on to state that Resident #521 finally came over to her side of the room after dinner sometime and lashed out at her hitting her, causing several small scratches on her hand. She stated she was fending off the blows with her arm raised. and Resident #521's fingernails scratched her. She went on to state that the staff saw it and moved her out of the room until they could find a place for Resident #521. She stated that Resident #521 was moved Sometime late that night around midnight. Resident #20 was asked if she was afraid of Resident #521, and she stated no, she went to the hospital and I don't think she's ever coming back.
Nursing staff on the units where Resident #521 was housed were interviewed and stated they remembered Resident #521, and her aggressive behaviors, however, those working during survey interviews were not present during the abuses. They stated they were aware of the incidents, however, most of the staff were from a staffing agency and did not work there every day.
During interview and review of the clinical record, it was found that the Social Worker/Discharge Planner (SWDP) was only involved with Resident #521 on 3 occasions. Those instances follow below:
1. Nine days after admission on [DATE] for a Trauma Informed Care assessment which was negative for trauma experienced by the Resident.
2. After the first abuse on 9-20-24 to Resident #68, to notify Resident #521's son of the first room change.
3. Finally, at the first Interdisciplinary care plan meeting on 9-26-24 with only the SWDP and the Activity Assistant present.
The facility staff provided a copy of their Abuse policy, and the policy review revealed that all allegations of abuse will be investigated, Residents will be protected and prevented from further abuse, reports will be sent initially to the State agency VDH/OLC (and other agencies) within 24 hours or within 2 hours if serious injury occurs, and a follow up report will be sent in 5 days to include findings and corrections.
Resident #68 reported abuse for days before staff observed the abuse and moved Resident #521.
Resident #521 was then placed with Resident #20 who was not protected and was abused.
Resident #521 was moved again and went to a third unknown Resident's room to abuse.
The allegations of abuse were never reported to the state agency. Residents were not protected from a known abuser. Abuse was not investigated fully, and the facility policy was not implemented for the protections of Residents from abuse. Further, there was never any added staff supervision for Resident #521 to prevent the abuse from continuing.
No staff ever noted the suspicion of a crime, so no police report was ever filed. The first alleged report by the Administrator was never signed and had errors in information giving the appearance of a severely demented alleged abuser to APS in a single occurrence resulting in no investigation opened by them.
Resident #521's nursing and physician progress notes were reviewed and revealed the following:
9-8-24 nurses documented Resident with language barrier (speaks only Spanish) states frustration with interpreter.
9-11-24 the physician documented Plan: - The patient has had a diagnosis of depression or has had a diagnosis of Bipolar Disorder.
9-12-24 nurses documented refused, wants to be left alone to therapy, refused weight yelling in Spanish
9-19-24 nurses documented Google translater only means of translation in the facility.
9-20-24 nurses documented room change for safety.
9-21-24 12:47 AM nurses documented woke from nap anxious, stating dead bodies everywhere, resident extremely restless and gestures for sleep but will not stay in bed more than 15-20 minutes at a time.
9-21-24 10:41 PM nurses documented Aggression and hitting roommate, removed from room.
9-22-24 1:34 AM nursing notes documented another room change to a private room.
9-22-24 2:54 AM nursing notes Aggressive behavior standing over sleeping neighbor threatening neighbor room.
9-23-24 2:45 PM nursing note Psyche consult placed in psyche referral book.
9-23-24 11:12 PM nursing note difficulty communicating with Resident.
9-25-24 physician documented resident's roommate spoke up about Resident #521 laying hands on her multiple times. Staff made aware, management involved, room changed. That reveals that the physician was only aware of one abuse victim, and not the other two.
Resident #521's frustration was identified on day 1, and no plan was implemented to improve communication between staff and residents for this Resident.
The psychiatric evaluation was put in a book at the nursing station awaiting the next visit from psyche professionals to see other residents before they knew Resident #521 needed services. This was revealed during interview at the nursing station when the consult book was requested, on 10-7-24 they stated that's our procedure.
From 9-4-24 through 10-1-24 (28 days), no psychosocial nor behavioral services were ever afforded a disturbed Resident #521 even after 3 abuses of other Residents and aggression toward staff.
Resident #521's care plan was reviewed and revealed no focus nor interventions for dementia, language barrier, nor behaviors was ever derived nor implemented before or after the abuses occurred.
Resident #521's physician's orders and progress notes were reviewed and revealed On 9-8-24 Geriatric psyche consult (as needed) PRN. No other assessments nor orders for behavioral health support were ever obtained.
On 10-9-24 at approximately 5:30 p.m., the facility Administrator, Corporate Registered Nurse, and Corporate Administrator were notified of the findings. They stated they had no further information or documentation to offer.
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 F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interview, staff interview, clinical record review, and review of facility documents, the facili...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interview, staff interview, clinical record review, and review of facility documents, the facility staff failed to ensure significant medication was administered for 5 of 55 residents (Resident #47, Resident #57, Resident #424, Resident #372 and #161), in the survey sample.
The findings included:
1. Resident #47 was originally admitted to the facility 3/11/20. The resident's diagnoses included chronic obstructive pulmonary disease, essential hypertension, anemia, and constipation.
The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/22/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #47's cognitive abilities for daily decision making were intact.
On 10/1/24 at 7:00 PM an interview was conducted with Resident #47. Resident #47 stated that there was no nurse on unit 3 from 3pm to 11pm and 11pm to 7am on 8/17/24. Resident #47 also stated that due to this, she did not receive the scheduled dose of Lisinopril on 8/18/24. Resident #47 voiced that due to not taking this medication, she experienced severe pain in her neck, head, and shaking of her hands.
The Physician's Order Summary (POS) for August 2024 read: Lisinopril Tablet 5 MG Give 1 tablet by mouth two times a day for hypertension Hold for SBP<110mmHg.
A review of the Medication Administration Record (MAR) revealed that Resident #47 missed 1 dose of Lisinopril Tablet 5 MG Give 1 tablet by mouth two times a day on the following date: 8/18/24.
Lisinopril is in a class of medications called angiotensin-converting enzyme (ACE) inhibitors. It works by decreasing certain chemicals that tighten the blood vessels, so blood flows more smoothly and the heart can pump blood more efficiently. https://medlineplus.gov/druginfo/meds/a692051.html
On 10/7/24 at 12:50 PM an interview was conducted with the two Regional Nurse Consultants. The Regional Nurse Consultants stated that the medication was available for Resident #47, and they could not explain why the resident was not administered the medication on 8/18/24.
On 10/9/24 at approximately 5:30 PM, a final interview was conducted with the Administrator, Assistant Administrator, Director of Nursing, and the two Regional Nursing Consultants. They had no further comments and voiced no concerns regarding the above allegation.
4. Resident #372 was originally admitted to the facility on [DATE] from an acute hospital stay and discharged on 8/16/24.The facility's staff failed to procure and administer Resident #372's Anti-Seizure medication, Insulin and Analgesic, narcotic medications for numerous days. Diagnosis for Resident #372 included but not limited to Diabetes Mellitus and Stage 3 Chronic Kidney Disease.
The discharge Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 08/16/24 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #372 cognitive abilities for daily decision making were intact.
The Physicians Order Summary (POS) for July read:
clonazepam Oral Tablet Disintegrating 0.125 MG (Clonazepam) Give 1 tablet by mouth two times a day for psychosomatic disorder. Dated: 7/28/2024.
Clonazepam Oral Tablet Disintegrating 0.125 MG (Clonazepam) Give 2 tablet by mouth two times a day for psychosomatic disorder. Dated: 7/30/24.
Divalproex Sodium ER Oral Tablet Extended Release 24 Hour 500 MG (Divalproex Sodium) Give 1 tablet by mouth at bedtime for seizure disorder. Dated: 7/28/24.
Insulin Glargine Subcutaneous Solution Pen injector 100 UNIT/ML Inject 10 unit subcutaneously at bedtime for Diabetes Mellitus 2. Dated: 7/30/2024.
Insulin Glargine Subcutaneous Solution Peninjector 100 UNIT/ML. Inject 10 unit subcutaneously one time a day. Dated: 7/28/24.
Insulin Glargine subcutaneously one time a day for Diabetes 2 Dated: 7/30/24 Insulin Glargine, Subcutaneous Solution Peninjector 100 UNIT/ML (Insulin Glargine) Inject 20 unit subcutaneously at bedtime for Diabetes Mellitus.
Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) Give 1 tablet by mouth every 8 hours as needed for Pain for 14 Days. Order date 7/29/2024.
The POS for August Read:
Divalproex Sodium ER Oral Tablet Extended Release 24 Hour 500 MG (Divalproex Sodium) Give 1 tablet by mouth at bedtime for seizure disorder. Order Date 7/28/2024. Missed dose on 7/31/24 at 9:00 PM, 8/03/24 at 9:00 PM.
Insulin Glargine Subcutaneous Solution Peninjector 100 UNIT/ML (Insulin Glargine) Inject 20 unit subcutaneously at bedtime for Diabetes Mellitus. Order Date 7/30/2024. Missed dose on 7/31/24 at 9:00 PM, 8/03/24 at 9:00 PM.
Clonazepam Oral Tablet Disintegrating 0.125 MG (Clonazepam) Give 2 tablet by mouth two times a day for psychosomatic disorder. Order Date 7/30/2024. Missed dose on 8/03/24 at 6:30 PM.
Ketorolac Tromethamine Tablet 10 MG Give 1 tablet by mouth two times a day for inflammation for 5 Days. Order Date 8/01/2024. Missed doses on 8/03/24 at 4:00 PM.
Lidocaine Pain Relief External Patch 4 % (Lidocaine) Apply to back topically two times a day for pain. Order Date 7/28/2024. Missed doses 8/03/24 at 7:30 AM., and on 8/07/24 at 4:00 PM.
Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) Give 1 tablet by mouth three times a day for pain. Order Date 08/01/2024. Missed 8/03/24 at 8:00 PM.
What is clonazepam used for? Clonazepam is commonly used to treat the following conditions. Certain types of seizure disorders, also called epilepsy.
How does clonazepam work (mechanism of action)?
Clonazepam produces a calming effect on the brain and nerves, which helps to reduce anxiety, prevent seizures, and promote relaxation. How is clonazepam supplied (dosage forms)?
Clonazepam is available as Klonopin, Klonopin ODT, and generic clonazepam in the following dosage forms that are taken by mouth.https://www.webmd.com/drugs/2/drug-920-6006/klonopin-oral/clonazepam-oral/details.
Divalproex sodium is used to treat certain types of seizures (epilepsy). This medicine is an anticonvulsant that works in the brain tissue to stop seizures (https://www.mayoclinic.org/drugs-supplements/divalproex-sodium-oral-route/description/drg-20072886).
Insulin glargine is a long-acting type of insulin that works slowly, over about 24 hours. Insulin is one of many hormones that help the body turn the food we eat into energy. This is done by using the glucose (sugar) in the blood as quick energy. Also, insulin helps us store energy that we can use later. When you have diabetes mellitus, your body cannot make enough insulin or does not use insulin properly. This causes you to have too much sugar in your blood. Like other types of insulin, insulin glargine is used to keep your blood sugar level close to normal. You may have to use insulin glargine in combination with another type of insulin or with a type of oral diabetes medicine to keep your blood sugar under control.https://www.mayoclinic.org/drugs-supplements/insulin-glargine-recombinant-subcutaneous-route/description/drg-20067770.
Oxycodone hydrochloride: A drug used to treat moderate to severe pain. It is made from morphine and binds to opioid receptors in the central nervous system. Oxycodone hydrochloride is a type of analgesic agent and a type of opiate.https://www.cancer.gov/publications/dictionaries/cancer-terms/def/oxycodone-hydrochloride.
Prescription lidocaine transdermal (Dermalid, Lidoderm, Ztildo) is used to relieve the pain of post-herpetic neuralgia (PHN; burning, stabbing pains, or aches that may last for months or years after a shingles infection). Nonprescription (over-the-counter) lidocaine (Absorbine Jr, Aspercreme, Lidocare, Salonpas, others) is also available to relieve minor pain in shoulders, arms, neck and legs in adults and children [AGE] years of age and older. Lidocaine is in a class of medications called local anesthetics. It works by stopping nerves from sending pain signals.https://medlineplus.gov/druginfo/meds/a603026.html
On 10/11/2024 at approximately 6:00 p.m., the above findings were shared with the Acting Administrator in Training, Director of Nursing and the Regional Nurse Consultant. An opportunity was offered to the facility's staff to present additional information but no additional information was provided.
2. For Resident #57 the facility staff failed to administer Flomax, Gabapentin, and Eliquis and amlodipine as ordered by physician.
Resident #57 was admitted to the facility on [DATE] with diagnoses that include but were not limited to hemiplegia and hemiparesis following cerebral infarction, benign prostatic hyperplasia, acute embolism and thrombosis, and personal history of transient ischemic attack. Resident #57 most recent MDS (Minimum Data Set with an ARD (Assessment Reference Date) of 10/3/24 coded Resident #57 as having a BIMS (Brief Interview of Mental Status) score of 15/15 indicating no cognitive impairment.
On the morning of 10/8/24 an interview was conducted with Resident #57 who stated that sometimes he didn't get his medicine on time. He stated that sometimes they even missed his meds if he went to an activity.
On 10/10/24 a review of the clinical record revealed that Resident #57 had the following orders:
Eliquis Oral Tablet 2.5 MG (Apixaban) Give 1 tablet by mouth two times a day for anticoagulation -Order Date-09/13/2023
Not given on 9/13. 9/14/24 at 5 p.m.
Baclofen Tablet 10 MG Give 2.5 tablet by mouth in the afternoon for Muscle relaxer -Order Date- 03/27/2023
9/13-14 4p.m.
Baclofen Tablet 10 MG Give 2 tablet by mouth at bedtime for Muscle relaxer -Order Date 9p.m. 9/13/14/18
Not given 9/13, 9/14/24 at 4.pm.
Not given 9/13, 9/14, & 9/18/24 at 9 p.m.
Flomax Capsule 0.4 MG (Tamsulosin HCl) Give 1 capsule by mouth one time a day for benign prostatic hyperplasia
-Order Date- 08/01/2022
Not given on 9/13, 9/14/24 at
Not signed off as administered on 9/13/24 and 9/14/24 at 5 p.m.
Gabapentin Capsule 300 MG Give 1 capsule by mouth two times a day for pain -Order Date- 08/02/2022.
Not signed off as being administered on 9/13/24 and 9/14/24 at 5 p.m.
Eliquis Oral Tablet 2.5 MG (Apixaban) Give 1 tablet by mouth two times a day for anticoagulation -Order Date-
09/13/2023
9/13/24, 9/14/24, 10/4/24 at 5 p.m. and 10/3/24 at 9 a.m.
Amlodipine besylate Tablet 5 MG Give 1.5 tablet by mouth one time a day for HTN Hold for SBP<120 -Order Date- 10/04/2022
Amlodipine - Signed off as given on 9/7/24, with b/p of 106/63, on 9/8/24 with b/p of 106/63, 9/9/24 given with bp 104/65, on 9/21/24 with a b/p of 116/81, and on 9/28/24 with a b/p of 115/80.
A review of the clinical record revealed that there was no nursing notes entered to explain why medications were not given for the dates in September however the 10/3/24 and 10/4/24 progress notes read:
Orders -Administration Note - Note Text: Pt. not in room, when med due.
On 10/10/24 at approximately 2 p.m. an interview with the DON and the Clinical Nurse Consultant was conducted, and the DON stated, If it wasn't documented it wasn't done. She indicated that the nurse should have done the vital signs and held the medications per parameters for the amlodipine. When asked if it is the expectation of the facility that nurses administer medications per physician order, and she stated that it was. When asked what should be done if the Resident was not in the room when she was passing medications, she stated that the nurse should have come back at a later time or went to find the Resident. When asked what should be done when a medication is not given, she stated that the physician should be notified, and it should be documented in the chart.
A review of the medication administration policy revealed the following excerpts.
Page 4
II Administration
2. Medications are administered in accordance with written orders of the prescriber.
Page 5
16. For residents not in their rooms or otherwise unavailable to receive medications on the pass, the MAR is flagged. After completing the medication pass, the nurse returns to the missed resident to administer the medication.
On 10/10/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.
3. For Resident #424 the facility staff failed to notify physician / seek clarification on giving medications the pharmacy has identified as having a possible serious drug interaction.
Resident #424 was admitted to the facility on [DATE] with diagnoses of but not limited to extended Spectrum Beta Lactamase (ESBL) Resistance, vascular dementia, without behavioral disturbance, psychotic disturbance, mood disturbance anxiety, COPD (Chronic Obstructive Pulmonary Disease, CHF (Congestive Heart Failure) diabetes and A-Fib.
On 10/10/24 a review of the clinical record revealed that on 10/5/24 Resident #424 was prescribed Levofloxacin (an antibiotic) for respiratory symptoms associated with COPD.
After entering the order for Levofloxacin into the system the pharmacy responded by entering the following alert into the progress notes:
Effective Date: 10/05/2024 4:16 p.m. Type: Order Note: The order you have entered Levofloxacin Tablet [an antibiotic] 500 MG Give 1 tablet by mouth one time a day for infection for 5 Days Has triggered the following drug protocol alerts/warning(s):
Drug to Drug Interaction:
The system has identified a possible drug interaction with the following orders:
Citalopram Hydrobromide Tablet 20 MG [an anti-depressant]
Give 1 tablet by mouth one time a day for depression
Severity: Severe
Interaction: Additive QT interval prolongation may occur during coadministration of moderate-risk QT-prolonging agents, Citalopram
Hydrobromide Oral Tablet 20 MG and levofloxacin Oral Tablet 500 MG.
This warning was repeated 2 more times in the progress notes on the following dates/times:
Effective Date: 10/06/2024 12:19 p.m.
Effective Date: 10/06/2024 8:32 p.m.
[QT Prolongation can be caused by electrolyte abnormalities or certain medications, such as antibiotics, antifungals, diuretics, antidepressants, antipsychotics, and antiarrhythmics. A prolonged QT interval can lead to torsade's de pointes, a potentially life-threatening type of irregular heart rhythm. A corrected QT interval (QTC) of more than 500 milliseconds (MS) or an increase in the QTC of more than 60 MS is generally considered to indicate a high risk of torsade's de pointes.]
On the afternoon of 10/9/24 an interview was conducted with LPN (Licensed Practical Nuse) #6 who was asked what the nurses do when the pharmacy flags a new order with a drug-to-drug interaction. LPN #6 stated that she thought that alert was for the prescriber to deal with since they have access to Resident charts.
On 10/10/24 at approximately 2 p.m. an interview with the DON and the Clinical Nurse Consultant was conducted, when asked if it is the expectation of the facility that nurses administer medications per physician order and the DON stated that it was. When asked what should be done if the physician order is questioned by the pharmacy, is flagged by the pharmacy or is unclear and she stated the physician should be notified and clarification should be given and documented in the nurse notes. When asked if this was done in this case and she stated that it was not.
On 10/10/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.
5. For Resident # 161, the facility staff failed to ensure that antibiotics were administered as per physician's orders. There were six missed doses during the course of treatment including 4 consecutive doses.
Resident # 161 was admitted to the facility on [DATE] with the diagnoses of, but not limited to, Primary Osteoarthritis of the Knee, Septic Arthritis of the Knee, Heart Failure, and edema.
The most recent Minimum Data Set (MDS) was an admission Assessment with an Assessment Reference Date (ARD) of 9/10/2024. Resident # 161's BIMS (Brief Interview for Mental Status) Score was a 14 out of 15, indicating no cognitive impairment.
Review of the clinical record was conducted on 10/9/2024-10/11/2024.
Review of the clinical record revealed the following order:
Amoxicillin Oral Capsule 500 mg (milligrams) Give 2 capsules by mouth three times a day related to Arthritis due to other bacteria, left knee, for 14 Days. Give with food. Order Date-09/18/2024 0833.
Review of the September 2024 MAR (Medication Administration Record) revealed that the order was started on 9/18/2024 at 9:00 a.m. and continued through 10/01/2024 at 9:00 p.m.
The scheduled times of administration were 9:00 a.m., 2:00 p.m., and 9:00 p.m. Review revealed there were six doses not administered during the course of treatment.
Amoxicillin was not administered on:
9/21/2024 at 9:00 p.m.
9/28/2024 at 9:00 p.m.
9/29/2024 at 9:00 a.m.
9/29/2024 at 2:00 p.m.
9/29/2024 at 9:00 p.m.
10/1/2024 at 9:00 a.m.
Review of the Progress Notes revealed documentation that the Amoxicillin was not administered because it was on order.
On 10/11/2024 during clinical record review, it was noted that Resident # 161's order for Amoxicillin was supposed to be administered for 14 days. The Medication Administration Record revealed there had been 6 doses missed during the prescribed course of treatment. Four consecutive doses were missed from 9/28/2024 at 9:00 p.m. to 9/29/2024 at 9:00 p.m. The six missed doses equated to a total of two full days of missed doses. There was no indication that the antibiotic was extended to additional days to cover the missed doses.
On 10/11/2024, the Regional Nurse Consultant (Corporate-2) was asked if antibiotics should be continued as ordered. She stated it was very important. When asked why it was important to continue the antibiotics as prescribed, Corporate-2 stated that it was important because the antibiotics were prescribed to kill the bacteria. She also stated that taking all of the antibiotic as prescribed would prevent the bacteria from growing and becoming antibiotic resistant.
According to the Mayo Clinic, antibiotics are important drugs that can successfully treat infections caused by bacteria. Antibiotics can prevent the spread of disease. The way drugs are used affects how quickly and to what degree resistance occurs.
It also stated:
You need to to take the full treatment to kill the disease-causing bacteria. If you do not take an antibiotic as prescribed, you may need to start treatment again later. If you stop taking it, it can also promote the spread of antibiotic-resistant properties among harmful bacteria.
The article also stated that Drug resistant infections can cause many problems including: More-serious illness, longer recovery, more-frequent or longer hospital stays, more health care provider visits and more- expensive treatments.
Complete the entire treatment.
During the end of day debriefing on 10/11/2024, the Facility's Acting Administrator, Administrator in Training, Regional Nurse Consultant (Corporate-2) 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
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation and staff interview, the facility staff failed to remove expired medications and provide the date medications were opened on 2 of 4 facility units.
The findings included:
1. On 1...
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Based on observation and staff interview, the facility staff failed to remove expired medications and provide the date medications were opened on 2 of 4 facility units.
The findings included:
1. On 10/9/24 at 12:55 PM an observation of the medication administration cart on Unit 3 with Licensed Practical Nurse (LPN) #1 revealed 1 opened multi-dose Humalog (insulin lispro) 100 units/ml KwikPen with an open date of 9/6/24. A review of the manufacturer's literature indicated to discard the insulin lispro Kwikpen 28 days after opening.
An interview with LPN #1 was conducted on 10/9/24 at 12:57 PM. LPN #1 stated that the Humalog (insulin lispro) 100 units/ml KwikPen should not be on the medication cart due to the opening date being more than 28 days.
2. On 10/9/24 at 1:05 PM an observation of the medication administration cart on Unit 3 with Licensed Practical Nurse (LPN) #1 revealed 1 opened multi-dose Fiasp (insulin aspart) 100 units/ml injection pen with an open date of 7/31/24. A review of the manufacturer's literature indicated to discard the Fiasp (insulin aspart) 100 units/ml injection pen 28 days after opening.
An interview with LPN #1 was conducted on 10/9/24 at 1:07 PM. LPN #1 stated that the Fiasp (insulin aspart) 100 units/ml injection pen should not be on the medication cart due to the opening date being more than 28 days.
3. On 10/9/24 at 1:10 PM an observation of the medication administration cart on Unit 3 with Licensed Practical Nurse (LPN) #1 revealed two (2) Toujeo (insulin glargine) 300 units/ml injection pens opened and undated.
An interview with LPN #1 was conducted on 10/9/24 at 1:10 PM. LPN #1 stated that per training/competency, every nurse should put the date of opening on medications.
On 10/9/24 at approximately 5:30 PM, a final interview was conducted with the Administrator, Assistant Administrator, Director of Nursing, and the two Regional Nursing Consultants. They had no further comments and voiced no concerns regarding the above allegation.
4. For Unit 4-Skilled unit on the B cart, the facility staff failed to ensure the over-the- counter medications were labeled when opened.
There were two carts ( Cart A and Cart B) on each of the four units at the facility.
On 10/9/2024 at 2:05 p.m., inspection of the B cart on Unit 4 was conducted with LPN (Licensed Practical Nurse)- 4.
There were four bottles of over the counter medications that were open and available for use but not dated with a date of when opened. The medications not dated were:
Senna 8.6 milligrams bottle of 100 tablets- bottle not dated, seal was open- approximately half empty.
Ferrous Sulfate 325 milligrams - not dated and approximately a quarter was missing.
Naproxen 220 milligrams, not dated, seal broken, approximately a quarter of the bottle was missing.
Chewable aspirin 81 milligrams not dated, seal was broken, approximately a quarter of the bottle was missing.
While inspecting the medication cart, an interview was conducted with LPN (Licensed Practical Nurse)-4 who stated the expectation was for all medications to be dated when opened. LPN-4 stated nurses should check to see the date the bottle was opened prior to administering the medications.
During the end of day debriefing on 10/9/2024, the facility Administrator, [NAME] President of Operations-Acting Administrator (Administration-2), Director of Nursing and two Regional Nurse Consultants (Corporate-1 and Corporate-2) were informed of the findings. The Director of Nursing stated the expectation was for the bottles of medications to be dated upon opening.
No further information was provided prior to survey exit
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 F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
Based on observation, interview, clinical record review and facility documentation the facility staff failed to maintain an effective pest control program so that the facility is free of pests for the...
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Based on observation, interview, clinical record review and facility documentation the facility staff failed to maintain an effective pest control program so that the facility is free of pests for the facility.
The findings included:
For the facility, the facility staff failed to ensure the environment was kept pest free, roaches both alive and dead were observed at the facility.
On 10/7/24 during the kitchen inspection there were 2 dead roaches noted in the dry storage area and one in the kitchen near the 3-compartment sink.
On 10/11/24 observation of the ice machine in closet across from the dining room revealed standing water on the floor, a rubber mat with live roaches (5-6 of them) crawling around and under it, the ice machine drainage pipe was dripping on the floor not in the drain. Under the ice machine was black slimy substance and wet paper trash as well. The entire area smelled of dampness and mildew.
During the entire survey there were fruit flies as well as large flies noted on all units and in the common areas as well.
A review of the pest control logs revealed that the facility is having pest control services come to the building on a monthly basis however this is not an effective pest control program as the pests continue to be visible.
On 10/11/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0940
(Tag F0940)
Could have caused harm · This affected multiple residents
Based on staff interview 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 ...
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Based on staff interview 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 and Relias training transcripts revealed that not all facility staff had completed all the required training.
On 10/11/24 at approximately 8:15 PM, a final interview was conducted with the Administrator, Interim Administrator, Director of Nursing and two regional Nurse Consultants. They had no comments and voiced no concerns regarding the above information.
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 review of facility documents and staff interview the facility staff failed to ensure that all staff members were educated on Resident's rights and facility responsibilities.
The findings incl...
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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 Resident's rights and facility responsibilities.
The findings included:
Review of the Staff Education and Relias training transcripts revealed that not all facility staff had completed all the required training for the rights of the resident and the responsibilities of a facility to properly care for its residents.
On 10/11/24 at approximately 8:15 PM, a final interview was conducted with the Administrator, Interim Administrator, Director of Nursing and two regional Nurse Consultants. They had no comments and voiced no concerns regarding the above information.
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 review of facility documents and staff interview the facility staff failed to ensure that all staff members were educated regarding the Quality Assurance and Performance Improvement
The findi...
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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 regarding the Quality Assurance and Performance Improvement
The findings included:
Review of the Staff Education and Relias training transcripts revealed that not all facility staff had completed all the required training for Quality Assurance and Performance Improvement.
On 10/11/24 at approximately 8:15 PM, a final interview was conducted with the Administrator, Interim Administrator, Director of Nursing and two regional Nurse Consultants. They had no comments and voiced no concerns regarding the above information.
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 and Relias training transcripts revealed that not all facility staff had completed all the required training for Compliance and Ethics.
On 10/11/24 at approximately 8:15 PM, a final interview was conducted with the Administrator, Interim Administrator, Director of Nursing and two regional Nurse Consultants. They had no comments and voiced no concerns regarding the above information.
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 Nurses Aides (CNA) completed the mandatory twelve (12) hours of education each year.
T...
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Based on review of facility documents and staff interview the facility staff failed to ensure that all Certified Nurses Aides (CNA) completed the mandatory twelve (12) hours of education each year.
The findings included:
Review of the Staff Education and Relias 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 10/11/24 at approximately 8:15 PM, a final interview was conducted with the Administrator, Interim Administrator, Director of Nursing and two regional Nurse Consultants. They had no comments and voiced no concerns regarding the above information.
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 review of facility documents and staff interview the facility staff failed to ensure that all staff members were educated on Behavioral health.
The findings included:
Review of the Staff Edu...
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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 Behavioral health.
The findings included:
Review of the Staff Education and Relias training transcripts revealed that not all facility staff had completed all the required training for Behavioral health care and services.
On 10/11/24 at approximately 8:15 PM, a final interview was conducted with the Administrator, Interim Administrator, Director of Nursing and two regional Nurse Consultants. They had no comments and voiced no concerns regarding the above information.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: [NAME], [NAME]
4. Unit 3:
a. In room [ROOM NUMBER] small, flat black spots with a powdery texture was observed behin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: [NAME], [NAME]
4. Unit 3:
a. In room [ROOM NUMBER] small, flat black spots with a powdery texture was observed behind the bedroom door extending toward the bed. Resident #424 was observed in bed and an interview was conducted with her on 10/8/24 at 12:45 PM. The resident stated the black spots have been on the wall for a while. Resident #424 also stated she believes the black spots are the reason she is not feeling well and cannot get well. The resident's admission Minimum Data Set Assessment (MDS) dated [DATE] coded the resident Brief Interview for Mental Status (BIMS) score as 15 out of 15. This indicated her daily decision-making ability was intact.
On 10/8/24 at 4:00 PM two maintenance personnel were observed cleaning the wall that was covered in small, flat black spots with a powdery texture in room [ROOM NUMBER].
b. On 10/4/24 at 12:18PM a live cockroach was observed outside of room [ROOM NUMBER] in the hallway on Unit 3. The Director of Nursing (DON) and Maintenance Director were notified. The Maintenance Director was observed catching the pest in a Styrofoam cup and disposing the pest.
3. Unit 1B
During the initial tour on 10/01/24 at approximately 4:30 PM., on unit 1 B across from the laundry room in the hallway were 3 large trash bags on the floor, filled with clothing. A rolling laundry cart was also observed in the hallway with approximately 16 items hanging from it. The items observed hanging were shirts, pants and 1 coat.
On 10/01/24 an interview was conducted on 10/01/24 at approximately 4:45 PM., with the House Keeping /Laundry aide (Other Staff Member/OSM) #11 concerning the above issue. OSM #11 said that they didn't have enough room inside the laundry room, so they were keeping additional laundry items on the hall.
Unit 2B, room [ROOM NUMBER]
On 10/08/24 at approximately 10:28 AM., an observation of room [ROOM NUMBER] on unit 2B was conducted. Ceiling tiles in the left corner of room appeared wet looking with brown stains. The roommate, Resident #3 said they changed the tiles on yesterday and it's staining already.
Unit 1A, room [ROOM NUMBER]A
On 10/07/24 at approximately 3:28 PM., an observation was made of room [ROOM NUMBER]A on unit 1A. Cobb webs were observed on the wall near the resident's bed, [NAME] stains were observed on 2 ceiling tiles, the curtains hanging at the window also had a brown substance on them. The resident appeared irritated and angry due to his room being nasty and filthy. Resident #371 also said that he's afraid to touch things due to the filth. He also said that They need to burn this place down.
On 10/07/24 at approximately 3:35 PM., Registered Nurse (RN) #3 entered the resident's room. RN #3 reassured the resident concerning his room condition.
On 10/07/24 at approximately 3:41 PM. The maintenance tech (Other Staff Members/OSM) #13, entered the resident's room with a ladder and started removing and replacing 2 ceiling tiles that had a black substance on them. OSM #13 said that the discoloration is coming from condensation of the chiller pipes from heating and air unit.
On 10/11/2024 at approximately 6:00 p.m., the above findings were shared with the Acting Administrator in Training, Director of Nursing and the Regional Nurse Consultant. 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 provide a sanitary ice machine, adequate pest control, palatable meals, and timely laundry and linens to meet the needs of the Residents.
On 10/7/24 during the kitchen inspection there were 2 dead roaches noted in the dry storage area and one in the kitchen near the 3-compartment sink, and the floor in the dry storage had paper trash and some food debris as well as needing to be mopped, there were visible stains on the floor.
On 10/11/24 observation of the ice machine in closet across from the dining room revealed standing water on the floor, a rubber mat with live roaches (5-6 of them) crawling around and under it, the ice machine drainage pipe was dripping on the floor not in the drain. Under the ice machine was black slimy substance and wet paper trash as well. The entire area smelled of dampness and mildew.
During the entire survey there were fruit flies as well as large flies noted on all units and in the common areas as well.
A review of the pest control logs revealed that the facility is having pest control services come to the building on a monthly basis however the pests continue to be visible.
On 10/7/24 at approximately 3:00 p.m. an interview was conducted with Resident #153 who stated that he had Mold and Mildew in his ceiling, and they keep just painting over it. He pointed out a spot on the ceiling that appeared freshly painted, however there were black spots bleeding through the painted area. Resident #153 that the ceiling leaks and then it dries and then when he complains of the black spots They just paint over it, that is not fixing the problem.
Food temps on all units ranged between 80-100 degrees, Residents on 4/4 units complained of Lukewarm or Cold food. Many Residents stated that since they started using Styrofoam the food is cold. A review of the work orders and emails from maintenance to corporate revealed the dishwasher has been inoperable since 8/9/24.
Residents on 4/4 units complained of lack of linens and personal clothing taking too long to come back from laundry,
On 10/10/24 at 3:00 pm, an interview was conducted with the director of housekeeping who was asked why there was a shortage of linens, and the laundry was not getting done in a timely manner. She stated that they are doing the best they can with 1 washing machine. When asked if that is all the facility has for 180 beds, she stated that the other 2 washers are broken. She stated that they are working 7 days a week with the one washer they have to try and keep up with all the linens and facility laundry as well as Resident personal clothing.
On 10/11/24 during the end of day meeting the Administrator was made aware of the concerns and no further information was provided.
Based on observations, resident interviews, staff interviews, facility document reviews, and review of the facility's policy, the facility staff failed to provide a sanitary, comfortable, and homelike environment on four of four units and some common areas, which resulted in Substandard Quality of Life.
The findings included:
1. Upon entering the facility on 10/4/24 at approximately 10:20 AM, water was observed leaking from the ceiling in the lobby. During the initial tour of Unit one at approximately 11:15 AM, the corridor was with much debris, many dark spots and a bed near the rear exit door. room [ROOM NUMBER]'s floors were soiled, the trash can was without a liner and a used glove was observed on the floor.
room [ROOM NUMBER] was with strong odors, straw papers, sugar packages and other debris was also observed on the floor. In room [ROOM NUMBER] pungent odors was in the room and the toilet was observed to be clogged. In room [ROOM NUMBER] soiled linen was observed beneath the sink and many black splatter marks were on the floor. In room [ROOM NUMBER] the privacy curtain for the A bed was fifty percent covered with a dark brown substance.
On 10/7/24 at 2:00 PM a Resident Group meeting was held with the President, [NAME] President, four resident who attends the group meeting regularly and one who does not attend the regularly. It was a consensus of all attending the meeting that their home was not sanitary, comfortable, and homelike.
A review of six months of the Resident Group minutes revealed that the residents voiced the following concerns multiple times regarding the call bells are not answered and often they are just turned off, their rooms/floors not getting cleaned, trash is not removed from the rooms on the weekends, toilet paper is not replenished, ceiling tiles over resident beds are frequently wet and sometimes their personal belongings become wet because of the wet tiles.
Residents in the group meeting also stated roaches and water bugs were seen frequently in their rooms especially when the lights are turned off. Resident representative from units 1, 2 and 3 stated that the roaches are also seen climbing the walls and they fly onto the TV screens. One resident stated when she opened the Styrofoam box to consume her lunch on 10/8/24, a roach was observed crawling on the food and she shut the top and did not eat because of the abhorrence. The consensus of all of the resident were they are tired of it and their desire is for action to be taken immediately.
An interview was conducted with Resident #6 on 10/9/24 at approximately 12:25 PM. Resident #6 stated often there are constant strong urine odors on unit 1, the trash can in her room is without liners and waste is seen falling onto the floor. Resident #6 further stated the bathrooms are not cleaned and the floors are not mopped daily. Resident #6 pointed to the dark areas on the floor in her room and in the corridor outside of her room.
On 10/11/24 at approximately 8:15 PM, a final interview was conducted with the Administrator, Interim Administrator, Director of Nursing and two regional Nurse Consultants. They had no comments and voiced no concerns regarding the above information.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected most or all residents
Based on observation, interview, clinical record review and facility documentation, the facility staff failed to serve food that is palatable, attractive, and an appetizing temperature for Residents o...
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Based on observation, interview, clinical record review and facility documentation, the facility staff failed to serve food that is palatable, attractive, and an appetizing temperature for Residents on 4/4 units.
The findings included:
The facility staff was utilizing Styrofoam take out containers to serve food due to an inoperable dishwasher from August 9, 2024 - October 10, 2024. The Residents of all units complained about food being cold due to it sitting on the carts in the hall before being served.
On 10/7/24 during the kitchen inspection it was noted that all food temps were within safe and acceptable ranges. food was plated in the Styrofoam containers and placed on the cart to send to the various units.
Once arriving on the units the food was distributed by the CNA's. The time the carts sat on the floor before trays were delivered ranged from 10-20 minutes.
Residents on 4/4 units complained of Lukewarm or Cold food. Many Residents stated that since they are using Styrofoam the food is cold. A review of the work orders and emails from maintenance to corporate revealed the dishwasher has been down since 8/9/24. Residents complained the portions were small and the food was not good.
The following are excerpts from the Resident council indicating that the repeated food concerns have gone unaddressed by the Administration.
4/24/24 - Oatmeal watery, some residents getting trays not enough food not getting coffee o every meal not getting food that is on the ticket, not getting alternative requested.
5/29/24 Bring back dinner in dining room, would like hot tea instead of coffee, who do you tell you want alternative meal?
6/26/24 - Diets not being followed, tickets not matching trays, want more vegetables and fruits, condiments and decaf coffee, Chicken is hard over cooked difficult to eat, French fries/potatoes are not cooked all the way, food is cold.
7/23/24 - residents' would like bigger breakfast portions, more fresh fruit, diets not being followed / trays not matching ticket, decaf coffee, English muffin/bread not being toasted.
8/28/24 - portions small for all meals food cold no flavor more seasoning more variety.
9/24/24 - Small potions during breakfast / dinner meals, want more fruit, only getting a half a sandwich for snack, more variety of meals.
On 10/11/24 during the end of day meeting the Administrator was made aware of the concerns and 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
Administration
(Tag F0835)
Could have caused harm · This affected most or all residents
Based on observation, staff interview, facility documentation review, the facility staff failed to ensure the facility was administered effectively to maintain the highest practicable well being of ea...
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Based on observation, staff interview, facility documentation review, the facility staff failed to ensure the facility was administered effectively to maintain the highest practicable well being of each resident.
The findings included:
The facility had a multi-system failure to include deficient practices including environmental services, sanitary and a safe building and dining, infection control practices, medication storage and administration, and resident abuse. These issues affected the quality of life of the residents in the facility.
During the survey, investigations revealed the facility had issues involving multiple systems. There were issues involving environmental services to include inadequate laundry services with only one working washing machine for several months. Residents were complaining of not having adequate linens for their beds, not being able to get clean gowns , not getting their personal clothing washed and returned in timely manner. Staff members were observed while performing duties and providing care. Some staff members were overheard apologizing to other staff members for using the last gowns during incontinence care rounds. Staff members were interviewed by surveyors who stated there had been issues with the laundry for months.
Inspection of the kitchen revealed unsanitary conditions including rodent activity, roaches and an unsanitary ice machine. Resident expressed concerns about the food from the Dietary department.
There were issues with resident to resident abuse where the facility staff did not protect other residents from the perpetrator.
Substandard quality of care was identified at the facility during the survey resulting in an extended survey from 10/8/2024-10/11/2024.
The Maintenance logs, Pest control logs were reviewed by the survey team.
Review of the Resident Council minutes and Grievance logs revealed the facility's administration was aware of issues/concerns voiced by residents and families. The issues continued for several months without resolution.
On 10/9/2024 at approximately 4:20 p.m., an interview was conducted with the Administrator who stated he was aware that the washing machines were not working. He stated he had been employed at the facility for 4 weeks and recognized there were issues with the washing machines. The Administrator stated he had ordered parts but received the wrong parts for one washing machine. He stated he was aware of the impact on the amount of linen for the residents.
During the end of day debriefing on 10/9/2024, the Facility Administrator, the Regional [NAME] President of Operations, Administrator in Training, two Regional Nurse Consultants (Corporate-1 and Corporate-2) and Director of Nursing were informed of the findings of the multi-system failures that were identified by the survey team.
On 10/10/2024 upon arrival at the facility, the survey team was informed that the Administrator was no longer working at the facility as of the evening of 10/9/2024. The Regional [NAME] President of Operations was serving as the Acting Administrator.
During the end of day debriefing on 10/11/2024, the Facility's Acting Administrator, Administrator in Training, Regional Nurse Consultant (Corporate-2) and Director of Nursing were informed of the findings. The Acting Administrator stated he would address the issues identified by the survey team.
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
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected most or all residents
Based on staff interview and facility documentation review, the facility staff failed to devise a facility-specific facility assessment
The Findings included:
On 10/9/2024 at 4:00 p.m., the facility A...
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Based on staff interview and facility documentation review, the facility staff failed to devise a facility-specific facility assessment
The Findings included:
On 10/9/2024 at 4:00 p.m., the facility Administrator was informed of the plan to review the Facility Assessment with the Administrator on 10/10/2024. A copy of the Facility Assessment was given to the surveyor.
On 10/10/2024 upon arrival at the facility, the survey team was informed that the Administrator was no longer working at the facility as of the evening of 10/9/2024. The Regional [NAME] President of Operations was serving as the Acting Administrator.
On 10/10/2024 at 11:15 a.m.,review of the facility assessment was conducted with the Regional Director of Operations (Acting Administrator). Review revealed the assessment was not tailored to the facility. The facility assessment was 22 pages in length. The assessment utilized a template but did not answer the questions as they related to the facility.
Examples of non-compliance included:
The facility assessment was dated 9/3/2024. There was no documentation that the assessment was reviewed by the Quality Assurance Process Improvement (QAPI) Committee. The date for review by the QAA/QAPI committee was blank.
On page 18/22, 3.10, the answer was written about monthly meetings, daily rounds and an open door policy for staff, residents and families to speak with the Administrator. There was no mention of a compliance hot line, grievance process, Resident Council, Family Council or QAPI.
Under # 3.11 List of contracts was written All contracts are kept in the Administrator's office and/or Medical Records office. There was no description of the facility's process for overseeing the services and how the services would meet the needs of the residents.
Per the Regional consultant, Medical Records actually keeps them in the Medical Records office. The Regional Consultant stated the facility assessment did not list the contracts, memoranda of understanding or agreements with third parties.
On page 19/22 -3.12-List health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations.
The only answer written was :The facility EHR (electronic health record) is PointClickCare.
The assessment did not address how the facility would securely transfer health information to a hospital, home health agency, or other providers for any resident transferred or discharged from the facility. There were concerns identified during the survey regarding residents not receiving access to their medical records upon request and copies were not obtained within required time frames.
The Acting Administrator stated, We have a back up of the EHR (Electronic Health Record.) We have systems in place but they are not in this assessment.
The facility assessment did not include an evaluation of the physical environment necessary to meet the needs of the residents. It did not address how the facility needed to be equipped and maintained to protect and promote the health and safety of residents. There was only one working washing machine in the facility at the time of survey. According to interviews conducted with the Housekeeping staff, the other washing machines had been inoperable for at least two months prior to survey.
During the end of day debriefing on 10/11/2024, the Facility's Acting Administrator, Administrator in Training, Regional Nurse Consultant (Corporate-2) and Director of Nursing were informed of the findings that throughout the facility assessment, there were only generalizations but no tailoring of the assessment to the facility. The Acting Administrator stated the facility assessment needed more details added to it to make sure it reflected the facility.
No further information was provided prior to survey exit.
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
Based on observation, Resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure the facility maintained a safe, sanitary, and comfo...
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Based on observation, Resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure the facility maintained a safe, sanitary, and comfortable environment to prevent the transmission of communicable diseases, infections, Legionnaires', and other potentially transmissible waterborne pathogens, on 4 of 4 Resident living units and communal spaces.
The findings included;
The facility staff failed to ensure that the facility was free from dampness, and mold. Surveyors observed wet mold on floors, walls, ceiling tiles, ceiling insulation and pipes, shower grout, base boards, and shower curtains, and Resident rooms. Unsanitary areas also included shower rooms, laundry facilities, the main kitchen, insects on 4 of 4 units, ice machines were not kept clean and sanitary, and staff further failed to complete, and document preventative maintenance, water/water damage testing, and cleaning schedules.
On 10-9-24 observation of the Resident hydration ice machine in the closet across from the dining room revealed standing water on the floor, a ½ inch thick, 3 foot by 3 foot rubber hole punched mat, with live cock roaches (5-6 of them) crawling around it, and under it. The ice machine drainage pipe was dripping directly onto the floor, and not into a drain.
Under the ice machine was an approximately 4 inches wide, by 4 inches long, by ½ inch high, irregularly shaped circular, black slimy mold growing substance. The mold had a gelatinous, semi solid, humped shape, with encircled stringy, anemone like tentacle out growths. The out growths had the appearance of a fringe with a yellow colored cast around the outer edges. The mold was partially on the wet floor and partially on the 5-7 pieces of wet paper trash under the ice machine, and behind it. The entire area smelled of dampness, dirt, and mold.
The Administrator was coming down the hall at that time and was asked to view the area. When asked if he thought it was safe and sanitary for Residents to consume ice made in that environment, he stated that it was not.
The date on the ice machine filter was illegible. There was no documentation of a cleaning schedule, nor inspection of the area. On 10-9-24 the Maintenance Director was asked about the cleaning schedule for the ice machines and he stated we wipe them down once a month, then quarterly we empty it and sanitize it, then every 6 months we change the filters. He was then asked to provide the policy for ice room and machine cleaning.
The ice machine in the kitchen area had a filter change date of 6-7-24, however, the ice machine cleaning log had not been filled in (all sheets were blank).
The following excerpt from the ice machine policy read:
Policy: All ice machines will be inspected regularly as scheduled and preventative maintenance will be performed to verify proper and safe operation.
Procedure: Monthly
1. Shut ice machines down for preventive maintenance service.
2. Check water valves and connectors.
3. Check for slime, sediment, build up, rust or corrosion clean/repair as needed.
4. Clean according to manufacturer instructions using nickel safe cleaner.
The Centers for (CDC) Disease Control was stated as the facility standard for infection control practices and procedures for the facility. The CDC states in teaching that mold growing in buildings, regardless of type indicates there is a problem with water or moisture that should be immediately addressed.
The CDC standards on mold review revealed the following:
Exposure to damp and moldy environments may cause a variety of health effects. For some people, mold can cause a stuffy nose, sore throat, coughing or wheezing, burning eyes, or skin rash. People with asthma or who are allergic to mold may have severe reactions. Immune-compromised people and people with chronic lung disease may get infections in their lungs from mold. For people who are sensitive to molds, exposure to molds can lead to symptoms such as stuffy nose, wheezing, and red or itchy eyes, or skin. Severe reactions, such as fever or shortness of breath, may occur among workers (or those living in an environment) exposed to large amounts of molds in a setting.
In 2004 the Institute of Medicine (IOM) found there was sufficient evidence to link indoor exposure to mold with upper respiratory tract symptoms, cough, and wheeze in otherwise healthy people; with asthma symptoms in people with asthma; and with hypersensitivity pneumonitis in individuals susceptible to that immune-mediated condition.
In 2009, the World Health Organization issued additional guidance, the WHO Guidelines for Indoor Air Quality: Dampness and Mold. Other recent studies have suggested a potential link of early mold exposure to development of asthma in some children, particularly among children who may be genetically susceptible to asthma development, and that selected interventions that improve housing conditions can reduce morbidity from asthma and respiratory allergies.
The National Institute of Occupational Safety and Health (NIOSH) recommendations follow:
The health of those who live, attend school, or work in damp buildings has been a growing concern through the years due to a broad range of reported building-related symptoms and illnesses. Research has found that people who spend time in damp buildings are more likely to report health problems such as these:
o Respiratory symptoms (such as in nose, throat, lungs)
o Development or worsening of asthma
o Hypersensitivity pneumonitis (a rare lung disease caused by an immune system response to repeated inhalation of sensitizing substances such as bacteria, fungi, and organic dusts.)
o Respiratory infections
o Allergic rhinitis (often called hay fever)
o Bronchitis o Eczema Exposures in damp buildings are complex. They vary from building to building, and in different places within a building.
Mildew versus mold identification is not typically difficult. Mildew will appear as a white/gray, or tan powdery appearance which is superficial to the surface it is on, making cleaning and eradication easier than mold . Mold is imbedded in a surface and is much more difficult to eradicate, and in some instances impossible, thus the surface must be replaced entirely. Moisture allows indoor mold to multiply more easily on building materials or other surfaces, and people inside buildings may be exposed to microbes and their structural components, such as spores, biologically released chemicals, and fungal fragments.
Mold may also produce substances that can cause or worsen health problems, and these substances vary depending on the mold species and on conditions related to the indoor environment.
Moisture can also attract cockroaches, rodents, and dust mites. Moisture-damaged building materials can release volatile organic compounds that can cause health problems.
Researchers have not found exactly how much exposure to dampness-related substances it takes to cause health problems.
Research studies report that finding and correcting sources of dampness is a more effective way to prevent health problems. Therefore, NIOSH developed a tool to help assess areas of dampness in buildings and to help prioritize remediation of problems areas.
Legionnaires' and other potentially transmissible waterborne pathogens.
Resident symptoms were noted and complained of by 8 Residents on all 4 Resident living units. The complaints ranged from intractable headaches, to sore throats, asthma, shortness of breath, nausea, diarrhea, body aches, and head pressure with nasal congestion. Residents #424, 38, 151, 68, 20, and #127 all complained of these symptoms to 4 different surveyors independently of one another, and without knowing others had complained as well.
On 10-7-24 at approximately 3:00 p.m. an interview was conducted with Resident #153 who stated that he had Mold and Mildew in his ceiling, and they keep just painting over it. He pointed out a spot on the ceiling that appeared freshly painted, however there were black spots bleeding through the painted area. Resident #153 stated that the ceiling leaks and then it dries and then when he complains of the black spots They just paint over it, that is not fixing the problem.
On 10-7-24 at approximately 3:30 PM an interview was conducted with Resident #424. The surveyor was talking to two nurses at the nursing station and Resident #424 came up the hall yelling someone has got to do something about my room! I am trying to get over pneumonia and I can not get better with that mold in my room. It's keeping me sick. A second surveyor joined and the three went to the Resident's room to inspect it. The ceiling tiles had been recently replaced and the room still smelled of fresh paint, however, black mold dots appeared through the paint behind the door all the way from the ceiling to the floor in varying stages of emergence. Some still under the new paint and some clearly visible on top of it. There were also 2 ceiling tiles which showed the mold coming through them as well.
The surveyors continued back to the nursing station to find the Maintenance Director standing in the hallway under an open area in the ceiling where ceiling tiles had been removed. The area above was clearly wet and leaking, and he stated it was from condensation caused by the air conditioning lines, and the insulation around the pipes were soaking wet and slimy. The entire building was experiencing this water leakage with buckets and trash cans in the hallways noted to be under the continuously dripping leaks. Staff members stated this had been an ongoing issue for many months, and it's worse when it rains. Staff complained that they had symptoms too, and it was true what the Residents were saying.
During the interview he explained he had just found 22 Blowers in the ceiling which would have kept air circulation above the ceiling moving, so that this would not happen. He went on to say he had been unaware of the blowers existence until he saw one today while changing out a ceiling tile. He stated they had not been operating and he was working on getting them operating. He was asked why the wet insulation was left in the ceiling which would continue to leak until it was removed. He stated that it needed to be removed, and he was working on it, however, if he could get the blowers working that would solved the problem.
During the above interview at 4:30 PM the Maintenance Director came to the conference room and stated that he had the one blower working and it was an easy fix, so he was going to get them all working. He was asked if testing had been done in the ceiling and insulation to determine what was growing up there, as mold was already apparent throughout the building, and those blowers would then spread (aerosolize) it into the air. He stated no testing had been done and they were not required to test unless Residents had symptoms. He was informed that he was now aware that residents did have symptoms, and conditions were present for multiple pathogenic organisms to grow. He was asked for the Legionnaires' policy at that time.
A review of the Legionnaires' policy revealed that the Infection Preventionist and the Maintenance Director would work together to identify those areas where there was a potential risk for contaminates associated with the development of Legionnella.
Those areas include Standing/non-circulating water, scale and sediment build-up, and the presence of biofilm, also known as slime.
The policy goes on to say Conduct daily, weekly, monthly, and as needed rounds to inspect and monitor the environment .in order to identify whether conditions are present that could lead to the spread of Legionnella. If conditions are present they need to contact a professional water treatment service in order to obtain samples and send to the lab for analysis. The policy goes on to describe areas in the facility where Legionnella could grow which included the cooling system.
The facility staff was aware of the standing water in the leaking ceiling, and the slime on the insulation and should have known that this was an identified area of risk. Further, the policy did not state testing must only be completed after symptoms in the population. That would be counterproductive. Infection control policies are required by regulation to be implemented in order to guide the prevention of the spread of infection and communicable disease.
Communal Resident shower room observations on all 4 units were made on 10-9-24 at 2:40 p.m. and were as follows:
Unit 1 - Women's shower room- A wet washcloth left in bathroom on floor, floor needed mopping, stains were visible on the floor, black substances in shower area in grout lines and near the floor of shower.
Unit 1 Men's shower room - The trash had not been emptied, the shower room smelled of urine, the floor was dirty, shower stalls had black substance in corners and at base of the shower.
Unit 2 - Women's shower room - Bariatric shower seat in the stall which had a soaking wet sheet on it stained with brownish yellow stains, the toilet paper holder was broken, shower curtains had black substance on the bottom edge, opened toothpaste and deodorant sitting on the shelf with no name on it, the floor needed to be cleaned.
Unit 2 Men's shower room - Rust stains behind a toilet, dirty pajama bottoms and socks were on the floor, strong urine odor was present in the shower room, shower curtains had black stains, and the shower stall floors had black in the grout and the corners.
Unit 3 Women's shower room -Rust on a shower chair, chipped broken tiles at the corner of a wall, toilet paper holder was broken.
Unit 3 Men's shower room - Oxygen concentrator was in the shower room with no name or room number on it, the light in toilet area was not working, the toilet paper holder was broken, and black and rust colored stains were in the shower area.
Unit 4 Women's shower room - A dirty wash cloth was on a chair, the shower area was dirty, especially at the base where wall and floor meet encrusted in a black/brown substance, and the floor needed to be swept and mopped.
Unit 4 Men's shower room - A used incontinence brief was in the trash, the floor needed to be swept and mopped, paper trash was on the floor, the shower area was dirty, with a black substance in the corners and in the grout.
Pest Control Review:
During the entire survey there were fruit flies as well as large flies, and cock roaches noted on all 4 living units, in the kitchen, and in the common areas.
A review of the pest control logs revealed that the facility is having pest control services come to the building monthly, however, the pests continue to be in the facility.
Laundry and linen review:
Residents on 4 of 4 units complained of lack of linens and personal clothing taking too long to come back from laundry, and wearing clothing for 2-3 days straight.
On 10-10-24 at 2:00 PM, an interview was conducted with the director of housekeeping who was asked why there was a shortage of linens, and the laundry was not getting done in a timely manner. She stated that they are doing the best they could with 1 washing machine. When asked if that is all the facility has for 180 beds, she stated that the other 2 washers were broken. She stated that the laundry staff are working 7 days a week with the one washer, and they must try and keep up with all the linens and facility laundry as well as Resident personal clothing.
Facility maintenance records indicated that on 9-30-24 Washer 1 & 2 down and waiting on replacement for #1. As of the close of survey on 10-11-24 the washing machines had still not been repaired nor replaced.
Kitchen Review:
On 10-4-24 at 12:45 PM during the active lunch service, the dining room and kitchen inspection was continued. 14 hospital beds were stacked haphazardly on the right side of the dining room close to the kitchen door. 3 of those beds were new, and 11 were old, used, and dirty, commingled with the new beds.
The old used dirty beds were encrusted with hair, dust, brown greasy substances, what looked like food debris and cracker crumbs, rust, mold, chipped wood particles, and the head boards and foot boards were separating and broken. Residents were in the dining room eating lunch and being fed at tables in close proximity to the beds.
Two CNAs were in the dining room assisting Residents at the time and both stated those beds have been in here for months. They are using this as a storage room and it's dangerous, they are nasty, and someone could fall.
Two dead cock roaches were noted in the kitchen's dry food storage area and one in the kitchen near the 3-compartment sink. The floor in the dry storage area had paper trash and food debris on the floor. The floor was visibly stained, and the dishwasher was found to be inoperable.
On 10-8-24 an interview was conducted with Other Employed #5 who stated that he wasn't exactly sure how long the dishwasher had been down. He was asked to research and provide a timeline. The kitchen staff were noted to be using Styrofoam take out containers for food service during the lunch and dinner meals.
When questioned Other Employee #9 stated the dishwasher has been broken for weeks maybe months now. He stated, we have a new one it's just not hooked up yet.
Food temps on 4 of 4 Resident living units was investigated, temperatures were taken, and found to be between 80 - 100 degrees Fahrenheit. On all 4 units the Residents complained of continued lukewarm, or cold food. Many Residents stated that since they started using Styrofoam boxes the food is cold.
A review of the work orders and emails from the Maintenance Director to the facility corporate office revealed the dishwasher had been inoperable since 8-9-24.
Review of those emails and communications follow below:
8-6-24 - dishwasher was purchased (evidenced by email from corporate purchasing office to maintenance).
9-24-24 - dishwasher arrived at facility (as evidenced by email between maintenance and supplier).
10-10-24 -during the survey, the dishwasher installed and running as of breakfast meal.
On 10-11-24 at the end of day debriefing the facility Administrator, Director of Nursing and other corporate staff were made aware of the concerns. They stated they had no further information to provide prior to survey exit.
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 F0921)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility documentation the facility staff failed to provide a safe, functional, sanitary, a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility documentation the facility staff failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.
The findings included:
For the facility staff failed to ensure that the facility was free from damp mildew smell, wet ceiling tiles, unsanitary shower rooms, and ice machines were kept clean and sanitary and document preventative maintenance and cleaning schedules.
On 10/11/24 observation of the ice machine in closet across from the dining room revealed standing water on the floor, a rubber mat with live roaches (5-6 of them) crawling around and under it, the ice machine drainage pipe was dripping on the floor not in the drain. Under the ice machine was black slimy substance and wet paper trash as well. The entire area smelled of dampness and mildew.
The Administrator was coming down the hall and asked to view the area when asked if he thought it was safe and sanitary for Residents to consume ice made in that environment, he stated that it was not. The date on the ice machine filter was illegible. There was no documentation of cleaning schedule or inspection.
On 10/11/24 the maintenance person was asked about the cleaning schedule for the ice machines and he stated we wipe them down once a month, then quarterly we empty it and sanitize it and every 6 months we change the filters. He was then asked to provide the policy for ice machine cleaning.
The ice machine in the kitchen area had a filter change date of 6/7/24 however the ice machine cleaning log had not been filled in (all sheets were blank).
The following excerpt from the ice machine policy read:
Policy: All ice machines will be inspected regularly as scheduled and preventative maintenance will be performed t6 verify p-[NAME] and safe operation.
Procedure: Monthly
1. Shut ice machines down for preventive maintenance service
2. Check water valves and connectors
3. Check for slime, sediment, build up, rust or corrosion clean/repair as needed
4. Clean according to manufacturer instructions using nickel safe cleaner.
Observations made on 10/11/24 at 2:40 p.m.
Unit 1 - Women's shower room-wet washcloth left in bathroom on floor, floor needs mopping, stains visible on floor,
black substance in shower area in grout lines and near floor of shower.
Unit 1 Men's shower room - trash had not been emptied, shower room smelled of urine, floor dirty, shower stall has black substance in corners and at base of the shower.
Unit 2 - Women's shower room - bariatric shower seat in the stall had a soaking wet sheet on it stained with brownish yellow stains, the toilet paper holder is broken, shower curtains have black substance on the bottom edge, opened toothpaste and deodorant sitting on the shelf no name on it. Floor needs to be cleaned.
Unit 2 Men's shower room - rust stains behind toilet, dirty pajama bottoms and socks on the floor, strong urine odor in shower room, shower curtains have black stain, and the shower stall floors have black in the grout and the corners.
Unit 3 Women shower room -Rust on shower chair, chipped broken tiles at corner of wall, toilet paper holder is broken.
Unit 3 Men's shower - Oxygen concentrator in shower room no name or room number on it, light in toilet area is not working, toilet paper holder was broken, and black and rust colored stains in the shower area.
Unit 4 Women's shower room - Dirty wash cloth on chair, shower area dirty especially at base where wall and floor meet, black/brown substance, and floor needs swept and mopped.
Unit 4 Men's shower room - used incontinence brief in trash, floor needs swept and mopped, paper trash on floor, shower area dirty black substance in corners and in grout,
On 10/11/24 during the end of day meeting the administrator was made aware of the concerns and no further information was provided,
May 2024
9 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 review of facility's documentation and staff interview, it was determined that the facility failed to promote and enhan...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility's documentation and staff interview, it was determined that the facility failed to promote and enhance each resident's right to a dignified existence and being respected for one of five residents in the survey sample, Resident #1.
The findings include:
Resident #1 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CKD (chronic kidney disease), vascular dementia and stroke with hemiplegia.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 4/22/24, coded the resident as scoring a 99 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was unable to complete the interview. A review of the MDS Section G-functional status coded the resident as requiring total dependence for transfer and bathing; extensive assistance for bed mobility, dressing, hygiene, toileting and eating.
A review of the comprehensive care plan dated 5/22/23 revealed, FOCUS: Resident is at risk for weight loss or malnutrition related to past medical history or diagnosis of dehydration, acute renal failure, dysphagia requiring modified-texture diet, nausea/ vomiting, suboptimal PO intakes- receiving oral nutrition supplements. BMI < 18.5, indicative of underweight status. INTERVENTIONS: Registered dietician consult as needed. Record % meal intake. Provide supplements as ordered.
On 5/28/24 at 1:20 PM, observation of Resident #1 being fed by CNA (certified nursing assistant) who was standing up. Unable to interview this CNA.
An interview was conducted on 5/29/24 at 8:45 AM with CNA #4. When asked how residents should be fed, CNA #4 stated, All the trays are passed out, so the patient is not looking at the tray. Respectful and dignity are involved. You should sit patient up, make eye contact and get a chair so it's like we're having a meal together. When asked if standing while feeding a resident was respectful, CNA #4 stated, No, it is not.
An interview was conducted on 5/29/24 at 9:00 AM with Resident #1. When asked if the CNAs sit when they are feeding her, she stated,No, most of the time they stand. When asked if that makes her feel respected, Resident #1 stated, Oh, God no. I do not like it at all.
On 5/29/24 at 1:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the assistant administrator, ASM #3, the DON (director of nursing) ASM #4, the regional director of clinical services and ASM #5, the regional director of clinical services was made aware of the findings.
No further information was provided prior to 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
Deficiency F0553
(Tag F0553)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and facility document review, it was determined the facility staff failed to respect the resident's and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and facility document review, it was determined the facility staff failed to respect the resident's and RP's (responsible party) right to participate in care planning for one of five residents in the survey sample, Resident #1.
The findings include:
Resident #1 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CKD (chronic kidney disease), vascular dementia and stroke with hemiplegia.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 4/22/24, coded the resident as scoring a 99 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was unable to complete the interview. A review of the MDS Section G-functional status coded the resident as requiring total dependence for transfer and bathing; extensive assistance for bed mobility, dressing, hygiene, toileting and eating.
A review of the comprehensive care plan dated 5/22/23 revealed, FOCUS: Resident is at risk for weight loss or malnutrition related to past medical history or diagnosis of dehydration, acute renal failure, dysphagia requiring modified-texture diet, nausea/ vomiting, suboptimal PO intakes- receiving oral nutrition supplements. BMI < 18.5, indicative of underweight status. INTERVENTIONS: Registered dieticians consult as needed. Record % meal intake. Provide supplements as ordered.
On 5/24/24, the facility was asked to provide evidence of care plan meetings and invites for Resident #1 and their RPs.
A review of the progress note dated 5/2/24 at 2:04 PM revealed, IDT met today to review pt's plan of care. Members in attendance were D/C Planner, Activities Assistant, LPN, and Ombudsman. Patient's son was called but was unable to attend meeting via telephone due to work. The Ombudsman went over the patient's family's concerns with the IDT. The team addressed possible plans of action to address concerns. Staff will continue to communicate with patient's family and monitor and review patient's plan of care.
Facility provided evidence of last care plan meeting notes dated 8/23/23. No evidence of care plan meetings from 8/23-5/24.
An interview was conducted on 5/28/24 at 2:15 PM with OSM (other staff member) #7, the MDS coordinator. When asked who is responsible for and the process for care plan meetings, OSM #7 stated, The responsibility is mine. I go by assessment date, we do care plans on Wednesday and Thursday, when I update assessments. The front desk mails off letters to let the RPs know of care plan meeting dates. When asked for evidence of any letters for Resident #1 and their RP, OSM #7 stated, There is not any that we can find.
On 5/29/24 at 1:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the assistant administrator, ASM #3, the DON (director of nursing) ASM #4, the regional director of clinical services and ASM #5, the regional director of clinical services was made aware of the findings.
No further information was provided prior to 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
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 and facility document review, it was determined the facility staff failed to notify the RP (responsible...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and facility document review, it was determined the facility staff failed to notify the RP (responsible party) of a change in condition for one of five residents in the survey sample, Resident #1.
The findings include:
The facility failed to notify the RP for Resident #1's weight loss. Resident #1 weighed 127 pounds on 1/13/23, 117.6 pounds on 5/6/23 and currently 99.3 on 5/1/24. No notification to family after 7/28/23.
Resident #1 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CKD (chronic kidney disease), vascular dementia and stroke with hemiplegia.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 4/22/24, coded the resident as scoring a 99 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was unable to complete the interview. A review of the MDS Section G-functional status coded the resident as requiring total dependence for transfer and bathing; extensive assistance for bed mobility, dressing, hygiene, toileting and eating.
A review of the comprehensive care plan dated 5/22/23 revealed, FOCUS: Resident is at risk for weight loss or malnutrition related to past medical history or diagnosis of dehydration, acute renal failure, dysphagia requiring modified-texture diet, nausea/ vomiting, suboptimal PO intakes- receiving oral nutrition supplements. BMI < 18.5, indicative of underweight status. INTERVENTIONS: Registered dieticians consult as needed. Record % meal intake. Provide supplements as ordered.
A review of the progress notes titles Communication with Family) from 1/20/23-5/20/24 did not reveal any communication with family regarding weight loss.
A review of the RD/Dietary progress note dated 7/24/23 at 8:57 AM revealed, Staff made RD aware that resident's son wished to be contacted regarding diet change/weight loss. RD left for this contact on 7/24. Will cont. to monitor.
A review of the RD/Dietary progress note dated 7/28/23 at 9:15 AM revealed, RD spoke with resident's POA this AM due to requests of discussing weight loss. POA requesting information on if resident is consuming enough nutrition to sustain her weight. RD did make POA aware of current weight loss and prescribed interventions that have been put in place. Resident is currently consuming all supplements adequately- 100% and receives assistance with her meals to support good PO intake. She is also noted w/ Mirtazapine with potential side effects for appetite stimulation. RD made POA aware that resident is being weighed weekly for closer monitoring. POA thankful for communication. Will continue to monitor.
A review of the RD/Dietary progress note dated 4/19/24 at 9:10 AM revealed, WEIGHT WARNING: Value: 101.0 Vital Date: 2024-04-15 4:15 PM, -10.0% change. Malnutrition Universal Screening Tool completed Quarterly Assessment: Diet: Regular, Dysphagia Puree, with thins. PO intake/feeding ability: 75-100% assist with meals. Supplements: health shake x2 & magic cup with meals; 4 oz Medplus 2.0 QID. Weight Resident noted w/ a significant weight loss -10.2% x180 days. Resident has numerous supplements in place with good acceptance & good PO intake for weight support. Recommendations: 1) Cont. w/ current diet & supplements as tolerated. 2) RD to monitor/follow as per protocol.
An interview was conducted on 5/29/24 at 8:00 AM with OSM (other staff member) #4, the registered dietician. When asked about Resident #1, OSM #4 stated, If staff alert me that they are not eating well, then I go to see her. Have observed her 1 time. Otherwise, I monitor the ADL record for % meal eaten. I go off of what is documented. House Shakes and Magic Cups higher protein and more calories as well as the Med Plus (more calorie dense option).
On 5/29/24 at 1:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the assistant administrator, ASM #3, the DON (director of nursing) ASM #4, the regional director of clinical services and ASM #5, the regional director of clinical services was made aware of the findings.
No further information was provided prior to exit.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to me...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to meet professional standards for one of five residents in the survey sample, Resident #4.
The findings include:
The facility staff failed to meet professional standards by administering medications as ordered for Resident #4.
Resident #4 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: sepsis, dementia, cardiomyopathy, Parkinson's and COPD (chronic obstructive pulmonary disease).
The most recent MDS (minimum data set) assessment, a significant change assessment, with an ARD (assessment reference date) of 10/27/23, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring total dependence for transfer, bathing, bed mobility, dressing, hygiene, toileting and moderate assist for eating.
A review of the comprehensive care plan dated 11/11/21 revealed, FOCUS: Resident has Congestive Heart Failure. INTERVENTIONS: Give cardiac medications as ordered.
A review of the physician orders dated 11/30/22 revealed, Atorvastatin Calcium Oral Tablet 40 MG (milligram). Give 1 tablet by mouth at bedtime for HLD. Sinemet Oral Tablet 25-100 MG. Give 1 tablet by mouth two times a day for Parkinsons; and those dated 12/23/23: Zaleplon Oral Capsule 10 MG. Give 1 capsule by mouth at bedtime for insomnia. Xalatan Ophthalmic Solution 0.005%, Instill 1 drop in right eye at bedtime.
A review of the December MAR (medication administration record) revealed, missing 9:00 PM doses on 12/31/23 of Atorvastatin Calcium Oral Tablet 40 MG (milligram). Give 1 tablet by mouth at bedtime for HLD. Sinemet Oral Tablet 25-100 MG. Give 1 tablet by mouth two times a day for Parkinsons; and those dated 12/23/23: Zaleplon Oral Capsule 10 MG. Give 1 capsule by mouth at bedtime for insomnia. Xalatan Ophthalmic Solution 0.005%, Instill 1 drop in right eye at bedtime.
An interview was conducted on 5/28/24 at 11:00 AM with LPN (licensed practical nurse) #3. When asked if there is adequate staffing, LPN #3 stated, No, not all of the time. It is getting better, but it was not good a couple of months ago. When asked specifics, LPN #3 stated, There would be no nurse scheduled for a unit or CNAs would be minimal not enough to meet the resident's needs. When asked if not administering medications as ordered was following professional standards, LPN #3 stated, No, it is not.
On 5/29/24 at 1:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the assistant administrator, ASM #3, the DON (director of nursing) ASM #4, the regional director of clinical services and ASM #5, the regional director of clinical services was made aware of the findings.
No further information was provided prior to exit.
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** Based on observations, staff interviews, facility document review and clinical record review, it was determined the facility sta...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, facility document review and clinical record review, it was determined the facility staff failed to provide evidence of ADL (activities of daily living) care for one of five residents in the survey sample, Resident #1.
The findings include:
The facility staff failed to provide evidence of ADL (specifically incontinence care and feeding assistance) care for Resident #1.
Resident #1 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CKD (chronic kidney disease), vascular dementia and stroke with hemiplegia.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 4/22/24, coded the resident as scoring a 99 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was unable to complete the interview. A review of the MDS Section G-functional status coded the resident as requiring total dependence for transfer and bathing; extensive assistance for bed mobility, dressing, hygiene, toileting and eating.
A review of the comprehensive care plan dated 5/22/23 revealed, FOCUS: Resident is at risk for weight loss or malnutrition related to past medical history or diagnosis of dehydration, acute renal failure, dysphagia requiring modified-texture diet, nausea/ vomiting, suboptimal PO intakes- receiving oral nutrition supplements. BMI < 18.5, indicative of underweight status. INTERVENTIONS: Registered dieticians consult as needed. Record % meal intake. Provide supplements as ordered.
A review of the ADL (activities of daily living) document for March 2024 revealed missing documentation for: bladder elimination: day shift-3/16, 3/17 and 3/31; evening shift-3/8, 3/17 and 3/29.
A review of the ADL (activities of daily living) document for March 2024 revealed missing documentation for: bladder elimination and grooming: day shift-3/16, 3/17 and 3/31; evening shift-3/8, 3/17 and 3/29.
A review of the ADL (activities of daily living) document for April 2024 revealed missing documentation for:
bladder elimination and grooming: day shift-4/3, 4/13, 4/14, 4/17, 4/19 and 4/21; evening shift-4/5, 4/7-4/22 [16 shifts], 4/24, 4/25 and night shift 4/6 and 4/15.
A review of the ADL (activities of daily living) document for May 2024 revealed missing documentation for: bladder elimination and grooming: evening shift 5/2, 5/19 and 5/20.
An interview was conducted on 5/28/24 at 8:00 AM with CNA (certified nursing assistant) #1. When asked the frequency of incontinence care, CNA #1 stated, We try to do it every two hours but it depends upon staffing and the resident's needs. When asked where there would be evidence of incontinence care, CNA #1 stated, In PCC.
An interview was conducted on 5/29/24 at 9:00 AM with Resident #1. When asked if she is kept dry, Resident #1 stated, Not always, sometimes I wait a long time. It is getting better.
On 5/29/24 at 1:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the assistant administrator, ASM #3, the DON (director of nursing) ASM #4, the regional director of clinical services and ASM #5, the regional director of clinical services was made aware of the findings.
No further information was provided prior to exit.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to me...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, it was determined the facility staff failed to meet provide catheter care for one of five residents in the survey sample, Resident #4.
The findings include:
The facility staff failed to provide urinary catheter care for Resident #4.
Resident #4 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: sepsis, dementia, cardiomyopathy, Parkinson's and COPD (chronic obstructive pulmonary disease).
The most recent MDS (minimum data set) assessment, a significant change assessment, with an ARD (assessment reference date) of 10/27/23, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring total dependence for transfer, bathing, bed mobility, dressing, hygiene, toileting and moderate assist for eating.
A review of the comprehensive care plan dated 11/11/21 revealed, FOCUS: Resident has Congestive Heart Failure. INTERVENTIONS: Give cardiac medications as ordered.
A review of the physician orders dated 12/1/23 revealed, Foley care every shift and revised on 12/15/23 Foley care every shift. Document output every shift. Monitor for signs/symptoms of infection. Notify MD as needed.
A review of the December 2023 and the January 2024 TAR (treatment administration record) revealed missing documentation on the following shifts and dates:
Day Shift: 12/9/23, 12/21/23, 12/22/23, 12/30/23, 1/2/24, 1/3/24 and 1/8/24.
Evening Shift: 12/11/23, 12/15/23, 12/24/23 and 1/20/24.
Night Shift: 12/10/23, 12/15/23, 12/22/23 and 1/4/24.
An interview was conducted on 5/28/24 at 11:00 AM with LPN (licensed practical nurse) #3. When asked where evidence of foley catheter care would be found, LPN #3 stated, It would be found on the TAR. When asked if there is no documentation of the foley catheter care being provided, was it provided, LPN #3 stated, No, it was not.
On 5/29/24 at 1:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the assistant administrator, ASM #3, the DON (director of nursing) ASM #4, the regional director of clinical services and ASM #5, the regional director of clinical services was made aware of the findings.
No further information was provided prior to exit.
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 F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, facility document review and clinical record review, it was determined the facilit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, facility document review and clinical record review, it was determined the facility staff failed to provide feeding assistance to prevent weight loss for one of five residents in the survey sample, Resident #1.
The findings include:
The facility failed to provide feeding assistance to prevent weight loss for Resident #1. Resident #1 weighed 127 pounds on 1/13/23, 117.6 pounds on 5/6/23 and currently 99.3 on 5/1/24.
Resident #1 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CKD (chronic kidney disease), vascular dementia and stroke with hemiplegia.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 4/22/24, coded the resident as scoring a 99 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was unable to complete the interview. A review of the MDS Section G-functional status coded the resident as requiring total dependence for transfer and bathing; extensive assistance for bed mobility, dressing, hygiene, toileting and eating.
A review of the comprehensive care plan dated 5/22/23 revealed, FOCUS: Resident is at risk for weight loss or malnutrition related to past medical history or diagnosis of dehydration, acute renal failure, dysphagia requiring modified-texture diet, nausea/ vomiting, suboptimal PO intakes- receiving oral nutrition supplements. BMI < 18.5, indicative of underweight status. INTERVENTIONS: Registered dieticians consult as needed. Record % meal intake. Provide supplements as ordered.
A review of the ADL (activities of daily living) document for March 2024 revealed missing documentation for: eating/self-performance: Day shift (breakfast and lunch)-3/16, 3/17 and 3/31. Evening shift (supper)-3/8, 3/17 and 3/29.
A review of the ADL (activities of daily living) document for April 2024 revealed missing documentation for:
eating/self-performance: Day shift (breakfast and lunch)-4/3, 4/13, 4/14, 4/17, 4/19 and 4/21. Evening shift (supper)-4/5, 4/7-4/22 [16 shifts], 4/24 and 4/25.
A review of the ADL (activities of daily living) document for May 2024 revealed missing documentation for: eating/self-performance: Evening shift (supper)-5/2, 5/19 and 5/20.
An interview was conducted on 5/28/24 at 8:00 AM with CNA (certified nursing assistant) #1. When asked about feeding assistance, CNA #1 stated, We feed them as quickly as possible. When asked where there would be evidence of feeding assistance being provided, CNA #1 stated, We document it in PCC the ADL/CNA form.
An interview was conducted on 5/29/24 at 9:00 AM with Resident #1. When asked if she is provided feeding assistance, Resident #1 stated, Not always, I wait a long time and sometimes the food is cold, or I do not get fed at all.
On 5/29/24 at 1:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the assistant administrator, ASM #3, the DON (director of nursing) ASM #4, the regional director of clinical services and ASM #5, the regional director of clinical services was made aware of the findings.
No further information was provided prior to exit.
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 F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview, resident observation, facility document review and clinical record review, it was determi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview, resident observation, facility document review and clinical record review, it was determined that the facility staff failed to provide sufficient staffing to meet resident needs for two of five residents in the survey sample, Resident #1 and Resident #4.
The findings include:
1.The facility staff failed to provide sufficient staffing to meet Resident #1's needs.
During the course of the standard, licensure and complaint Medicare survey conducted 5/24/24-5/29/24, a request was made on 5/24/24 for the as worked staffing schedule for 3/1/24-5/24/24. When asked during the entrance conference if there were any staffing waivers, ASM (administrative staff member) #2, the director of nursing, stated, No, there are no waivers.
Resident #1 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: CKD (chronic kidney disease), vascular dementia and stroke with hemiplegia.
The most recent MDS (minimum data set) assessment, a quarterly assessment, with an ARD (assessment reference date) of 4/22/24, coded the resident as scoring a 99 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was unable to complete the interview. A review of the MDS Section G-functional status coded the resident as requiring total dependence for transfer and bathing; extensive assistance for bed mobility, dressing, hygiene, toileting and eating.
A review of the comprehensive care plan dated 5/22/23 revealed, FOCUS: Resident is at risk for weight loss or malnutrition related to past medical history or diagnosis of dehydration, acute renal failure, dysphagia requiring modified-texture diet, nausea/ vomiting, suboptimal PO intakes- receiving oral nutrition supplements. BMI < 18.5, indicative of underweight status. INTERVENTIONS: Registered dieticians consult as needed. Record % meal intake. Provide supplements as ordered.
A review of the ADL (activities of daily living) document for March and April 2024 revealed missing documentation for: bladder elimination: evening shift-3/8, 4/7-4/22 [16 shifts].
A review of the as worked staffing sheets for 3/1/24-5/24/24 revealed Unit 2 evening shift: 3/8/24 no CNA, 4/6/24- 2 CNAs, 4/7-2 CNAs, 4/15 no CNA, 4/17-2 CNAs.
An interview was conducted on 5/24/24 at 8:45 AM with Resident #2 (BIMS of 15), when asked about staffing, Resident #2 stated, Yes, it was awful back in March and April, it is getting better now.
An interview was conducted on 5/28/24 at 8:00 AM with CNA (certified nursing assistant) #1. When asked the frequency of incontinence care, CNA #1 stated, We try to do it every two hours but it depends upon staffing and the resident's needs.
An interview was conducted on 5/28/24 at 11:00 AM with LPN (licensed practical nurse) #3. When asked if there is adequate staffing, LPN #3 stated, No, not all of the time. It is getting better, but it was not good a couple of months ago. When asked specifics, LPN #3 stated, There would be no nurse scheduled for a unit or CNAs would be minimal not enough to meet the resident's needs.
An interview was conducted on 5/29/24 at 8:30 AM with OSM (other staff member) #13, the scheduler. When asked how long she had been in the position, OSM #13 stated, It was the end of April. The previous person was PRN (as needed). I am not sure what process they used then. When asked the staffing pattern for Unit 2, OSM #13 stated, On day shift- 3 nurses and 4-5 CNAs, evening shift -2 nurses and 3-4 CNAs and night shift- 1 nurse and 2 CNAs. When asked how staffing holes are filled, OSM #13 stated, We use occulus as our agency for staffing. I give them the needs schedule 3-4 weeks out. If there are staffing holes due to vacancies and/or call outs then the DON or ADON is to come and assist. When asked about holes on the schedules March April, she stated, We were shorter staffed then.
An interview was conducted on 5/29/24 at 9:00 AM with Resident #1. When asked if she is provided feeding assistance, Resident #1 stated, Not always, I wait a long time and sometimes the food is cold, or I do not get fed at all. They have not had good staffing.
On 5/29/24 at 1:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the assistant administrator, ASM #3, the DON (director of nursing) ASM #4, the regional director of clinical services and ASM #5, the regional director of clinical services was made aware of the findings.
No further information was provided prior to exit.
2.The facility staff failed to provide sufficient staffing to meet Resident #4's needs.
During the course of the standard, licensure and complaint Medicare survey conducted 5/24/24-5/29/24, a request was made on 5/24/24 for the as worked staffing schedule for 12/1/23-1/31/24. When asked during the entrance conference if there were any staffing waivers, ASM (administrative staff member) #2, the director of nursing, stated, No, there are no waivers.
Resident #4 was admitted to the facility on [DATE] with diagnosis that included but were not limited to: sepsis, dementia, cardiomyopathy, Parkinson's and COPD (chronic obstructive pulmonary disease).
The most recent MDS (minimum data set) assessment, a significant change assessment, with an ARD (assessment reference date) of 10/27/23, coded the resident as scoring a 13 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was cognitively intact. A review of the MDS Section G-functional status coded the resident as requiring total dependence for transfer, bathing, bed mobility, dressing, hygiene, toileting and moderate assist for eating.
A review of the comprehensive care plan dated 11/11/21 revealed, FOCUS: Resident has Congestive Heart
Failure. INTERVENTIONS: Give cardiac medications as ordered.
A review of the physician orders dated 11/30/22 revealed, Atorvastatin Calcium Oral Tablet 40 MG (milligram). Give 1 tablet by mouth at bedtime for HLD. Sinemet Oral Tablet 25-100 MG. Give 1 tablet by mouth two times a day for Parkinsons; and those dated 12/23/23: Zaleplon Oral Capsule 10 MG. Give 1 capsule by mouth at bedtime for insomnia. Xalatan Ophthalmic Solution 0.005%, Instill 1 drop in right eye at bedtime.
A review of the December MAR (medication administration record) revealed, missing 9:00 PM doses on 12/31/23 of Atorvastatin Calcium Oral Tablet 40 MG (milligram). Give 1 tablet by mouth at bedtime for HLD. Sinemet Oral Tablet 25-100 MG. Give 1 tablet by mouth two times a day for Parkinsons; and those dated 12/23/23: Zaleplon Oral Capsule 10 MG. Give 1 capsule by mouth at bedtime for insomnia. Xalatan Ophthalmic Solution 0.005%, Instill 1 drop in right eye at bedtime.
A review of the as worked staffing sheets for 12/1/23-1/31/24 revealed Unit 1: 12/31/23 no nurse scheduled after 7:00 PM. Staffing sheets were not available for review from 12/21/23-12/28/23.
An interview was conducted on 5/28/24 at 11:00 AM with LPN (licensed practical nurse) #3. When asked if there is adequate staffing, LPN #3 stated, No, not all of the time. It is getting better, but it was not good a couple of months ago. When asked specifics, LPN #3 stated, There would be no nurse scheduled for a unit or CNAs would be minimal not enough to meet the resident's needs.
An interview was conducted on 5/29/24 at 8:30 AM with OSM (other staff member) #13, the scheduler. When asked how long she had been in the position, OSM #13 stated, It was the end of April. The previous person was PRN (as needed). I am not sure what process they used then. When asked the staffing pattern for Unit 2, OSM #13 stated, On day shift- 3 nurses and 4-5 CNAs, evening shift -2 nurses and 3-4 CNAs and night shift- 1 nurse and 2 CNAs. When asked how staffing holes are filled, OSM #13 stated, We use (name of staffing agency) as our agency for staffing. I give them the needs schedule 3-4 weeks out. If there are staffing holes due to vacancies and/or call outs then the DON or ADON is to come and assist. When asked about holes on the schedules March April, she stated, We were shorter staffed then.
On 5/29/24 at 1:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the assistant administrator, ASM #3, the DON (director of nursing) ASM #4, the regional director of clinical services and ASM #5, the regional director of clinical services was made aware of the findings.
No further information was provided prior to exit.
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 F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to provide snacks at bedtime and meals in a timely manner.
The findings include:...
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Based on observations, staff interview, and facility document review, it was determined that the facility staff failed to provide snacks at bedtime and meals in a timely manner.
The findings include:
Mealtimes provided by the facility indicated that breakfast was to be delivered to unit 2A at 8:10 AM and unit 2B at 8:40 AM; lunch was to be delivered to unit 2A at 12:15 PM and unit 2B at 1:05 PM.
During the survey period of 5/24/24-5/29/24 meals were observed to be delivered on 5/24/24 unit 2B at 9:00 AM. On 5/28/24 on unit 2A breakfast was delivered at 8:30 AM unit 2 B at 8:55 AM and unit 2A lunch at 12:35 PM and unit 2B at 1:15 PM.
5/28/24 tour of the pantries on all units revealed the following:
1:10 PM observations of Unit 1 pantry: Lance PB cheese crackers 6 packs, 12 chocolate puddings, no applesauce, no graham crackers, no milk, no cheese.
1:15 PM observations of Unit 2 pantry: Lance PB cheese crackers 5 packs, Lance Toasted crackers 10 packs, no applesauce, no graham crackers, no milk, no cheese.
1:25 PM observations on Unit 3 pantry: Lance PB cheese crackers 3 packs, no applesauce, no graham crackers, no milk, no cheese.
1:35 PM observations on Unit 4 pantry: Lance PB cheese crackers 5 packs, 2 chocolate puddings, no applesauce, no graham crackers, no milk, no cheese.
An interview was conducted on 5/28/24 at 12:40 PM with LPN (licensed practical nurse) #1. When asked if snacks are provided, LPN #1 stated, We usually only have saltines or graham crackers. The kitchen has told us snacks are not in the budget. Sometimes there is not applesauce or pudding to use for medication administration.
An interview was conducted on 5/28/24 at 2:20 PM with CNA (certified nursing assistant) #3. When asked if there are snacks available for bedtime, CNA #3 stated, No, not usually. We do not offer them because we do not have them.
An interview was conducted on 5/28/24 at 2:40 PM with OSM (other staff member) #5, the Regional Director of Operations Culinary, and OSM #6, the new dietary manager (started 527/24). When asked about meal tray delivery, OSM #5 stated, We are short staffed, I have housekeeping helping out, rolling carts out to the floor and scraping plates. We are hiring staff in order to be able to get the meals out on time. When asked about snacks in the pantries, OSM #5 stated, The previous manager evidently did not do this. Normally there is a pantry par level and it is adjusted all the time, based on resident and unit needs. Yes, there should be a variety. We have been unable to obtain milk in cartons, only have large containers of whole milk. We just got an order in today of snacks, Lance PB cheese crackers, fig bars, granola bars, applesauce, pudding and graham crackers.
An interview was conducted on 5/29/24 at 9:00 AM with Resident #1, when asked if she is offered snacks at bedtime, Resident #1 stated, No, I am not.
An interview was conducted on 5/29/24 at 9:05 AM with Resident #2, when asked if she is offered snacks a bedtime, Resident #2 stated, No, there is not an offer of snacks. I do not believe they have any.
On 5/29/24 at 1:45 PM, ASM (administrative staff member) #1, the administrator, ASM #2, the assistant administrator, ASM #3, the DON (director of nursing) ASM #4, the regional director of clinical services and ASM #5, the regional director of clinical services was made aware of the findings.
No further information was provided prior to exit.
Feb 2024
3 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 F0635
(Tag F0635)
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 failed to ensure the necessary care and se...
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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 failed to ensure the necessary care and services are provided consistent with the resident's physical status and immediate needs upon admission to the facility for one (1) Resident (#1) in a survey sample of 28 Residents.
The findings included:
For Resident #1 the facility staff failed to perform an admission assessment, obtain vital signs, enter orders, administer oxygen, notify the physician to verify the orders, review the discharge summary from the hospital for the provision of immediate care resulting in the resident being found on the floor of his room unresponsive 2 hours after arrival at the facility.
Resident #1 was transferred to the facility from an acute care hospital with diagnoses that include but are not limited to acute hypoxic respiratory failure secondary to influenza A, COPD (Chronic Obstructive Pulmonary Disease), history of prostate cancer, history of tongue cancer, and hypertension. A review of the hospital discharge summary revealed that Resident #1 was supposed to be on 3 liters of oxygen. His discharge summary shows his oxygen saturation of 94% on 3 liters of oxygen.
Resident #1 was discharged from the hospital on [DATE] to the nursing home via medical transport (stretcher). According to the medical transportation trip run sheet they arrived at the facility with Resident #1 at 3:30 PM, transferred care at 3:45 and at 3:46 PM left the facility.
On [DATE] a review of the clinical record revealed no vital signs had been documented, no admission assessment had been started, no weight & height had been documented and no admission note had been entered.
On [DATE] at 10:45 AM an interview was conducted with LPN C who was asked to explain the admission process from the nurse's perspective. LPN C stated, Usually Employee G (Admissions) comes with a red folder and tells us we are getting an admission and lets us know what time and what room they will be going to. The nurse for that room will get the folder and review the information, and housekeeping will make sure the room is ready. Sometime before they arrive the hospital calls report and lets us know information about the resident usually it is why they were admitted , if they have a Foley catheter, issues with mobility, last BM, and any other pertinent information. We usually put in med orders before they arrive but do not activate them until they arrive. Employee G's folder has the discharge summary and med orders, therapy orders too. Once they arrive medical transport brings them in, we usually go in the room with transport and an aide comes to help get them into bed. Then we get vitals and do the skin assessment or admission assessment. When they arrive med transport hands us a folder with the discharge summary. When they give us the folder, we verify the orders with the doctor to get him or her to sign off so the medications will be on the way from the pharmacy.
On [DATE] at 10:15 AM an interview was conducted with Employee G, and she was asked how the admission process works. She stated that the hospitals contact the Admissions department and let them know that they have a patient in need of a stay. They will send over some information and nursing decides if we can meet their needs. She stated that once they have decided that the facility can meet the resident's needs and the Resident is ready to leave the hospital they call and ask about room availability, then they present the options to the Resident and family and let them decide. She stated that she then downloaded the H&P (history and physical), the discharge summary, and the discharge orders including meds treatments and therapy. She stated, I print all that out and fill out an admission Alert with the resident's name date of birth , diagnoses, allergies, code status, what hospital they are coming from, and what room they are assigned to. They also get a copy of the face sheet. Once all of this is collected the information goes into a red folder and then I take it to the nursing unit and find out which nurse has that hall. Give them the folder with the info. If I know that they are busy I will take it to the NP [Nurse Practitioner] or the doctor myself, to get them to sign off on meds and then give it to the nurse.
On [DATE] at 4:32 PM an interview was conducted with CNA C who stated that on [DATE] at the start of shift, they were made aware they would be getting an admission. She stated that she and CNA B continued to make rounds and pass ice until the Resident arrived by ambulance. She stated that she and CNA B both went into the room to show him how to use the remote, bed controls, and call bell. He asked to use the bathroom, but CNA C stated that she was told that Residents must be screened by PT (Physical Therapy) before ambulating to the bathroom so they provided the Resident with a urinal and told him to use the urinal or the incontinent brief he was wearing.
On [DATE] at 5:04 PM an interview was conducted with CNA B who stated that Resident #1 arrived about 3:30 PM she stated she and CNA C were assigned that hall and they checked on him and showed him how to use the call bell, and the remote for the bed. She stated that CNA C was passing out dinner trays and found Resident #1 lying on his back on the floor, she yelled for the nurse. She stated after that nurses from other units came in to help RN B with CPR. She stated that she and CNA B went to get the crash cart. She stated that LPN D was doing compressions and RN B was using the Ambu bag for respirations.
On [DATE] at 3:00 PM, an interview was conducted with RN B who stated that she was passing medications at the top of the hall when the medical transport arrived. She stated that she did not go down to the room when medical transport arrived. She stated that she was in the middle of a med pass. She stated My CNAs know my expectations so they were up and down the hallway checking on him.
On [DATE] at 3 PM an interview was conducted with the DON who was asked about the admission process. The DON stated that the admission process should start as soon as possible after arrival at the facility. She said, You would orient the Resident to the room and get the CNA set up the room making sure the Resident has what they need. The DON was asked about when the assessment should be done, and she stated it would depend on when they arrived. She said, They do the best they can. They have 24 hours to get the admission assessment completed. You might be able to enter some information immediately but not most of it. It takes multiple shifts to get it completed. When asked if would she expect the nurse to at least go in and see the Resident soon after he arrives, she stated yes, I do expect them to At least set eyes on them and welcome them to the building.
[DATE] at 3 PM an interview was conducted with RN B who admitted that she had not read the admission folder and had not gone in the room until the CNA found Resident #1 on the floor and nonresponsive.
The clinical record revealed there were 3 notes written in the progress notes section of the EMR. The code blue note was first followed by the notification of death to the physician by the facility and the last was a note by the physician stating that the police phoned him to ask if he would sign the death certificate.
The first entry into the progress notes (the code blue note) read as follows:
Effective Date: [DATE] 6:04 PM -Type: Code Blue is called (indicate staff name and time) : RN B (Registered Nurse B Name redacted.) 1724 CPR is initiated (indicate staff name and time) : (RN B name redacted) and LPN D (Licensed Practical Nurse D name redacted) 1724 Essential staff respond to the CODE BLUE promptly (indicate staff names and time) : 1726(Don name redacted) (LPN B name redacted), LPN F (name redacted), RNC (name redacted) and the Administrator. Nurse on the scene functions as the CODE LEADER (indicate staff name and time): DON 1726 (Director of Nursing name redacted). Designate staff to bring crash cart arrived at room (indicate staff name and time): CNA C (Certified Nursing Assistant C name redacted) and CNA B (name redacted) Physician notified of CODE BLUE (indicate staff name and time): : (On call physician name redacted) being notified by nurse 911 Call (indicate staff name and time): :CNA B (name redacted) 1726 Responsible Party made aware of events (indicate whom and time): : 1744 attempted to contact emergency contact #1, brother(name redacted), left message to call facility. Spoke to res son, (name redacted), @ 1746. Arrival of EMS (indicate time): 1733 EMT's arrived Outcome after EMS arrived (departure time to ER or pronunciation): EMT's pronounced res at 1755.
On [DATE] during the end-of-day meeting the Administrator was made aware of the findings and no further information was provided.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected multiple residents
Based on interviews, clinical record review, and facility documentation the facility staff failed to notify the physician of not of medications not being administered to 20 Residents (the entire Unit ...
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Based on interviews, clinical record review, and facility documentation the facility staff failed to notify the physician of not of medications not being administered to 20 Residents (the entire Unit 3 B Assignment) in a survey sample of 28 Residents.
The findings included:
For the 20 Residents on assignment B in Unit 3, the facility staff failed to notify the physician that she did not give medications from 3 PM - 7 PM on 2/6/24. Those meds included insulin, cardiac medications, anti-convulsant medications, anti-coagulants, and controlled substances for pain.
On 2/20/24 at 5:29 PM RN B (Registered Nurse B) was interviewed, and she stated that on 2/6/24 she Volunteered to work 3 PM-7 PM shift to fill in the gap on the schedule. When asked if she was passing medications and working the floor, she stated that she was. She was asked if she received an admission that night, she stated that she had but was busy passing medications, so she had not gotten to the admission. When asked which assignment she had she stated that she had the B assignment which encompassed 20 Residents.
On 2/20/24 Surveyor B conducted a review of the clinical record was conducted and it was found that none of the Residents on Unit 3 assignment B had received medications or treatments from 3-7 PM on 2/6/24.
On 2/21/24 at 3 PM an interview was conducted with the DON (Director of Nursing), the Administrator, RN B, Employee E, and Employee F. The DON was asked what the expectation of the nurses was when passing medications, she responded, They are to follow physician orders. When asked what they are to do if they do not give the medications as ordered she stated they should notify the physician to see if he has anything he wants to monitor or change. RN B was asked if she had completed her medication pass that day and she stated that she had not. When asked if she had obtained blood sugar or given any medications to those rooms, she stated that she did not. When asked if she had notified the physician of the medications not being given, she stated that she had not.
On 2/21/24 at approximately 4:30 PM an interview was conducted with the physician who was asked if he expected to be notified if a Resident did not get their medication on time or if a dose was missed, and he stated, Yes that is the expectation. When asked if he expected to be notified if a medication is given when it should have been held due to parameters, he said, Yes definitely. When asked what the danger is of giving lisinopril when the blood pressure is outside of the parameters, he stated that it could increase the risk of falls, as Residents could become dizzy when standing causing sudden drops in blood pressure and it could become dangerously low. When asked if he should have been made aware if this happened 6 days consecutively, he stated, that it should have been told to him so he could evaluate the Resident.
On 2/22/24 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
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
**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 services that meet...
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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 services that meet professional standards of care for 20 Residents in a survey sample of 28 Residents.
The findings included:
For all 20 Residents in Unit 3 nursing assignment B, the facility staff failed to administer medications as ordered by the physician.
On 2/20/24 at 5:29 PM RN B (Registered Nurse B) was interviewed, and she stated that on 2/6/24 she Volunteered to work the 3 PM-7 PM shift to fill in the gap on the schedule. When asked if she was passing medications and working the floor, she stated that she was. When asked which assignment she had she stated that she had the B assignment which encompassed 20 Residents.
On 2/20/24 Surveyor B conducted a review of the clinical record, and it was found that none of the Residents on Unit 3 assignment B had received medications or treatments from 3-7 PM on 2/6/24. Medications were either not given, or given late, when the 7 PM -11 PM nurse came in.
On 2/20/24 at 3:13 PM, an interview was conducted with LPN E (the nurse who came in at 7 PM on 2/6/24). When asked had the nurse before she passed any medications, she stated that Nothing had been done. She stated that when she arrived at 7 PM, none of the medications and treatments had been done. She stated, The 4 PM blood sugar had not been done and that insulin had not been given. She stated that she could not give it because it was too close to the 9 PM dose. She stated that most of the time when she relieves a nurse at 7 PM they will have passed all the meds up to 6 PM.
On 2/21/24 at 3 PM an interview was conducted with the DON (Director of Nursing), the Administrator, RN B, Employee E, and Employee F. The DON was asked what the expectation of the nurses is when passing medications. She stated that they are to follow physician orders. When asked what they are to do if they do not give the medications as ordered she stated they are to notify the physician to see if he has anything he wants to monitor or change. RN B was asked if she had completed her medication pass that day and she stated that she had not. When asked if she had obtained blood sugar or given any medications to those rooms, she stated that she did not. When asked if she had notified the physician of the medications not being given, she stated that she had not.
On 2/22/24 during the end-of-day meeting, the Administrator was made aware of the findings, and no further information was provided.
A review of the facility's medication administration policy revealed the following excerpts:
Page 2
4. At a minimum, the 5 Rights - Right Patient, Right Drug, Right Dose, Right Route, Right Time- should be applied to all medication administration and reviewed at three steps in the process of preparation.
Page 4
II Administration
2. Medications are administered in accordance with written orders of the prescriber.
Page 5
12. Medications are administered within 60 minutes of the scheduled administration time, except before, with, or after meal orders, which are administered based on mealtimes.
Nursing 2012 Drug Handbook. (2012). [NAME] & [NAME]: Philadelphia, Pennsylvania
Rights of Medication Administration
1. Right patient
2. Right medication
3. Right dose
4. Right route
5. Right time
6. Right documentation
7. Right reason
8. Right response
Dec 2021
17 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of facility policy the facility failed to ensure dignity was maintain...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of facility policy the facility failed to ensure dignity was maintained for one of thirty-four sample residents (Resident (R) 404)). Specifically, R404's foley catheter bag was uncovered and within view of individuals in the corridor.
Findings include:
Review of facility policy title Suprapubic Catheter Reinsertion dated 11/01/19 instructs staff to . 18. Hang bag below level of the bladder and place privacy bag over the drainage bag.
Review of the admission note, in the Progress Notes tab of electronic medical record (EMR), dated 12/24/21, revealed R404's diagnoses included metabolic encephalopathy in the setting of hyponatremia and acute cystitis.
Review of R404's physician's orders in the Orders tab of EMR revealed R404 was admitted on [DATE] with an order for a Suprapubic Foley Catheter.
Review of the R404's admission Minimum Data Set (MDS) dated 12/30/21 revealed R404 required extensive assistance with bed mobility; one person physical assist with dressing; two person physical assist with toilet use; one person physical assist with personal hygiene and had an indwelling catheter during the assessment period.
Observation on 12/27/21 at 1:06 PM and on 12/29/21 at 10:59 AM revealed R404 was observed lying in his room. The door to his room was open and a foley catheter bag containing urine was hanging on the side of the bed within view of individuals in the hall/corridor.
Observation on 12/29/21 at 10:59 AM revealed Certified Nursing Assistant (CNA) 13 was in the hallway outside of R404's room. CNA13 verified she could see the catheter bag partially full of urine from where she was in the hallway. CNA13 further stated she was not sure if the catheter bag was supposed to be in a dignity bag.
During an interview on 12/29/21 at 12:35 PM, Assistant Director of Nursing (ADON) confirmed dignity bags were required per facility policy, and verified R404's urinary collection bag was hanging on the side of the bed within view of individuals in the hall/corridor.
During an interview on 12/29/21 at 4:05 PM, Director of Nursing (DON) confirmed dignity bags are required per facility policy.
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, interview, record review, and facility policy, the facility failed to ensure one of 34 sampled residents (...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy, the facility failed to ensure one of 34 sampled residents (Resident (R) 85) had a physician's order and was screened/assessed for the self-administration of medications prior to medications being stored at the bedside and self-administered.
Findings include:
Review of the facility policy Self-Administration Medication at Bedside, dated 11/01/19, revealed, .physician's order in patient's chart for self-administration . complete self-administration screen . self-administration must be reviewed by interdisciplinary team . medications . to be self-administered will be identified on MAR [medication administration record].
Review of R85's electronic medical record (EMR) under the Profile tab revealed R85 admitted to the facility on [DATE].
Review of R85's EMR under the Med Diag tab revealed, multiple diagnoses to include congestive heart failure.
Review of R85's Orders tab in the EMR revealed .Muro 128 Ointment 5 % (Sodium Chloride (Hypertonic)) Instill 1 dose in right eye at bedtime for edema put 1/4 inch strip OD [right eye] and Muro 128 Solution 5 % (Sodium Chloride (Hypertonic)) Instill 1 drop in right eye four times a day for edema . dated 10/19/21. R85's physician's orders did not include an order for R85 to self-administer medications.
Review of R85's EMR under the Misc tab revealed, no documentation of a self-administration assessment.
Review of R85's EMR under the Care Plan tab revealed, there was no documentation regarding the self-administration of medication.
Review of R85's EMR under the MAR tab revealed facility's staff documented administering eye drops and lubricant for R85, for the month of December 2021.
Review of R85's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/17/21, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R85 was cognitively intact.
An observation on 12/27/21 at 12:08 PM revealed, two medication bottles on R85's bedside table, in her room (unsupervised and unattended by facility's staff) to include, 1. Sodium Chloride 5 % lubricant instill 1/4 inch at bedtime in right eye. The medication bottle was labeled Refrigerate. 1/8-ounce tube. 2. Sodium Chloride 5% solution 1 drop right eye four times a day. 1/2-ounce bottle expires 11/23. R85 stated, I administered these drops myself.
A second observation on 12/27/21 4:56 PM, two medication bottles were on 85's bed, in her room, (unsupervised and unattended by facility's staff) to include, the following, 1. Sodium Chloride 5 % lubricant instill 1/4 inch at bedtime in right eye. (The medication bottle was labeled Refrigerate) 1/8-ounce tube. 2. Sodium Chloride 5% solution 1 drop right eye four times a day. 1/2-ounce bottle expires 11/23.
A third observation was conducted on 12/29/21 at 9:47 AM of two medication bottles (1. Sodium Chloride 5 % lubricant instill 1/4 inch at bedtime in right eye. The medication bottle was labeled Refrigerate. 1/8-ounce tube. 2. Sodium Chloride 5% solution 1 drop right eye four times a day. 1/2-ounce bottle expires 11/23), were on R85's bedside table, in her room (unsupervised and unattended by facility's staff).
During an interview on 12/29/21 at 11:41 AM, Registered Nurse (RN) Unit Manager (UM), verified and confirmed there were two medications bottles (unattended by facility's staff) on R85's bedside table in her room on 12/29/21. RN UM confirmed the medication should not be stored in R85's room.
During an interview on 12/29/21 2:52 PM with RN UM present, R85 stated she was self-administering eye drops for a month or two.
During an interview on 12/29/21 at 2:57 PM, RN UM verified and confirmed R85 did not have a physician's order to self-administer medication, including the eye drops and lubricant stored at her bedside, in her room. RN UM further verified and confirmed, R85 was not assessed by the interdisciplinary team for self-administration of medication with a determination made, prior to R85 performing self-administration of medication.
During an interview on 12/30/21 at 7:26 PM, the DON (Director of Nursing) confirmed, resident medications cannot be stored in resident's room without a physician's order and all staff are responsible for following physician orders.
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 interview, record review, and facility policy review, the facility failed to ensure an accurate Level 1 pre-screening o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to ensure an accurate Level 1 pre-screening of the resident for a mental disorder (MD) or intellectual disability (ID) prior to admission to the facility was completed for two of three residents (Resident (R) 13 and R133) reviewed for Level 1 Pre-admission Screening and Resident Review (PASRR).
Findings include:
Review of the facility's policy titled, Discharge Planning Policies and Procedures dated 01/06/20, indicated, Prior to the arrival of a planned admission the Discharge Planner will collaborate with the Admissions Director to preview the transferring hospital's Level 1 PASRR (Level 1 Screening for Mental Illness, Intellectual Disability, or Related Conditions) and/or initiate completion of the Level 1 PASRR if not completed by the transferring hospital.
1. Review of R13's Face Sheet located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 08/11/04 and included, but was not limited to, the following diagnoses: obsessive compulsive disorder, schizoaffective disorder, borderline personality disorder, anxiety disorder, and major depressive disorder.
Review of R13's Screening for Mental Illness, Mental Retardation/Intellectual Disability, or Related Conditions located in the EMR under the Misc tab, dated 05/24/19, documented R13 did not have a current mental illness. The document reviewed is also referred to as a Level 1 PASRR.
During an interview on 12/30/21 at 1:49 PM with the Director of Social Services (DSS), she stated the Level 1 PASRR that was completed in 2019, was incorrect due not indicating R13's mental illness. She further stated if the Level 1 PASRR had been completed, R13 would have been referred for a Level II PASRR in order to receive specialized services.
2. Review of R133's Med Diag tab in the EMR revealed R133 was admitted to the facility on [DATE] with multiple diagnoses to include major depressive disorder, delusional disorder, anxiety disorder, and intracranial brain injury.
Review of R133's Order tab in the EMR revealed R133 received antipsychotic medication and antidepressant medication.
Review of R133's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/06/21 revealed a Brief Interview Mental Status (BIMS) score of 9 out of 15, which indicated R133 was cognitively impaired.
Review of the Misc tab of the EMR, did not reveal a Level 1 PASARR.
A review of a paper, photocopy of document, provided by DSS, titled SCREENING FOR MENTAL ILLNESS RETARDATION/INTELLECTUAL DISABILITY, OR RELATED CONDITIONS, dated and signed 02/08/10, revealed .2. INDIVIDUAL HAVE A CURRENT SERIOUS MENTAL ILLNESS . yes was marked and .5. RECOMMENDATION ., the box beside .MI [Mental Illness] (#2 above is checked Yes) was empty and not marked. Instead, the box beside .Does not meet the application criteria for serious MI . was marked with a line. The box besides, .No referral for active treatment needs assessment required. was marked with a line.
During an interview on 12/30/21 at 11:11 AM, the DSS verified and confirmed there was no PASAAR on R133's electronic medical record, the screening form was completed incorrectly and the facility failed to refer R133 to appropriate state designated authority for PASAAR Level II evaluation and determination.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to ensure a baseline care plan was develo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours of admission to the facility for one resident of eight residents (Resident (R)404) reviewed for baseline care plans in a total sample of 34 residents.
Findings include:
Review of facility policy titled, Care Planning, dated 11/01/19, revealed, A licensed nurse, in coordination with the interdisciplinary team, develops and implements an individualized care plan for each patient in order to provide effective, person-centered care, and the necessary health-related care and services to attain or maintain the highest practical physical, mental, and psychosocial well-being of the patient. The computerized baseline Care Plan is initiated and activated within 48 hours. The Center will provide the patient and representative(s) with a summary of the baseline care plan that includes but is not limited to: . any services and treatments to be administered by the Center and personnel acting on behalf of the Center.
Review of the admission note, in the Progress Notes tab of the electronic medical record (EMR), dated 12/24/21, revealed R404's diagnoses included metabolic encephalopathy in the setting of hyponatremia and acute cystitis.
Review of R404's physician's orders in the Orders tab of the EMR revealed R404 was admitted on [DATE], with orders dated 12/24/21 for Suprapubic foley catheter (20 French (fr) 30 milliliters (ml)) monitor every shift; flush suprapubic catheter with 60ml of normal saline every shift; Check Foley anchor placement every shift; Change suprapubic catheter insertion site dressing every day and as needed using split gauze.
Review of R404's admission Assessment/Screening V.1.2, dated 12/24/21 under the Progress Notes tab of EMR, revealed in section H. GU/Bladder.1. Nondistended bladder 3. Incontinent of bladder. 6a. Type of catheter b. Suprapubic Catheter was left blank and did not document that R404 had a catheter.
Review of R404's admission Minimum Data Set (MDS) dated 12/30/21 revealed R404 required extensive assistance with bed mobility; two person physical assist with toilet use; one person physical assist with personal hygiene and had an indwelling catheter during the assessment period.
Review of R404's Baseline Care Plan, found in the EMR under the Care Plan tab and dated 12/24/21, revealed the care plan did not address suprapubic indwelling catheter status.
During observation on 12/27/21 at 1:06 PM and on 12/29/21 at 10:59 AM, R404 was observed lying in his room. The door to his room was open and a foley catheter bag containing urine was hanging on the side of the bed within view of individuals in the hall/corridor.
During an interview on 12/30/21 at 11:05 AM, the Director of Nursing (DON) said it was her expectation that baseline care plans addressed all issues residents needed assistance with. The DON confirmed R404 admitted on [DATE] with indwelling suprapubic catheter. DON also confirmed the admission Assessment/Screening V.1.2 dated 12/24/21 was inaccurate and did not document R404's suprapubic catheter. The DON indicated the assessment was used to create the Baseline Care Plan. The DON confirmed the Baseline Care Plan dated 12/24/21 in EMR, under Care Plan tab, did not include suprapubic catheter status and should have.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0660
(Tag F0660)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policy, the facility failed to develop, assist, and follow through to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policy, the facility failed to develop, assist, and follow through to completion with discharge plans for one of 34 sampled residents (Resident (R) 133) reviewed for discharge planning. The facility did not have a person-centered discharge plan for R133.
Findings include:
Review of the facility policy, titled Discharge Planning Policies and Procedures, dated 01/06/20 revealed, Discharge planning will review extended care (long-term care) patients for discharge planning needs and pursue placement . Communicate with patient. discharge plans . Discharge planning staff will proactively spearhead the discharge planning process and follow through to completion to ensure a discharge.
Review of R133's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/06/21, revealed a Brief Interview for Mental Status (BIMS) score of nine out of 15, which indicated R133 had moderate cognitive impairment.
Review of R133''s Profile tab in the electronic medical record (EMR), revealed R133 was admitted to the facility on [DATE].
Review of R133's Care Plan tab revealed .The patient's preference for discharge is: LTC [long term care] at [the facility] Created on: 09/16/2014.
During an interview on 12/27/21 at 12:29 PM, R133 expressed desire/wish to be discharge from the facility to go home to Georgia. R133 stated she had told facility staff, but no one had talked to her about her desire to discharge.
During an interview on 12/30/21 at 2:44 PM, the Director of Social Services (DSS) confirmed and verified, the facility was aware of R133's desire to have a discharge plan from the facility and no discharge plan had been addressed with R133. The DSS further confirmed and verified, the facility did not develop or assist R133 with discharge plans and the facility should develop and assist R133 with a discharge plan (according to her wishes/desires). The DSS confirmed, the facility did not proactively spearhead a discharge plan process or follow through to ensure a discharge from the facility for R133.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy the facility failed to provide an individualized a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy the facility failed to provide an individualized activity program for two of 34 sampled residents (Resident (R) 33 and R51).
Findings include:
Review of the facility's policy titled Activities Policies and Procedures dated January 2020 documented activities staff will monitor, evaluate and record patient's activities participation and response to activities. and .utilize the patient record to determine whether the patient's participation in activities and/or independent activities pursuits achieves the stated goals on the patient's plan of care.
1. Review of an admission Record located in R33's electronic medical record (EMR) under the Profile tab indicated she was admitted on [DATE] with diagnoses including major depressive disorder
Review of a care plan dated 10/06/21 found in R33's EMR under the Care Plan tab indicated she would engage in independent leisure pursuits 2-4x's [times] weekly. The leisure activities listed included listening to music on her TV, visiting with family and friends and reading. The care plan indicated R33 needed assistance with leisure at times due to her diagnosis.
Review of R33's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/07/21 revealed R33 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact. Some of the activities R33 listed as very important to her included pets, keeping up with the news, religious activities, and going outside.
Review of the Activity Log, provided by the facility from 10/17/21 to 12/30/21 indicated R33 was coded -97 on 10 days which meant not applicable. It showed R33 participated in one 1:1 activity and was actively engaged. R33 participated in one seasonal/special event activity in 74 days. There was no documentation on the log that R33 was offered an activity and refused.
During an interview on 12/28/21 at 11:23 AM, R33 said they don't seem to have a lot to do around here. I'm not sure what I would want to do. They haven't brought me anything that I know of. I do have a book here, but I don't watch much tv. It would be nice to be asked what I would like to do.
R33 was observed on 12/29/21 at 3:18 PM sitting at the Unit 1 nurses station asking repeatedly what should I be doing? Am I just supposed to sit here?
R33 was observed on 12/30/21 at 11:45 AM sitting in her wheelchair at the Unit 1 nurses station asking what she was supposed to be doing and if she should just sit there. R33 was tearful and seemed confused about why she was sitting in the hallway. R33 said she liked to read sometimes.
R33 was observed on 12/30/21 at 2:46 PM sitting in her wheelchair at the Unit 1 nurses station asking what she should be doing. R33 seemed confused at times but was oriented to herself and where she was.
During an interview on 12/30/21 at 4:54 PM, the Director of Recreation (DOR) said the activity department needed to improve their documentation. The DOR stated they determined if residents were independent with leisure activities based on their interests. The DOR said they always try to invite residents to group activities and try to be supportive if they decline. The DOR said R33 had not gotten a lot of visitors and she did not do Zoom calls with family. The DOR said ideally one on one activities would be held three times a week for 15 minutes, but it was not always documented. The DOR stated R33 had not had any activities related to her interests of pets, keeping up with the news, religious activities, and going outside. She said due to R33's intermittent confusion and behaviors they try not to ask her too many times a day about activities, but it was not documented.
2. Review of an admission Record located in R51's EMR under the Profile tab indicated she was admitted on [DATE].
Review of a care plan dated 10/16/21 found in R51's EMR under the Care Plan tab indicated she would actively engage in independent leisure pursuits 2-4x a week. The care plan also indicated Staff provided materials for independent leisure such as a channel guide, magazines, and a devotional. Staff also provided puzzle books to do with family visitors.
Review of R51's MDS with an ARD of 12/17/21 revealed the resident had a BIMS score of 14 out of 15, which indicated the resident was cognitively intact. Some of the activities R51 listed as very important to her included pets, doing things with groups of people, religious activities, and going outside.
Review of the Activity Log, from 11/01/21 to 12/30/21 located in R51's EMR under the Tasks tab indicated R51 participated in four activities. R51 had two, one on one visits where she was actively engaged, one seasonal event, and one guest visit.
Review of an Activities Note dated 10/19/2021 found in R51's EMR under the Progress Notes tab indicated the Director of Recreation (DOR) contacted [local church] to add Pt [patient] to prayer and visitation list. The staff also informed the church to call ahead to check for any changes with COVID restrictions.
During an interview on 12/28/21 at 11:36 AM, R51 said she was unable to attend group activities currently because she was non-weight bearing due to a possible fracture since 12/10/21. R51 said she had to wait until her follow up appointment before could move around. R51 said, I suppose it would be nice to have something to do and the staff don't bring things that I can do.
During an interview on 12/30/21 at 11:11 AM, the Director of Recreation (DOR) said if it was a resident's preference to stay in bed, they would document it as an independent activity. The DOR said R51 had not done any of her preferred activities since admission. The DOR said according to the documentation there was no way to know if staff were having one on one visits with R51. The DOR said they had a Bible study but R51 did not participate, and it was not documented it was offered to her. The DOR said she had not reached back out to the clergy to arrange a religious visit for R51. The DOR said she was advised not to document if a resident declined an activity, but she had no way to show it was offered and they chose not to participate. The DOR said she was aware of R51's non-weight bearing situation and her daughter going to Greece so she should have scheduled one on one visits with her.
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 interview and record review the facility failed to ensure treatment and care in accordance with professional standards ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure treatment and care in accordance with professional standards of practice was provided for two of 34 sampled residents (Resident (R) 51 and R47). Specifically, the staff failed to ensure R51 was transported to her cardiologist follow up appointment on two different occasions. In addition, the staff failed to follow physician's orders for R47.
Findings include:
1. Review of an admission Record located in R51's electronic medical record (EMR) under the Profile tab indicated she was admitted on [DATE] with diagnoses including acute and chronic respiratory failure, type II diabetes, atrial fibrillation, and heart failure.
Review of R51's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/17/21 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated the resident was cognitively intact.
Review of the Progress Notes found in R51's EMR under the Assessments tab indicated she missed a cardiologist follow up appointment on 10/27/21 and 12/27/21 due to lack of transportation.
During an interview on 12/28/21 at 11:37 AM, R51 said she had a cardiologist appointment scheduled for 12/27/21 at 1:00 PM but she missed it. She said there was no transportation for her to get there. R51 said this happened before and she did not understand why the facility was not making sure she got to her appointment. She said there was a problem with the transportation company, and she was unsure what they are doing about it.
During an interview on 12/29/21 at 3:24 PM, family member (F) 1 said she was concerned about R51 missing her cardiologist appointment again that week. F1 said the facility had a problem with transportation and told her it was out of their hands.
During an interview on 12/29/21 at 3:30 PM, the Medical Records Assistant (MRA) said when a resident required an appointment, the nursing staff made her aware and she called to set up the appointment. Once she did that, she called the insurance provider or Medicaid to set up the transportation. The MRA said she did not directly deal with the transportation companies for residents with Medicaid. The MRA said the facility had a reoccurring problem with residents missing their appointments due to lack of transportation. The MRA said the facility had a paid transportation provider they used for residents on skilled care but not long-term care residents. She said using the paid transport was not discussed for R51 even though she missed two cardiologist appointments. The MRA said she would reschedule her appointment and transport and hope they show up. She said the facility had no way to track or trend when residents missed appointments. She said the administration was aware of the issue and it had been going on a long time.
During an interview on 12/30/21 at 7:17 PM, the Administrator, who came to the facility in September 2021, said she was made aware medical transport to resident appointments was not reliable. The Administrator said she developed a tool to track the resident information, their appointment date/time, which transport company was used and pickup/drop off time. The Administrator stated she thought the medical records department was using the tool but found out this week they were not, and she was unsure why. She said the facility would utilize paid transport for urgent appointments or scheduled procedures but not for follow up appointments. The Administrator said they could use the paid transport for resident follow up appointments if the tracker tool was in place so they could petition Medicaid for reimbursement. She said ultimately the facility was responsible for ensuring residents made it to their appointments.
The facility did not have a policy related to the transportation of residents.
2 A review of the policy provided by the facility, titled Medication Management, dated 11/01/19 revealed, .Nursing . are to reference . promote . consistency in medication administration and standards of best practices. A medication administration policy was not provided by the facility for review.
During an interview on 12/27/21 at 4:06 PM, R47 was upset about missing doses of medication and reported staff had run out of her oxybutynin before.
Review of R47's EMR, under the Clinical tab, revealed R47 was admitted to the facility on [DATE].
Review of R47's EMR under the tab, Med Diag [Medical Diagnosis], revealed multiple diagnoses to include multiple sclerosis.
Review of R47's EMR under the Orders tab, revealed, Urea Cream 10 %, Apply to bilateral feet topically at bedtime for dry skin . Oxybutynin Chloride 5 MG Tablet GIVE 3 TABLET (sic) BY MOUTH THREE TIMES A DAY FOR BLADDER SPASMS, dated 12/26/21.
R47's Medication Administration Record (MAR) located in the EMR under the MAR was reviewed for the months of October, November, and December 2021. There was no documentation for administration (no initials for dose given) for the following medications.
a. Oxybutynin 5 mg tablet on 10/22/21 at 2:00 PM, 11/21/21 at 2:00 PM, two incidents of not administered per physician orders.
b. Urea Cream 10 % on 10/15/21 at 9:00 PM and on 11/06/21 at 9:00 PM, two incidents of not administered per physician orders.
An interview was conducted on 12/30/21 07:26 PM, the DON (Director of Nursing), confirmed medication administered should be documented on the resident's MAR by the nurse and all the facility's staff are responsible for following physician's orders.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on interview, record review, and facility policy review, the facility failed provide treatment as ordered for prevention for pressure ulcer/skin injury for one of nine residents (Resident (R) 13...
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Based on interview, record review, and facility policy review, the facility failed provide treatment as ordered for prevention for pressure ulcer/skin injury for one of nine residents (Resident (R) 138) reviewed for pressure ulcers.
Findings include:
Review of the facility's policy titled, General Wound Care/Dressing Changes dated 11/01/19 indicated, Provide treatments as ordered.
Review of R138's Face Sheet located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 11/17/15 and included, but was not limited to, the following diagnoses: quadriplegia and diabetes.
Review of R138's Wound Evaluation located in the EMR under the Misc tab, dated 09/21/21, indicated an etiology of Moisture-Associated Skin Damage (MASD).
Review of R138's Order Summary Report located in the EMR under the Orders tab, revealed the following orders: 09/22/21 Hibiclens Liquid 4 % - Apply to bilateral buttocks topically every day and evening shift for MASD cleanse with hibicleanse, pat dry, apply Silver Sulfadiazine (SSD), cover with Abdominal (ABD) pad; 09/22/21 Hibiclens Liquid 4 % - Apply to bilateral rear thighs topically every day and evening shift for MASD cleanse with hibicleanse, pat dry, apply ssd, cover with ABD pad; 9/22/21 SSD Cream 1 % - Apply to bilateral buttocks topically every day and evening shift for MASD cleanse with hibicleanse, pat dry, apply ssd, cover with ABD pad; 9/22/21SSD Cream 1 % - Apply to bilateral rear thighs topically every day and evening shift for MASD cleanse with hibicleanse, pat dry, apply ssd , cover with ABD pad.
Review of R138's October 2021 Treatment Administration Record (TAR) located in the EMR under the Orders tab, revealed R138 did not receive ordered treatment to buttocks on evening shifts on 10/18/21, 10/20/21, or 10/22/21or the morning shifts on 10/09/21, 10/14/21, 10/18/21, 10/19/21, 10/26/21. R138 did not receive ordered treatment to rear thighs on evening shifts on 10/18/21, 10/20/21, or 10/22/21 or the morning shifts on 10/09/21, 10/14/21, 10/18/21, 10/19/21, or 10/26/21.
Review of R138's November 2021 TAR located in the EMR under the Orders tab, revealed R138 did not receive ordered treatment to buttocks on morning shifts on 11/02/21, 11/07/21 or 11/17/21. R138 did not receive ordered treatment to rear thighs on morning shifts on 11/02/21, 11/07/21, or 11/17/21.
Review of R138's December 2021 TAR located in the EMR under the Orders tab, revealed R138 did not receive ordered treatment to buttocks on evening shifts on 12/02/21, 12/03/21, or 12/21/21 or the morning shift on 12/27/21. R138 did not receive ordered treatment to rear thighs on evening shifts on 12/02/21, 12/03/21, or 12/21/21 or the morning shift on 12/27/21.
During an interview on 12/27/21 at 5:45 PM, R138 stated that he did not receive treatments to his backside twice a day as ordered.
During an interview on 12/30/21 at 3:10 PM with the Registered Nurse (RN) Unit Manager, she stated R138's treatments needed to be completed as ordered to prevent further skin breakdown.
During an interview on 12/30/21 at 5:31 PM with the Director of Nursing (DON), she stated treatments should be completed as ordered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on observation, interview, record review, and review of facility policy, the facility failed to ensure one of four residents (Resident (R) 67) reviewed for limited range of motion received appro...
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Based on observation, interview, record review, and review of facility policy, the facility failed to ensure one of four residents (Resident (R) 67) reviewed for limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, staff did not apply R67's right hand splint per physician's orders to maintain range of motion.
Findings include:
Upon request of a policy regarding residents' splints, the facility provided a documented titled, Assisting with Activities of Daily Living, undated, that revealed, .Splints keep . wrist, thumbs, fingers . in normal position.
Review of R67's electronic medical record (EMR), revealed R67 admitted to facility on 10/13/17.
Review of the Med diag [Medical Diagnosis] tab in the EMR revealed multiple diagnoses to include hemiplegia (paralysis on one side of the body) and hemiparesis (loss of strength on one side of the body) following cerebral infarction (ischemic stroke, result of disrupted blood flow to the brain) affecting right dominate side.
Review of the Orders tab in the EMR revealed R [right] hand splint to be worn at all times with skin checks QS [every shift]. dated 01/31/18.
Review of the column Interventions under the Care Plan tab in the EMR, revealed, .r hand splint to be worn at all times.
Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/01/21 revealed, R67 was assessed with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R67 was cognitively intact. The MDS revealed an end date for physical therapy services of 11/01/21.
An observation was conducted on 12/28/21 at 9:10 AM of R67. R67 was not wearing a splint on her right hand. Her right hand was closed, like a fist.
A second observation was conducted on 12/29/21 at 9:44 AM of R67 revealed there was no brace or splint on her right hand. R67's hand was closed like a fist.
A third observation was conducted on 12/29/21 at 10:57 AM of R67 revealed there was no brace on her right hand.
An interview was conducted on 12/27/21 at 1:16 PM, R67 revealed the facility was not applying or maintaining splint for her right hand.
An interview was conducted on 12/29/21 at 9:14 AM, Certified Nurse Aide (CNA) 9 confirmed R67 should wear a right-hand brace.
A fourth observation was conducted on 12/29/21 at 11:56 AM with Registered Nurse (RN) Unit Manager (UM) who verified and confirmed R67 was not wearing a brace on her right hand as ordered by the physician. RN UM further revealed not wearing a splint as per physician orders could cause muscle loss and contractures.
During an interview on 12/29/21 at 3:00 PM, RN UM verified there was a physician's orders for R67's splint at all times for right hand.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on interview, record review, and facility policy review, the facility failed prevent accidents by failing to safely transfer a resident and perform neurological assessments for one of three resi...
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Based on interview, record review, and facility policy review, the facility failed prevent accidents by failing to safely transfer a resident and perform neurological assessments for one of three residents reviewed for accidents (Resident (R) 42).
Findings include:
Review of the facility's policy titled, Falls Management Program dated 11/01/19 indicated, Evaluate, monitor, and document patient response for the first 24 hours (3 consecutive shifts) post fall, include a neurological assessment if the fall was unwitnessed and/or the patient hit his/her head.
Review of R42's Face Sheet located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 5/30/13 and included, but was not limited to, the following diagnoses: epilepsy, flaccid hemiplegia affecting left nondominant side, and anoxic brain damage.
Review of R42's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/17/21 indicated that R42 was to be transferred with a one-person assist.
During an interview on 12/27/21 at 5:16 PM, R42 stated that she had a fall about a week ago and hit her head against the wall. R42 stated the staff transferred her without using a gait belt or leverage from her pants.
Review of R42's EMR did not contain any neurological assessments for December 2021.
During an interview on 12/30/21 at 10:15 AM, Certified Nurse Aide (CNA) 10 stated she was in the room when another CNA assisted R42 with a transfer to the bed and she saw R42 fall forward and hit her head on the wall. The Director of Nursing (DON) was present during this interview.
During an interview on 12/30/21 at 10:25 AM, CNA15 confirmed she transferred R42 on 12/22/21. CNA15 stated she transferred R42 using her incontinence brief and R42 fell forward and hit her head on the wall. CNA 15 acknowledge she should have used a gait belt during the transfer. The DON was present during this interview.
During an interview on 12/30/21 at 10:28 AM, the DON stated R42 was inappropriately transferred by staff holding on to R42's incontinence brief. The DON and Regional DON stated when R42 returned from the hospital, neurological assessments should have been completed for 24 hours post fall.
During an interview on 12/30/21 at 3:18 PM, the Registered Nurse (RN) Unit Manager stated R42 should not have been transferred using her incontinence brief. The RN Unit Manager stated the CNAs should use a gait belt or the resident's pants for leverage.
During a follow up interview on 12/30/21 at 4:33 PM, the RN Unit Manager stated that neurological assessments should completed on a Neurological Assessment form. The RN Unit Manager confirmed there were no neurological assessments completed for R42 following her fall on 12/22/21 when she hit her head.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, the facility failed to follow physician's orders ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, the facility failed to follow physician's orders to maintain the suprapubic urinary catheter for one resident of two residents (Resident (R) 404) reviewed for catheters. Specifically, the facility failed to ensure R404's suprapubic urinary catheter was flushed every shift and daily dressing change per physician's orders.
Findings include:
Review of facility policy titled Suprapubic Catheter Care dated 11/01/19 revealed It is the Center's policy to provide safe and proper care of a patient with a suprapubic catheter by evaluating elimination status, minimizing risk of bladder infection and maintaining skin integrity in accordance with the physician's order.
Review of the admission note, in the Progress Notes tab of electronic medical record (EMR), dated 12/24/21, revealed R404's diagnoses included metabolic encephalopathy in the setting of hyponatremia and acute cystitis.
Review of R404's physician's orders in the Orders tab of EMR revealed R404 was admitted on [DATE] with an order for a Suprapubic Foley Catheter (20 french (fr) 30 milliliters (ml)), Check Foley anchor placement every (q) shift, and change suprapubic catheter insertion site dressing q day and as needed (prn) using split gauze.
Review of R404's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of revealed R404 required extensive assistance with bed mobility; two-person physical assist with toilet use; one person physical assist with personal hygiene and had an indwelling catheter during the assessment period.
Review of R404's Baseline Care Plan dated 12/24/21, located in EMR under the Care Plan tab did not address suprapubic catheter status.
Review of R404's Treatment Administration Record (TAR) dated 12/01/21 through 12/31/21 located in R404's EMR under Reports tab revealed on 12/29/21, 7AM-3PM shift the treatment orders: Change suprapubic catheter insertion site dressing Q day and prn using split gauze every shift for maintenance and Flush suprapubic catheter with 60ml of normal saline Q (shift) for protocol were not signed off as completed.
On 12/27/21 at 1:06 PM, R404 was observed to have a suprapubic catheter. R404 was not interviewable.
During an interview on 12/30/21 at 11:05 AM, the Director of Nursing (DON) was shown R404's physician's order and current TAR and asked what her expectations of her staff were when it came to following the physician's orders. The DON confirmed R404 was admitted [DATE] with a suprapubic catheter and treatment orders should be carried out per physician's orders. DON confirmed TAR entries were blank for 12/29/21, 7AM-3PM shift for Change suprapubic catheter insertion site dressing Q (every) day and prn (as needed) using split gauze every shift for maintenance and Flush suprapubic catheter with 60ml of normal saline Q (shift) for protocol. DON further stated, Licensed Practical Nurse (LPN) 14, R404's nurse on 12/29/21, notified her of not getting a chance to obtain vital signs but made no mention of not being able to perform suprapubic catheter care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy the facility failed to ensure that residents who required di...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for one of one resident (Resident (R) 58) reviewed for dialysis. The facility failed to ensure R58 had reliable transportation to and from dialysis and the facility did not demonstrate ongoing communication to the dialysis center and assessment of the resident prior to dialysis.
Findings include:
Review of R58's electronic medical record (EMR) under the Profile tab revealed R58 admitted to the facility on [DATE].
Review of R58's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/22/21, revealed R58 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating she was cognitively intact. The MDS revealed R58 had end stage renal disease and received dialysis.
Review of R58's Med Diag tab in the EMR revealed multiple diagnoses to include end stage renal disease and congestive heart failure.
Review of R58's Orders tab in the EMR revealed the following order dated 06/14/19, .Dialysis M-F [Monday and Friday]. Check-in at 10:45am for 11:15am.
1. Review of the Progress Note tab in the EMR revealed .patient was not pick [sic] up for dialysis. , dated 12/20/21 at 1:06 PM.
During an interview on 12/29/21 at 9:26 AM, R58 confirmed transport was late and she missed her dialysis treatment appointment.
During an interview on 12/30/21 at 10:19 AM, the Manager of the outpatient dialysis center confirmed, on 12/20/21 .we contacted the facility . was informed there were transport issues . transport arrived at the facility after scheduled appointment time . her scheduled appointment was already missed.
During an interview on 12/30/21 at 4:06 PM, Medical Record Assistant (MRA) confirmed the facility did not provide transportation for R58 to the dialysis clinic for her scheduled appointment time on 12/20/21 and R58 did not receive dialysis treatment on 12/20/21 as ordered by the physician. MRA revealed, residents missing schedule dialysis treatment could be potentially life or death situation for the residents residing at the facility.
During an interview on 12/30/21 at 7:26 PM, the DON (Director of Nursing) confirmed the dialysis center scheduled appointment times for residents receiving dialysis treatment and everyone was responsible for ensuring resident's transportation to dialysis for scheduled appointment. The DON further confirmed residents missing scheduled dialysis treatment could potentially cause resident to have respiratory issues.
The facility did not have a policy regarding transportation.
2. Review of the facility's policy titled, Hemodialysis, dated 11/01/19 revealed, The Dialysis Communication Form will be initiated prior to sending patient to dialysis.
The facility did not provide communication forms, for review for R58 to the outpatient dialysis center. The facility did not provide sign in or sign out logs for review for residents, leaving the facility for scheduled appointments. The facility did not provide contract for review with the outpatient dialysis center.
During an interview on 12/30/21at 5:29 PM, Registered Nurse (RN) Unit Manager (UM) confirmed and verified there were no completed communication forms for R58 for his dialysis appointments. RN UM verified the staff did not complete the documentation for communication with dialysis clinic.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide alternatives to residents who did not like wh...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide alternatives to residents who did not like what was served and failed to provide alternatives of similar nutritive value when alternatives were provided for three of 34 sampled residents (Resident (R)131, R405, R412).
Findings include:
Review of facility policy titled Dining and Food Preferences dated October 2019 documented, It is the center policy that individual dining, food, and beverage preferences are identified for all residents/patients.
Observation on 12/27/21 at 11:00 AM, revealed menu with alternative foods posted in main hallway.
1. R131 was admitted to the facility on [DATE], according to the electronic medical record (EMR) under the Medical Diagnosis tab.
Record review of R131, revealed a Dietary Progress Note in EMR, under Progress Notes tab, dated 12/07/21 revealed R131 typically consumed 26%-100% of meals.
Review of the EMR under Tasks tab revealed for month of December 2021 meal intake varied from 26%-100%.
Observation on 12/27/21 at approximately 4:30 PM, revealed R131 eating food that her family brought to her in her room.
During an interview on 12/28/21 at 10:00 AM, R131 stated she was on a special diet due to disease process; no replacement foods were offered, repetitive foods were served such as sausage was served almost every day, sometimes foods are cool that should be warm/hot; it's really bad, sometimes they give us tomato sauce with rice or hamburgers with pasta, it's just weird things that don't make sense . little pieces of fish, every meal has a lot of carbohydrates. R131 further stated she had spoken with Registered Dietitian (RD) who made notes of her preferences, but she still did not receive fresh foods.
2. R405 was admitted to the facility on [DATE], according to the EMR under the Progress Notes tab, admission Assessment/Screening V.1.2 dated 12/20/21.
Record review of R405, revealed a Dietary Progress Note in the EMR, under Progress Notes tab, dated 12/27/21 revealed R405 .not eating well due to repetitive meals, refuses meals at times and then is hungry later in evening; she requests menu alternatives.
Observation on 12/27/21 at 1:11 PM, revealed R405 eating lunch in her room with door open; percentage of meal consumed unknown.
During an interview on 12/28/21 at 11:22 AM, R405 stated repeated menu items were served such as chicken served for dinner will be served the following day for lunch; foods were frequently served cold, 12/28/21 breakfast meal was two French toast sticks with bacon, and both were cold. R405 further revealed the first few days she was at the facility she did not eat and decided to order out. Resident stated she was not offered an alternative meal choice if she did not like what was served; Resident further stated she was currently in quarantine and unable to go to the nurses' station to look at the menu.
3. R412 was admitted to the facility on [DATE], according to the EMR under the Medical Diagnosis tab.
Record review of R412, revealed Dietary Progress Note in EMR, under Progress Notes tab, dated 12/23/21 revealed R412's meal intake 51%-100%.
Record review of R412's Minimum Data Set (MDS) dated 12/24/21 in EMR, under MDS tab, revealed in part R412 requires total dependence for locomotion on/off unit; only able to stabilize with staff assistance, and requires wheelchair as mobility device.
During an interview on 12/27/21 at 5:00 PM, R412 stated food was bland and she would like to be able to pick her food.
During an interview on 12/30/21 at 9:53 AM, the Dietary Manager stated she made rounds every Thursday to Saturday on Units 1 through 3 and filled out weekly preference sheets that determined what would be served to each resident. The Dietary Manager stated weekly preference sheets were not available for Unit 4 where R131, R405 and R412 resided. The Dietary Manager stated the RD or charge nurse would send a note to the kitchen if a resident requested something special. Dietary Manger further stated she did not make rounds to Unit 4 and there was no particular reason for this. The Dietary Manager further stated alternative meals may be requested by residents through the charge nurse at any given time.
During an interview on 12/30/21 at 10:24 AM, the RD stated on admission she met with every resident/family to determine preferences, likes, and dislikes. During admission dietary assessment RD stated she told residents they could request alternate menu items if needed. The RD confirmed alternative menus were posted at nurses' stations and in the hallways; menus were not sent to resident rooms and staff did not make rounds to Unit 4 to determine if each resident wanted the main meal or alternative for breakfast, lunch, or dinner each day. Meal trays were sent based off preferences voiced during the admission meeting. The RD confirmed bed bound, quarantined, or isolated residents did not have alternative menus available to them. The RD further stated alternative meals may be requested by residents at any given time to their charge nurse, which was voiced to residents at admission.
During an interview on 12/30/21 at 3:01 PM, the Director of Nursing (DON) stated she was aware that a lot of residents order out their meals but have not told her why; no nurses/certified nurse aides had notified her of food concerns.
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 interview, record review, and facility policy, the facility failed to ensure advanced directives were offered and perio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy, the facility failed to ensure advanced directives were offered and periodically reviewed; and Do Not Resuscitate (DNR) forms were completed and accurate for ten residents out of 34 sampled residents (Resident (R) 51, R11, R33, R114, R67, R85, R407, R412, R126, and R107).
Findings include:
The facility's Advance Directives Policy, titled MFA [Medical Facilities of America] Policies Governing the Implementation of Self-Determination Rights read, in pertinent part, 3. All Residents at the time of admission will be provided with this document entitled MFA Policies Governing the Implementation of Self-Determination Rights which summarizes the Health & Rehabilitation Center's policies and procedures regarding advanced directives . 8. The original or a Health & Rehabilitation Center verified copy of any advance directive that is appropriately signed and witnessed as permitted by Virginia state law will be filed by the Health & Rehabilitation Center with the Resident's permanent medical record and appropriately noted in the chart. revealed Center will chart the Advance Directive Notification. in the Resident's permanent medical record . requiring the Resident to complete and sign the Advance Directive Notification and Acknowledgement form.
Review of facility policy Physician's Orders, Policy Number 203 dated 03/24/20 revealed in part .12) Code status: If a state DDNR [Durable Do Not Resuscitate] order, legible photocopy of the DDNR, DNR jewelry (bracelet or necklace), or POST [Physician Orders for Scope of Treatment] form does not accompany the patient upon admission the patient will be considered a full code until a singed physician order is secured. Ensure that the physician's order is correct and that the DDNR form or POST form, if applicable, is complete.
1. Review of an admission Record located in R33's electronic medical record (EMR) under the Profile tab indicated she was admitted on [DATE] and was her own responsible party.
R33's Physician Orders dated 11/11/21 found in the EMR under the Orders tab included an order that the resident was to be a full code, meaning resuscitation procedures would be provided in an emergency.
Review of R33's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/07/21 revealed R33 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact.
Review of R33's entire EMR revealed no documentation that advanced directive were offered or discussed with the resident by the facility staff.
During an interview on 12/28/21 at 11:35 AM, R33 said she did not recall the facility staff discussing an advanced directive with her upon admission. R33 said she wished to be resuscitated in an emergency and she would want to discuss advanced directives with someone.
During an interview on 12/28/21 at 3:05 PM, the Director of Nursing (DON) said there was no advanced directive or evidence it was discussed for R33. The DON said it should have been discussed and signed or declined upon R33's admission.
2. Review of an admission Record located in R11's EMR under the Profile tab indicated he was admitted on [DATE] and was his own responsible party. His brother was also listed as a contact.
R11's Physician Orders dated 04/21/21 found in the EMR under the Orders tab included an order that the resident was to be a full code.
Review of R11's admission MDS with an ARD of 10/07/21 revealed the resident had a BIMS score of 99 out of 15, which indicated the resident could not be assessed. The staff assessment for mental status indicated R11 had short term and long-term memory problems.
Review of R11's entire EMR revealed there was no documentation that advanced directives were offered or discussed with the resident or family member by the facility staff.
During an interview on 12/28/21 at 3:05 PM, the DON said there was no advanced directive or evidence it was discussed for R11. The DON said it should have been discussed and signed or declined upon R11's admission.
3. Review of an admission Record located in R51's EMR under the Profile tab indicated she was admitted on [DATE] and was her own responsible party.
R51's Physician Orders dated 04/21/21 found in the EMR under the Orders tab included an order that the resident was to be a full code.
Review of the resident's admission MDS with an ARD of 10/22/21 revealed the resident had a BIMS score of 14 out of 15, which indicated the resident was cognitively intact.
Review of R51's entire EMR revealed there was no documentation that advanced directives were offered or discussed with the resident or family member by the facility staff.
During an interview on 12/28/21 at 11:50 AM, R51 said she would want to be resuscitated and was not sure if anyone discussed it with her on admission. R51 said she thought it was an important issue and would want the staff to discuss it with her.
During an interview on 12/28/21 at 3:05 PM, the DON said there was no advanced directive or evidence it was discussed with R51. The DON said it should have been discussed and signed or declined upon R51's admission.
4. R407 was admitted to the facility on [DATE], according to the EMR under the Medical Diagnosis tab.
Review of R407's MDS, with ARD of 11/16/21, revealed R407 was severely cognitively impaired, with a BIMS score of 99, indicating the resident could not complete the interview. The MDS indicated the resident had both short and long-term memory deficits, and her cognitive skills for daily decision making were severely impaired.
Review of R407's MFA Policies Governing the Implementation of Self-Determination Rights Form, signed by the resident, dated 11/28/16, and provided by the facility, indicated the resident had not .executed Advance Medical Directive(s). and I DO NOT WANT MORE INFORMATION regarding advance directives.
Review of R407's DDNR, dated 12/02/20 and located in the EMR under the Miscellaneous tab, left both boxes unchecked leaving for the form incomplete related to the following: I further certify (must check 1 or 2): 1. The patient is CAPABLE of making an informed decision about providing, withholding, or withdrawing a specific medical treatment or course of medical treatment. (Signature of patient is required); 2. The patient is INCAPABLE of making an informed decision about providing, withholding, or withdrawing a specific medical treatment or course of medical treatment because he/she is unable to understand the nature, extent or probably consequences of the proposed medical decision, or to make a rational evaluation of the risks and benefits of alternatives to that decision. Review of document further revealed no Patient's Signature or Signature of Person Authorized to Consent on the Patient's Behalf.
Review of R407's Clinical Physician Orders, dated 12/16/21 and located in the EMR under the Orders tab, indicated the resident's code status was DNR.
During an interview on 12/29/21 at 3:10 PM, the Director of Admissions confirmed incomplete Durable Do Not Resuscitate Order was signed by a physician on 12/02/20, which was missing resident or responsible party's signature for R407. The Director of Admissions also confirmed there should be a signature in the area marked as patient's signature . I don't know if she had the capacity to sign at the time. If she did have the capacity in 2020 then she should of signed it, if she did not have capacity then the proxy or Power of Attorney should of signed it.
During an interview on 12/29/21 at 3:21 PM, the Director of Social Services (DSS) revealed R407's physician signature on Durable Do Not Resuscitate Order, dated 12/02/20 and did not check off selecting stating whether patient was capable of making decisions . resident does not have Power of Attorney and in the past she signed everything on her own . current DNR is not valid.
During an interview on 12/30/21 at 11:40 AM, the DON revealed R407 currently discharged to hospital. DON confirmed DNR on file dated 12/02/20 was missing R407's signature.
5. R412 was admitted to the facility on [DATE], according to the EMR under the Medical Diagnosis tab.
Review of R412's MDS, with an ARD of 12/24/21 revealed R412 was cognitively intact with a BIMS score of 15 out of 15.
Review of R412s Clinical Physician Orders, dated 12/18/21 and located in the EMR under the Orders tab, indicated the resident's code status was Full Code.
Review of R412's EMR revealed no documentation of advanced directives, or that facility staff discussed advanced directives with the resident.
Interview with DON on 12/28/21 at 3:23 PM, confirmed there is no advanced directive on file for R412.
Interview with the Director of Admissions on 12/29/21 at 2:56 PM, revealed the facility asks the resident or responsible party if there is an advanced directive. If there is none, I am not sure what is the process. If resident is a DNR facility obtains a copy from the hospital or family, DNR is then scanned into the chart and placed under the miscellaneous tab in EMR. The Director of Admissions confirmed in document manager located in EMR, there was no Advanced Directive information for R412.
6. R126 was admitted to the facility on [DATE], according to the EMR under the Medical Diagnosis tab.
Review of R126's Clinical Physician Orders, dated 12/30/21 and located in the EMR under the Orders tab, indicated the resident's code status was Full Code.
Review of R126's EMR revealed no documentation of advanced directives, or that facility staff discussed advanced directives with the resident.
Interview with DON on 12/28/21 at 3:23 PM, confirmed there is no advanced directive on file for R126.
Interview with R126 on 12/28/21 at 4:32 PM, revealed he did not recall being asked about Advanced Directives.
Interview with Director of Admissions on 12/29/21 at 2:56 PM, revealed facility asks the resident or responsible party if there is an advanced directive. If there is none, I am not sure what is the process. If resident is a DNR facility obtains a copy from the hospital or family, DNR is then scanned into the chart and placed under the miscellaneous tab in EMR. The Director of Admissions confirmed in document manager located in EMR, there was no Advanced Directive information for R126.
7. R107 was admitted to the facility on [DATE], according to the EMR under the Medical Diagnosis tab.
Review of R107's Clinical Physician Orders, dated 12/30/21 and located in the EMR under the Orders tab, indicated the resident's code status was Full Code.
Review of R107's EMR revealed no documentation of advanced directives, or that facility staff discussed advanced directives with the resident.
Review of R107's MDS with an ARD of 11/26/21 revealed R107 was cognitively intact with a BIMS score of 15 out of 15.
Interview with R107 on 12/28/21 9:02 AM, revealed she was not asked about advanced directives upon admission.
Interview with DON on 12/28/21 at 3:23 PM, confirmed there is no advanced directive on file for R107.
Interview with Director of Admissions on 12/29/21 at 2:56 PM, revealed facility asks the resident or responsible party if there is an advanced directive. If there is none, I am not sure what is the process. If resident is a DNR facility obtains a copy from the hospital or family, DNR is then scanned into the chart and placed under the miscellaneous tab in EMR. The Director of Admissions confirmed in document manager located in EMR, there was no Advanced Directive information for R107.
8. Review of R114's undated admission Record located in the EMR under the Profile tab indicated R114 was admitted to the facility on [DATE].
Review of R114's Physician Orders dated 11/23/21, located in the EMR under the Orders tab, revealed an order indicating R114 was full code.
Review of R114's Medication Administration Record (MAR) for December 2021, located in the EMR under the Orders tab under advance directives indicated R114 was full code.
Review of R114's EMR revealed no documentation of advanced directives or POST.
Review of R114's U.S. Living Will Registry Registration Agreement, dated 10/16/21, provided by the facility after retrieving the document from the outpatient hospital records, revealed under Section III- Specific Healthcare Instructions R114 initialed each box indicating no life-sustaining treatments; allow me to die naturally for the following: If I am unconscious, in a coma, or in a vegetative state and there are is little or no chance of recovery . If I have permanent, severe brain damage that makes me unable to recognize my family or friends (i.e., severe dementia, damage from stroke) . If I have a permanent condition where others must help me with my daily needs (such as eating and toileting) . If I have to be in bed and use a breathing machine 24/7 for the rest of my life . If I have severe pain or other severe symptoms that cause suffering and can't be relieved . and If I have a condition that will result in death soon, even with life-sustaining treatments.
During an interview on 12/28/21 at 4:01 PM, R114 was asked, what his wishes related to life sustaining interventions being initiated should he stop breathing and/or his heart would stop? R114 responded, I want the staff to do nothing, they should have my paperwork stating that. R114 stated, I informed the nurse practitioner [NP] that I don't want anything [life sustaining measures] done.
During an interview on 12/28/21 at 4:14 PM, Licensed Practical Nurse (LPN)17 was asked how she would know what R114's code status was? LPN17 stated, I would look at the MAR under advance directive and it would tell me what his code status is. LPN17 proceeded to show this surveyor R114's MAR indicating R114 was listed as a full code.
During an interview on 12/28/21 at 4:15 PM, the Licensed Practical Nurse Unit Manager (LPN-UM1) was questioned how would the staff know what R114's code status was? The LPN-UM1 stated, they would find it on the face sheet located in the resident's hard chart at the nursing station, which also reflected R114 was a full code.
During an interview on 12/30/21 at 8:35 AM, Admissions Assistant (AA) was questioned concerning the process of R114's advance directives. AA stated, if a resident is admitted from the hospital, I will access the hospital system and print out the resident's advance directives and scan the documents into the resident's medical record. AA was asked, when R114's advance directive had been pulled from the hospital system and placed into R114's medical record? AA stated, I forgot to do it for [R114], it was uploaded into the computer on 12/28/21. AA was asked who followed up with the resident/resident representative to ensure the advance directive were honored? AA replied, the social worker/discharge planning person to review in the care plan meeting.
During an interview conducted with the Director of Social Services (DSS) on 12/30/21 at 8:56 AM, the DSS was questioned, who was supposed to ensure the resident's advance directives were reviewed and kept updated? The DSS responded, admission is supposed to review and obtain all advance directives with resident.
9. Review of R67's Profile tab in the EMR, revealed R67 admitted to facility on 10/13/17 and code status was full code.
Review of R67's Orders tab in the EMR, revealed Full Code, dated 04/24/19.
Review of R67's Care Plan tab revealed no information regarding advance directives or code status.
Review of R67's EMR did not reveal any Advance Directives, or documentation of a discussion of advanced directives.
Review of a quarterly MDS with an ARD of 11/01/21 revealed, R67 was assessed with a BIMS score of 15 out of 15, indicating R67 was cognitively intact.
Review of paper document provided by the facility, titled MFA POLCIES GOVERING THE IMPLEMENTATION OF SELF-DETERMINATION RIGHTS, under the heading, ADVANCE DIRECTIVE ACKNOWLEDGEMENT, was not signed by R67 (signed by Responsible party), dated 10/13/17.
During an interview on 12/30/21 at 6:10 PM, R67 verified the facility had not reviewed advance directives or code status changes or continuation, with her since her admission to the facility in 2017.
An interview was conducted on 12/30/21 at 7:26 PM, the Director of Nursing (DON) confirmed the resident's code statuses were addressed at the time of resident's admission, and there was not a periodic review performed by the facility for resident's continuation or changes of advance directive instructions or code status. The DON denied knowing if resident's code status or advance directives were reviewed in care plan meetings.
10. Review of R85's EMR under the Profile tab revealed R85 admitted to the facility on [DATE], and code status was full code.
Review of R85's quarterly MDS with an ARD of 11/17/21 revealed a BIMS score of 15 out of 15, indicating R85 was cognitively intact.
Review of R85's Orders tab in the EMR, revealed full code physician order, dated 11/14/19.
Review of the misc tab in the EMR, under admission information contained a document, titled MFA POLCIES GOVERING THE IMPLEMENTATION OF SELF-DETERMINATION RIGHTS, under the heading ADVANCE DIRECTIVE ACKNOWLEGEMENT, the document was incomplete. There was no information entered on the document, including answers for questions regarding if R85 had an advance directive, the document was signed and dated 11/15/19.
Review of the Care Plan tab in the EMR revealed, no information for R85's code status or advance directive instructions.
An interview was conducted on 12/30/21 at 7:26 PM, the Director of Nursing (DON) confirmed the resident's code statuses were addressed at the time of resident's admission, and there was not a periodic review performed by the facility for resident's continuation or changes of advance directive instructions or code status. The DON denied knowing if resident's code status or advance directives were reviewed in care plan meetings.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and facility policy review, the facility failed ensure food was stored safely for three of four unit refrigerators. This failure could possibly lead to cross contamina...
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Based on observation, interview, and facility policy review, the facility failed ensure food was stored safely for three of four unit refrigerators. This failure could possibly lead to cross contamination and food-borne illness for the residents on three units.
Findings include:
During an observation of Unit 2 refrigerator with the Dietary Manager on 12/29/21at 12:25 PM, the following items were unlabeled and undated in the refrigerator: two bags of food in plastic grocery bags, two containers of lean cuisine frozen meals, one slice of pizza in a Ziploc bag. Additionally, there was a bottle of French dressing with an expiration date of 11/03/21.
During an observation of Unit 3 refrigerator with the Dietary Manager on 12/29/21at 12:30 PM, the following items were unlabeled and undated in the refrigerator: two opened bottles of water, one bottle of Frappuccino, a bag of apples, a bag of oranges, and a bottle of Gatorade.
During an observation of Unit 1 refrigerator with the Dietary Manager on 12/29/21at 12:35 PM, the following items were unlabeled and undated in the refrigerator: blue and white lunch bag, a opened bottle of Pepsi, an opened bottle of Gold Peak Tea, a Ziploc bag containing cornbread, and an unopened container of Quaker Oats grits.
During an interview with the Dietary Manager, on 12/29/21 at 12:36 PM, she confirmed the presence of all above listed items. The Dietary Manager stated only items belonging to residents should be in the fridge and should always be dated and labeled.
During an interview with the Registered Nurse (RN) Unit Manager, on 12/29/21 at 1:13 PM, she stated food in the unit refrigerators should be labeled and dated. The RN Unit Manager further stated it is nursing staff and the dietary staff's responsibility to ensure the unit refrigerators are in compliance.
Review of the facility's policy titled, Food Storage: Cold dated October 2019 indicated, It is the center policy to insure all Time/Temperature Control for Safety (TCS), frozen and refrigerated food items, will be appropriately stored in accordance with guidelines of the FDA Food Code. The policy further indicated, The Dining Services Director/Cook(s) insures [sic] that all food items are stored properly in covered containers, labeled and dated and arranged in a manner to prevent cross contamination
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policy, the facility failed to maintain a complete and accurate medica...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policy, the facility failed to maintain a complete and accurate medical record for six of thirty-four sampled residents (Resident (R) 107, R126, R199, R402, 407, and 412). Specifically, the nursing staff failed to document the completion of physician orders on the resident's medication administration records (MAR).
Findings Include:
Review of facility policy titled Documentation Summary dated 11/01/19 indicated Licensed Nurses and CNAs [Certified Nurse Aides] will document all pertinent nursing assessments, care interventions, and follow up actions in the medical record.
Review of facility policy titled Monitoring dated 11/01/19 indicated Licensed nurses will complete blood glucose monitoring as ordered by the physician .4. Blood glucose checks will be documented on the eMAR [Electronic Medication Administration Record].
1. R107 was admitted to the facility on [DATE], according to the electronic medical record (EMR) under the Medical Diagnosis tab, with diagnoses in part including Severe Calorie Malnutrition.
R107's Physician Orders found in the EMR under the Orders tab included blood sugar checks twice daily (dated 11/22/21) and respiratory assessment every four hours (dated 11/20/21).
Review of R107's Treatment Administration Record (TAR) dated 12/01/21-12/31/21, located in the EMR under the Reports tab revealed missing documentation of blood sugar level on 12/28/21 at 6:30 AM; and Respiratory Assessment documentation missing from 12/19/21 at 4:00 AM.
During an interview on 12/30/21 at 3:40 PM, the Director of Nursing (DON) confirmed R107's TAR had the following missing information: blood level was not recorded for 12/28/21 at 6:30 AM and Respiratory Assessment was not recorded for 12/19/21. The DON further stated every TAR should be filled out completely every shift and If it wasn't documented, it wasn't done.
2. R126 was admitted to the facility on [DATE], according to the EMR under the Orders tab, with diagnoses in part including congestive heart failure (CHF).
R126's Physician Orders dated 11/30/21 found in the EMR under the Orders tab included the following:
a. daily weights for congestive heart failure monitoring,
b. vital signs every shift,
c. respiratory assessment every 4 hours,
d. Continuous Positive Airway Pressure (CPAP) to be worn at night,
e. oxygen 2 liters per minute (LPM) via nasal canula every shift, and
f. 2-step tuberculosis (TB) screening upon admission.
Review of R126's TAR dated 12/01/21-12/31/21, located in the EMR under the Reports tab revealed the following missing documentation.
a. Daily weights for CHF monitoring on 12/01/21, 12/03/21 and 12/09/21.
b. Vital signs on 12/10/21 night shift.
c. Respiratory assessment (temperature and oxygen saturation level) on 12/11/21 at midnight and 4:00 AM, as well as 12/19/21 at 4:00 AM.
d. CPAP administration on 12/10/21 at bedtime.
e. Oxygen 2 LPM on 12/10/21 on night shift.
f. TB readings missing documentation on 12/01/21 and 12/08/21.
During an interview on 12/30/21 at 3:18 PM, the DON confirmed R126's TAR had the following missing information and the expectation was for treatment record to be filled out every shift per physician orders.
a. Daily weights for CHF monitoring on 12/1/21, 12/3/21 and 12/9/21. The DON stated, if the nurse doesn't weigh resident, they will not know if patient has 3+ pound (lbs) weight gain in 24-hour period .R126 has daily weights for CHF monitoring.
b. Vital signs for the 11 PM-7 AM shift on 12/10/21. The DON stated since Covid pandemic started they instituted vital sign monitoring every shift.
c. The respiratory assessment for 12/11/21 at midnight and 4:00 AM, and 12/19/21 at 4:00 AM.
d. CPAP not documented for 12/10/21.
e. Oxygen 2 LPM via nasal canula every shift for 12/10/21 night shift.
f. TB readings missing documentation on 12/01/21 and 12/08/21. The DON stated it was the facility's policy to do a TB test upon admission, read results two days later, then administer a second TB test seven days later, with results read two days later. The DON further reported, the initial TB test was performed on 11/29/21 and results should have been entered in TAR or progress note on 12/01/21; DON confirmed no documentation existed with TB results; second TB test performed on 12/6/21, results were not recorded on 12/8/21 and should have been per the DON.
3. R402 was admitted to the facility on [DATE], according to the EMR under the Medical Diagnosis tab, with diagnoses in part including unspecified diastolic (congestive) heart failure.
R402's Physician Orders dated 12/21/21 found in the EMR under the Orders tab included:
a. daily weights for three days upon admission and
b. vital signs every shift.
Review of R402's care plan dated 12/21/21 located in EMR under the Care Plan tab indicated R402 had constipation due to decreased mobility and congestive heart failure with orders to obtain weights as ordered.
Review of R402's TAR dated 12/01/21-12/31/21, located in the EMR under the Reports tab revealed the following missing documentation:
a. daily weight monitoring on 12/22/21 and 12/23/21, and
b. vital sign monitoring on 12/29/21, day shift.
Interview on 12/30/21 at 2:59 PM with DON, confirmed R402's TAR had the following missing information, and the expectation is for treatment record to be filled out every shift per physician orders:
a. daily weight not documented in TAR or nursing progress note for 12/22/21 and 12/23/21, and
b. vital signs every shift not documented for 12/29/21 day shift.
4. R404 was admitted to the facility on [DATE], according to the admission Physician Orders, in the Orders tab of EMR, dated 12/24/21, with diagnoses in part including indwelling suprapubic catheter.
R404's Physician Orders dated 12/24//21-12/25/21 found in the EMR under the Orders tab included the following:
a. change suprapubic catheter insertion site dressing every day and as needed using split gauze,
b. flush suprapubic catheter with 60 milliliters (ml) normal saline,
c. vital signs every shift,
d. respiratory assessment every four hours (temperature and oxygen saturations), and
e. droplet precautions in place 12/25/21 through 01/08/22.
Review of R404's TAR dated 12/01/21-12/31/21, located in the EMR under the Reports tab revealed the following orders had missing documentation:
a. change suprapubic catheter dressing on 12/29/21 day shift,
b. flush suprapubic catheter with 60ml of normal saline on 12/29/21 dayshift,
c. vital signs on 12/29/21 day shift,
d. respiratory assessment 12/29/21 at 12:00 PM,
e. maintaining droplet precautions 12/26/21, 12/27/21, 12/28/21, 12/29/21, and
Interview on 12/30/21 at 2:59 PM with DON, confirmed R404's TAR had the following missing information, and the expectation is for treatment record to be filled out every shift per physician orders:
a. changing suprapubic catheter dressing on 12/29/21 day shift;
b. flushing suprapubic catheter with 60ml of normal saline on 12/29/21 dayshift;
c. vital signs on 12/29/21 day shift;
d. respiratory assessment on 12/29/21 at 12:00 PM; and
e. maintaining droplet precautions on 12/26/21, 12/27/21, 12/28/21, and 12/29/21.
5. R412 was admitted to the facility on [DATE], according to the EMR under the medical diagnosis tab, with diagnoses in part including congestive heart failure.
R412's Physician Orders dated 12/21/21 found in the EMR under the Orders tab included daily weight notify Medical Doctor (MD) of weight gain of 3lbs in day or 5lbs in week and vital signs every shift.
Review of R412's care plan dated 12/18/21, revised 12/27/21 located in EMR under the Care Plan tab included CHF flare requiring therapeutic diet. Underweight BMI .resident will avoid significant weight change through next review. Gradual weight gain is desired .weekly weights .weights as ordered (daily).
Review of R412's MDS with an ARD of 12/24/21 revealed the resident had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact.
Review of R412's TAR dated 12/01/21-12/31/21, located in the EMR under the Reports tab revealed missing documentation of daily weight on 12/24/21, 12/25/21, and 12/26/21; and vital signs on 12/19/21 dayshift.
Interview on 12/30/21 at 2:59 PM with DON, confirmed R404's TAR had the following missing information, and the expectation is for treatment record to be filled out every shift per physician orders: daily weight on 12/24/21, 12/25/21, 12/26/21 and vital signs on 12/19/21 dayshift.
6. Review of R199's undated Administration Record located in the electronic medical record (EMR) under the profile tab indicated the resident was admitted to the facility on [DATE]. Diagnoses included diabetes, closed fracture of lower end of the left femur, and orthopedic aftercare.
Review of R199's physician orders located in the EMR under Orders tab revealed the following orders:
a. skin prep right (R) heel every day for prevention;
b. assess skin to left knee related to left knee immobilizer;
c. check movement, color, capillary refill of left toes related to immobilizer;
d. derma care to buttocks/sacral every shift for redness;
e. flush biliary drainage catheter on right side every shift,
f. keep dressing in place to left knee until follow up with [surgeon] in ten days;
g. TTWB [toe-touch weight bearing] LLE [left lower extremity] with [NAME] [total range of motion] knee immobilizer in lace;
h. [NAME] type locking hinged knee brace locked at 40 degrees of flexion;
i. and respiratory assessment every four hours for temperature and oxygen.
Review of R199's treatment administration record (TAR) for revealed on 07/01/21, 07/07/21, 07/17/21, there was no documentation indicating the nurse had completed the following physician's orders
a. skin prep (R) heel every day for prevention;
b. assess skin to left knee related to left knee immobilizer
c. check movement, color, capillary refill of left toes related to immobilizer;
d. derma care to buttocks/sacral every shift for redness,
e. flush biliary drainage catheter on right side every shift;
f. keep dressing in place to left knee until follow up with [surgeon] in ten days;
g. TTWB, LLE with [NAME] knee immobilizer in lace;
h. [NAME] type locking hinged knee brace locked at 40 degrees of flexion;
i. and respiratory assessment every four hours for temperature and oxygen.
During an interview with Licensed Practical Nurse (LPN) 8 conducted on 11/29/21 at 11:02 AM, LPN 8 was asked what is the process for documenting a resident's treatments and/or medication administration? LPN 8 responded whenever a medication or treatment is completed, we initial off on the MAR. LPN8 was asked what does it mean if the box on the MAR is empty, without initials? LPN8 responded if it is not initialed it was not done.
During an interview on 12/30/21 at 4:42 PM, the DON confirmed the lack of documentation on the TAR related to the physician's orders. The DON was questioned how would anyone know if these physician's orders was completed? The DON confirmed and stated, if it is not documented, it wasn't done.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, review of facility policy, and review of Centers for Disease Control and Prevent...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, review of facility policy, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases for six residents of nine residents (Resident (R) 403, R404, R405, R406, R407, and R408) reviewed for transmission-based precautions; three of seven residents (R37, R51, and R105) observed during the observation of medication administration; and three of seven residents (R3, R138, and R144) reviewed for catheter care. Specifically, enhanced droplet precautions were not followed for R403, R404, R405, R406, R407, and R408. Staff did not perform hand hygiene between R37, R51, and R105. Additionally, R3, R138, and R144's catheter bags were observed lying on the ground.
Findings include:
1. Review of the CDC's Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, updated 09/10/21, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html on 01/06/21 stated, In general, all unvaccinated residents who are new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission.
Review of the CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 09/10/21, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html on 01/06/21 stated, 2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected . SARS-CoV-2 infection. Place a patient with suspected . SARS-CoV-2 infection in a single-person room . The door should be kept closed (if safe to do so) . HCP [Health Care Professionals] who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face).
Review of United States COVID-19 County Level of Community Transmission as Originally Posted retrieved from https://data.cdc.gov/Public-Health-Surveillance/United-States-COVID-19-County-Level-of-Community-T/8396-v7yb on 01/06/21 on 12/29/21 the county level of community transmission for the facility was high at 18.06%.
Review of R403's electronic medical record (EMR) under the Profile tab revealed an admission date of 12/15/21. Treatment record under Reports tab of EMR revealed orders for enhanced droplet precautions from 12/16/21 through 12/29/21. Review of the Immunization Report, provided by the facility, revealed no COVID-19 immunization information for R403.
Review of the admission note, in the Progress Notes tab of EMR, dated 12/24/21, revealed R404's admitted to the facility on [DATE]. Treatment record under Reports tab of EMR revealed orders for enhanced droplet precautions from 12/25/21 through 1/07/22. Review of the Immunization Report, provided by the facility, revealed R404 had received SARS-COV-2 (COVID-19) (STEP 1) on 12/23/21.
R405 was admitted to the facility on [DATE], according to the EMR under the Progress Notes tab, admission Assessment/Screening V.1.2 dated 12/20/21. Physician's orders, under Orders tab of EMR revealed orders for enhanced droplet precautions from 12/20/21 through 1/04/22. Review of the Immunization Report, provided by the facility, revealed R405 had received SARS-COV-2 (COVID-19) (STEP 1) on 12/20/21.
Review of R406's entry tracking Minimum Data Set (MDS), dated 12/18/21 revealed R406 admitted to the facility on [DATE]. Review of the Immunization Report, provided by the facility, revealed R406 had received SARS-COV-2 (COVID-19) (STEP 1) on 01/19/21.
R407 was readmitted to the facility on [DATE], according to the EMR under the Medical Diagnosis tab with primary diagnosis ileus. Physician orders located in EMR, under Orders tab revealed enhanced barrier precautions as of 12/16/21 with no end date. Review of the Immunization Report, provided by the facility, revealed R407 had refused the COVID-19 vaccination.
Review of an admission Record located in R408's EMR under the Profile tab indicated she was admitted on [DATE] with diagnosis including acute eczema exacerbation. Review of the Immunization Report, provided by the facility, revealed R408 was fully vaccinated and had received SARS-COV-2 (COVID-19) (STEP 1) on 12/20/20 and received SARS-COV-2 (COVID-19) (STEP 2) 01/10/21.
The following observations were made on Unit 4A, which served as the quarantine hall for COVID-19 for new admissions to the facility. During the following observations on 12/27/21 from 12:51 to 1:44 PM the plastic curtain hanging from the ceiling on Unit 4 A, separating the quarantine rooms from non-quarantine rooms, was not zip closed, leaving it open from top to bottom.
a. On 12/27/21 at 12:54 PM, R403's bedroom door was open with green sign indicating Enhanced Droplet-Contact Precautions posted on the front of the door and a personal protective equipment (PPE) cart in the hallway outside of bedroom door. Review of the undated sign included instructions to perform hand hygiene, wear N95 mask, gown while in room, gloves when entering room, keep door closed, remove PPE and perform hand hygiene before exiting room. R403 was sitting in her wheelchair being served lunch tray by Certified Nurse Aide (CNA) 22 who was wearing gloves, gown, N95 mask, and eye protection
b. On 12/27/21 at 1:06 PM, R404's door was open with the green sign indicating Enhanced Droplet-Contact precautions posted on the front of the door and a PPE cart in the hallway outside of bedroom door. R404 was in bed feeding himself. CNA22 observed serving meal tray to R404 who was wearing gloves, gown, N95 mask, and eye protection.
c. On 12/27/21 at 1:11 PM, R405's door was open with no sign on door indicating she was on transmission-based precautions (TBP). Resident was eating lunch.
d. On 12/27/21 at 1:13 PM, R406's door was open with green sign indicating Enhanced Droplet-Contact Precautions. R406 was sitting up in her wheelchair feeding herself lunch during observation.
e. On 12/27/21 at 1:18 PM, R407 was resting in her bed, watching television with the bedroom door open; observed green sign on door stating, Enhanced Droplet-Contact Precautions, PPE available outside the bedroom door, no PPE bins available in the room for disposing of PPE. Regular trashcan available next to the sink.
f. On 12/27/21 at 1:44PM, R408's bedroom door was open with sign indicating Contact Precautions posted on the door. Review of the undated, sign revealed Contact Precautions .Visitors must report to nursing station before entering. Perform hand hygiene ., wear gown, gloves, bag linen to prevent contamination of self, environment or outside bag, discard infectious trash to prevent contamination of self, environment or outside bag.
An observation on 12/28/21 at 11:11 AM, revealed the plastic curtain in Unit 4A dividing the quarantine and non-quarantine rooms was no longer in place. On 12/29/21 at 1:46 PM, an observation was made of the plastic curtain in Unit 4A being installed. During the following observations on 12/28/21 and 12/29/21 resident rooms were observed open while the plastic sheeting dividing the quarantine and non-quarantine rooms was not present.
a. On 12/28/21 at 11:22 AM, R403's bedroom door was open with a sign on door stating Enhanced Droplet-Contact Precautions and R403 was sitting up in her wheelchair next to her bed.
b. On 12/28/21 11:21 AM, R404's bedroom door was open with Enhanced Droplet-Contact Precautions sign hanging on outside of door; PPE cart in the hallway outside of bedroom also observed while resident slouched over in bed resting with eyes closed.
c. On 12/29/21 at 10:35 AM, R408's bedroom door was open and sign indicating Contact Precautions was posted on the door. Psychiatrist who was wearing N95 mask and no other PPE, entered the room of R408 who was on contact precautions. Psychiatrist entered room without donning PPE or performing hand hygiene. At approximately 10:38 AM, LPN14 notified Psychiatrist that R408 was on contact precautions and that PPE was required prior to entering the room. Psychiatrist stated he did not see the sign on the door, then excused himself.
d. On 12/29/21 at 10:40 AM, R405's bedroom door was open. There was not a sign posted on the door indicating R405 was on TBP. CNA13 was in the room making the bed and R405 was in her wheelchair next to the bed. CNA13 was wearing an N95 mask and eye protection.
e. On 12/29/21 10:59 AM, R404's bedroom door was open with Enhanced Droplet-Contact Precautions sign hanging on outside of door; PPE cart in the hallway outside of bedroom also observed. CNA13 was wearing an N95 mask and eye protection and was observed donning gown and gloves to enter room to administer bed bath.
During an interview on 12/27/21 at 12:54 PM, CNA22 confirmed R403, R404, R405, R406, R407, and R408 were on transmission-based precautions and a N95 mask, gown, gloves, and eye protection were required in the rooms. CNA22 was not sure if bedroom doors should be closed or not, CNA22 further indicated that the doors had been open all morning.
During an interview on 12/27/21 at 1:10 PM, Registered Nurse (RN) 3 verified all residents beyond the plastic sheeting were on enhanced droplet precautions and stated anyone not fully vaccinated must quarantine 14 days per facility policy. RN3 verified R403, R404, R405, R406, R407, and 408 were on enhanced-droplet precautions. RN3 verified R405 was also on enhanced droplet-contact precautions but did not have a sign on her door indicating transmission-based precautions were in place nor did she have PPE available in front of her room.
During an interview on 12/27/21 at 1:28PM, RN3 confirmed R407 was on enhanced droplet-contact precautions and that there were no PPE disposal bins available in the room. RN3 stated I need to get her some bins . you can put your PPE in regular trash as long as it's not contaminated. RN3 stated she was not sure if bedroom door is supposed to be shut due to plastic curtain in place.
During an interview on 12/28/21 at 11:22 AM, R405 confirmed she was on quarantine for 14 days due to recent admission.
During an interview on 12/29/21 at 10:35 AM, LPN14 confirmed Psychiatrist entered the room of R408 with only a N95 face mask. LPN14 confirmed R408 was on contact precautions and all staff must wear PPE while inside the room.
During an interview on 12/29/21 at 10:40 AM, CNA13 verified she entered the room of R405 wearing an N95 and eye protection, but without a gown and gloves. CNA13 confirmed R405 was on enhanced droplet-contact precautions and that she should have donned a gown, and gloves prior to entering the room.
During an interview on 12/29/21 at 1:28 PM, Assistant Director of Nursing (ADON) confirmed all doors to resident bedrooms that had signs indicating enhanced droplet-contact precautions should remain closed if there was no curtain up; if curtain was open or not in place, all doors should remain closed. ADON confirmed staff were currently moving residents for a quarantine and hot area due to multiple positive Covid cases in the building. The ADON confirmed all new admissions to the facility were quarantined and placed on enhanced droplet-contact precautions.
2. Review of a document provided by the facility titled Standard Precautions, dated 02/06/20 stated The Center promotes the fundamental guidelines for standard precautions, as recommended by the Center for Disease Control [CDC]. The Center utilizes standard precautions for all patients . Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces and before going to another patient. Perform hand hygiene upon removing gloves.
During a medication pass observation on 12/29/21 from 9:22 AM to 9:54 AM, Licensed Practical Nurse (LPN) 5 administered ophthalmic medication to R37 with gloved hands. LPN5 then adjusted R105's nasal canula without removing her gloves or performing hand hygiene. LPN5 was immediately interviewed and verified she did not perform hand hygiene and should have between R37 and R105. LPN5 then exited the room and doffed her gloves. LPN5 did not use Alcohol Based Hand Rub or wash her hands. LPN5 moved the medication cart and began dispensing medications for R51. At 9:54 AM, when asked if she had sanitized her hands, LPN5 stated she thought she had. LPN5 then performed hand hygiene with Alcohol Based Hand Rub and continued to dispense the rest of R51's medications.
3. Review of R3's Face Sheet located in the EMR under the Profile tab, revealed an admission date of 9/29/12 and included, but was not limited to, the following diagnoses: chronic kidney disease and benign prostatic hyperplasia.
During an observation on 12/30/21 at 11:34 AM, R3's urinary catheter drainage bag was observed to be on the floor on the right side of his bed.
During an interview on 12/30/21 at 11:36 AM, CNA16 stated the urinary catheter drainage bag should not be on the floor. CNA16 proceeded to secure the urinary catheter drainage bag to R3's bed.
4. Review of R138's Face Sheet located in the EMR under the Profile tab, revealed an admission date of 11/17/15 and included, but was not limited to, the following diagnoses: quadriplegia and neuromuscular dysfunction of bladder.
During an observation on 12/30/21 at 11:38 AM, R138's urinary catheter drainage bag was observed to be uncovered, on the floor, and under R138's bed.
During an interview on 12/30/21 at 11:40 AM, CNA16 stated the urinary catheter drainage bag should not be on the floor or exposed. CNA16 proceeded to secure the urinary catheter drainage bag to R138's bed and placed the drainage bag in a privacy cover.
During an interview on 12/30/21 at 3:10 PM, the Registered Nurse (RN) Unit Manager stated the urinary catheter drainage bags should not be on the floor. The RN Unit Manager stated when the urinary catheter drainage bags were on the floor, microorganisms could be introduced into the urine.
During an interview on 12/30/21 at 5:31 PM, the Director of Nursing (DON) stated urinary catheter drainage bags should not be on the floor.
5. Review of R144's undated Admission's Record located under the Profile tab in the EMR indicated the resident was initially admitted on [DATE] with a re-admission on [DATE] with diagnoses including urinary tract infection, down syndrome, dementia, and retention of urine.
During an observation conducted on 12/28/21 at 9:50 AM and on 12/29/21 at 7:32 AM, R144's urinary catheter bag was observed laying on the floor next to her bed. There was no barrier between the urinary catheter bag and the floor.
During an interview on 12/29/21 at 10:27 AM, at R144's bedside, CNA11 stated [R144's] catheter must be below the bladder level and covered with a dignity bag. CNA11 confirmed the catheter must be kept off the floor. CNA11 stated the urinary catheter bag would become dirty if left on the floor.
An attempt to interview the unit manager on was unsuccessful due to testing positive for COVID-19.
Facility policies for catheter care related were requested, policies did not address bag placement and infection control.
Mar 2019
14 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review the facility staff failed to ensure a complete DNR (do not resuscitate) form...
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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 complete DNR (do not resuscitate) form for 1 of 36 Residents, Resident #129.
The findings included:
For Resident #129 the facility staff failed to ensure a complete Virginia Department of Health DDNR (durable do not resuscitate) form.
Resident # 129 was admitted to the facility on [DATE]. Diagnoses included but not limited to Alzheimer's disease, dementia, seizure disorder, anxiety, depression, and psychotic disorder.
The most recent MDS (minimum data set) with an ARD (assessment reference date) of 02/13/19 coded the Resident as 3 out of 15 in Section C, cognitive patterns. This is a quarterly MDS.
Resident #129's clinical record was reviewed on 03/12/19. It contained a physician's order summary, which read in part Code status: DNR. The clinical record also contained a Virginia Department of Health DDNR form, which read as follows:
I further certify (must check 1 or 2):
[] 1. The Patient is CAPABLE of making an informed decision about providing, withholding, or withdrawing a specific medical treatment or course of medical treatment. (Signature of Patient is required).
[x] 2. The Patient is INCAPABLE of making an informed decision about providing, withholding, or withdrawing a specific medical treatment or course of medical treatment, because he/she is unable to understand the nature, extent or probable consequences of the proposed medical decision, or to make a rational evaluation of the risks and benefits of alternatives to that decision.
If you checked 2 above, check A, B, or C below:
[] A. While capable of making an informed decision, the patient has executed a written advanced directive which directs that life-prolonging procedures be withheld or withdrawn.
[] B. While capable of making an informed decision, the patient has executed a written advanced directive which appoint a Person Authorized to Consent on the Patient's Behalf with authority to direct that life-prolonging procedures be withheld or withdrawn. (Signature of Person Authorized to Consent on the Patient's Behalf is required.)
[] C. The patient has not executed a written advanced directive (living will or durable power of attorney for health care). (Signature of Person Authorized to Consent on the Patient's Behalf is required).
Section 2 of this form had not been completed.
Surveyor spoke with the DON (director of nursing) on 03/12/19 at approximately 1130 regarding the incomplete DDNR form. DON stated that the DDNR form was incomplete and that she would correct it. DON provided surveyor with a copy of the corrected DDNR form on 03/12/19 at approximately 1200.
The concern of the incomplete DDNR was discussed with the administrative team during a meeting on 03/13/19 at approximately 1415.
No further information provided prior to exit.
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** Based on staff interview and clinical record review, the facility staff failed to notify the physician of medication refusals fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to notify the physician of medication refusals for 3 of 36 residents in the survey sample (Resident #'s 126, 35 and 41).
The findings included:
1. The facility staff failed to notify the physician of medication refusals for Resident #126.
Resident #126 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to heart failure, high blood pressure, urinary tract infection, diabetes, manic depression, and chronic obstructive pulmonary disease. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/12/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #126 was also coded as requiring extensive assistance of 2 staff members for dressing, and 1 staff member for personal hygiene and being totally dependent on 1 staff member for bathing.
The surveyor performed a clinical record review of Resident #126's chart on 3/12/19 through 3/13/19. During this review, the surveyor noted Resident #126 refused to take the following medications on the dates and times as follows:
Bisacodyl EC tablet delayed release 5 mg (milligram) Give 2 tablets by mouth at 1700 (5 pm) Refused to be taken by the resident on 2/4/19, 2/6/19, 2/9/19, 2/11/19, 2/13/19, 2/14/19, 2/15/19, 2/16 19, 2/17/19, 2/18/19, 2/20/19, 2/21/19, 2/21/19,
Hydrocortisone Acetate Suppository 25 mg Insert 1 suppository rectally at bedtime Refused to be taken by the resident on 2/3/19, 2/6/19, 2/9/19, 2/10/19, 2/13/19, 2/18/19, 2/19/19, 2/20/19, 2/21/19, 2/23/19, 2/24/19, 2/25/19 and 2/26/19.
Linzess Capsule Give 1 capsule by mouth every 72 hours Refused to be taken by the resident on 3/7/19, 3/10/19 and 3/13/19.
On 3/13/19 at 2:14 pm, the surveyor notified the administrative team of the above documented findings. The surveyor asked what was the policy on notifying the physician of a resident refusing to take medications as ordered by the physician. The director of nursing stated, If a resident refuses to take his medications for 3 days then the staff is to notify the physician of this.
On 3/14/19, the surveyor reviewed the documentation in the nurses' notes for the above dates and times in which the resident refused to take his medications. The surveyor did not find any documentation that the physician had been notified of the resident refusing to take his medications on the above documented dates.
No further information was provided to the surveyor prior to the exit conference on 3/14/19.
2. The facility staff failed to notify the physician when Resident #35 had refused to take his medications as ordered.
Resident #35 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to high blood pressure, aphasia, stroke, anxiety disorder and depression. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/26/18, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 10 out of a possible score of 15. Resident #35 was also coded as requiring extensive assistance of one staff member for dressing, and personal hygiene and being totally dependent on 1 staff member for bathing.
During the clinical record review of Resident #35 on 3/12/19 and 3/13/19, the surveyor noted the resident had refused the following medications for the dates of times as follows:
Aspirin 81 mg (milligram) Give 2 tablet by mouth one time a day at 0800 Refused to be taken by the resident on 2/21/19, 2/25/19, 2/27/19, 3/1/19, 3/5/19, 3/6/19, 3/7/19, 3/8/19, 3/9/19, 3/10/19, 3/11/19, 3/12/19 and 3/13/19.
Atorvastatin Calcium 20 mg Give 1 tablet by mouth at bedtime Refused to be taken by the resident on 2/19/19, 2/21/19, 2/23/19, 2/24/19, 2/25/19, 2/27/19, 3/1/19, 3/3/19, 3/5/19, 3/7/19, 3/8/19, 3/9/19, 3/11/19 and 3/13/19.
Cholecalciferol 800 mg Give 1 tablet by mouth at 0800 Refused to be taken by the resident on 2/21/19, 2/25/19, 2/27/19, 3/1/19, 3/5/19, 3/6/19 and 3/8 through 3/13/19.
Colace 100 mg Give 1 tablet by mouth at bedtime Refused to be taken by the resident on 2/19/19, 2/21/19, 2/23/19, 2/24/19, 2/25/19, 2/27/19, 3/1/19, 3/3/19, 3/5/19, 3/7/19, 3/8/19, 3/9/19 and 3/11/19.
Neurontin 100 mg Give 1 capsule by mouth at bedtime Refused to be taken by the resident on 2/19/19, 2/21/19, 2/23/19, 2/24/19, 2/25/19, 2/27/19, 3/1/19, 3/3/19, 3/5/19, 3/7/19, 3/8/19, 3/9/19, 3/11/19 and 3/12/19.
Trazodone 300 mg Give 1 tablet by mouth at bedtime Refused to be taken by the resident on 2/19/19, 2/20/19, 2/23/19, 2/24/19, 2/24/19, 2/25/19, 2/27/19, 3/1/19, 3/3/19, 3/5/19, 3/7/19, 3/8/19, 3/9/19, 3/11/19 and 3/12/19.
Buspar 15 mg Give 1 tablet by mouth two times a day Refused to be taken by resident on 2/19/19 at 1700 (5 pm), 2/21/19 at 0900 and 3/5/19 through 3/12/19 at 1700.
The surveyor reviewed the resident's comprehensive care plan. The resident's comprehensive care plan did not reflect that it had been updated with the above documented findings of the resident refusing to take those medications.
On 3/13/19 at 2:14 pm, the surveyor notified the administrative team of the above documented findings. The surveyor asked what was the policy on notifying the physician of a resident refusing to take medications as ordered by the physician. The director of nursing stated, If a resident refuses to take his medications for 3 days then the staff is to notify the physician of this.
On 3/14/19, the surveyor reviewed the documentation in the nurses' notes for the above dates and times in which the resident refused to take his medications. The surveyor did not find any documentation that the physician had been notified of the resident refusing to take his medications on the above documented dates.
No further information was provided to the surveyor prior to the exit conference on 3/14/19.
3. For Resident #41, facility staff failed to notify the physician that the resident did not receive multiple doses of pain medication.
Resident #41 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, falls, hypertension, cardiopulmonary disease, polyneuropathy, and malignant neoplasms of the kidney and lung. On the quarterly minimum data set assessment with assessment reference date 1/8/19, the resident scored 10/15 on the brief interview for mental status, and was assessed as without signs of delirium, psychosis, and behaviors affecting care.
The resident complained to the surveyor of pain and not getting pain medication during an interview on 3/12/19.
Clinical record review 03/13/19 11:26 AM revealed a physician order dated 10/30/18 for Tramadol 25 mg every 8 hours for pain scheduled at midnight, 8 AM, and 4 PM. The medication administration record documented the resident not receiving the midnight dose 3/1 through 3/11 due to being asleep. The Tramadol dose was increased to 50 mg three times per day on 3/13/19 after the physician was contacted about continued complaints of pain. The midnight doses were not administered on 3/12-3/13 due to sleep.
The surveyor spoke with the unit manager, who said she did not know if the physician's office had been notified of all the holds on the Tramadol, but she would check. On 3/14/19 at 09:08 AM, the unit manager reported that the physician and nurse practitioner's office had not been notified that the Tramadol doses had been held.
The administrator and director of nursing were notified of the concern during a summary meeting on 3/14/19.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, and facility document review, the facility staff failed to protect the private healthcare information of residents on 1 of 4 units in the nursing facility (Unit ...
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Based on observation, staff interview, and facility document review, the facility staff failed to protect the private healthcare information of residents on 1 of 4 units in the nursing facility (Unit 2).
The findings included:
The facility staff failed to protect the private healthcare information of residents on Unit 2.
On 3/12/19 at 9:05 am, this surveyor observed confidential and private healthcare information for resident room #'s 46 through 60B. This information was on top of the medication cart and anyone walking by could view the information. This medication cart belonged to LPN (Licensed Practical Nurse) #1.
On 3/13/19 at 10:02 am, the surveyor observed private and confidential healthcare information for resident room #'s 31 through 45. This information was on top of the medication cart and anyone walking by could view the information. The medication cart belonged to LPN #2.
The surveyor requested and received a copy of the facility's policy concerning Confidentiality on 3/13/19 at approximately 10:30 am from the director of nursing. This policy read in part, .Protect all medical information of our patients and employees. Protection of medical information is everybody's business .and should not be disclosed to non-care givers, other patients, or the public at large .
The surveyor notified the administrative team of the above documented findings on 3/13/19 at 2:14 pm in the conference room.
No further information was provided to the surveyor prior to the exit conference on 3/14/19.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, the facility staff failed to review and revise the resident's comprehensive...
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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 review and revise the resident's comprehensive care plan for 1 of 36 residents in the survey sample (Resident #35).
The findings included:
The facility staff failed to review and review Resident #35's care plan in regards to his refusals of medications.
Resident #35 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to high blood pressure, aphasia, stroke, anxiety disorder and depression. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/26/18, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 10 out of a possible score of 15. Resident #35 was also coded as requiring extensive assistance of one staff member for dressing, and personal hygiene and being totally dependent on 1 staff member for bathing.
During the clinical record review of Resident #35 on 3/12/19 and 3/13/19, the surveyor noted the resident had refused the following medications for the dates of times as follows:
Aspirin 81 mg (milligram) Give 2 tablet by mouth one time a day at 0800 Refused to be taken by the resident on 2/21/19, 2/25/19,
Atorvastatin Calcium 20 mg Give 1 tablet by mouth at bedtime Refused to be taken by the resident on 2/19/19, 2/21/19, 2/23/19, 2/24/19, 2/25/19, 2/27/19, 3/1/19, 3/3/19, 3/5/19, 3/7/19, 3/8/19, 3/9/19, 3/11/19 and 3/13/19.
Cholecalciferol 800 mg Give 1 tablet by mouth at 0800 Refused to be taken by the resident on 2/21/19, 2/25/19, 2/27/19, 3/1/19, 3/5/19, 3/6/19 and 3/8 through 3/13/19.
Colace 100 mg Give 1 tablet by mouth at bedtime Refused to be taken by the resident on 2/19/19, 2/21/19, 2/23/19, 2/24/19, 2/25/19, 2/27/19, 3/1/19, 3/3/19, 3/5/19, 3/7/19, 3/8/19, 3/9/19 and 3/11/19.
Neurontin 100 mg Give 1 capsule by mouth at bedtime Refused to be taken by the resident on 2/19/19, 2/21/19, 2/23/19, 2/24/19, 2/25/19, 2/27/19, 3/1/19, 3/3/19, 3/5/19, 3/7/19, 3/8/19, 3/9/19, 3/11/19 and 3/12/19.
Trazodone 300 mg Give 1 tablet by mouth at bedtime Refused to be taken by the resident on 2/19/19, 2/20/19, 2/23/19, 2/24/19, 2/24/19, 2/25/19, 2/27/19, 3/1/19, 3/3/19, 3/5/19, 3/7/19, 3/8/19, 3/9/19, 3/11/19 and 3/12/19.
Buspar 15 mg Give 1 tablet by mouth two times a day Refused to be taken by resident on 2/19/19 at 1700 (5 pm), 2/21/19 at 0900 and 1700, 2/23/19 at 1700, 2/24/19 at 1700, 2/25/19 at 0900 and 1700, 3/1/19 at 0900 ad 1700, 3/3/19 at 1700, 3/5/19 through 3/13/19 at 0900 and 3/5/19 through 3/12/19 at 1700.
The surveyor reviewed the resident's comprehensive care plan. The resident's comprehensive care plan did not reflect that it had been updated with the above documented findings of the resident refusing to take those medications.
On 3/13/19 at 2:14 pm, the surveyor notified the administrative team of the above documented findings.
No further information was provided to the surveyor prior to the exit conference on 3/14/19.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
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 administer pain medications for 2 of 36 Reside...
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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 administer pain medications for 2 of 36 Residents, (Residents #38 and #41)
1. For Resident #38, facility staff failed to consistently administer pain medications per physician orders.
Resident #38 was admitted to the facility on [DATE] with diagnoses including paraplegia, muscle weakness, chronic pain, neurogenic bowel, hypertension, diabetes mellitus, anxiety, and depression. On the quarterly minimum data set assessment with assessment reference date 12/27/18, the resident scored 15/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care.
During an interview on 3/13/19 at 12:56 PM, the resident mentioned that during her stay, robaxin and gabapentin had both run out with no quick replacement.
Record review revealed that on 3/11 the Lidocaine patch was held (code 5=see note), without a nursing note to document the reason and on 1/10, Fentanyl and Lidocaine patches were both held with no explanation. Fentanyl was coded 5(=hold, see notes) and Lidocaine at 8 and 12 were coded 9(= other see progress notes). There were no progress notes on that date.
The administrator and director of nursing were notified of the concern with pain medication administration on 3/12/19.
2. For Resident #41, facility staff failed to administer multiple doses of pain medication, contributing to an increase in the pain medication dose.
Resident #41 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, falls, hypertension, cardiopulmonary disease, polyneuropathy, and malignant neoplasms of the kidney and lung. On the quarterly minimum data set assessment with assessment reference date 1/8/19, the resident scored 10/15 on the brief interview for mental status, and was assessed as without signs of delirium, psychosis, and behaviors affecting care.
The resident complained to the surveyor of pain and not getting pain medication during an interview on 3/12/19.
Clinical record review 03/13/19 11:26 AM revealed a physician order dated 10/30/18 for Tramadol 25 mg every 8 hours for pain scheduled at midnight, 8 AM, and 4 PM. The medication administration record documented the resident not receiving the midnight dose 3/1 through 3/11 due to being asleep. The Tramadol dose was increased to 50 mg three times per day on 3/13/19 after the physician was contacted about continued complaints of pain. The midnight doses were not administered on 3/12-3/13 due to sleep.
The surveyor spoke with the unit manager, who said she did not know if the physician's office had been notified of all the holds on the Tramadol, but she would check. On 3/14/19 at 09:08 AM, the unit manager reported that the physician and nurse practitioner's office had not been notified that the Tramadol doses had been held.
The administrator and director of nursing were notified of the concern during a summary meeting on 3/14/19.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to coordinate care with dialysis for Resident #316.
Resident #316 was admitted to the facility 3/7/...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The facility staff failed to coordinate care with dialysis for Resident #316.
Resident #316 was admitted to the facility 3/7/19 with the following diagnoses of, but not limited to end stage renal disease. The resident did not have an admission MDS (Minimum Data Set) completed at the time of this survey. However, it was noted by the surveyor that the resident was .alert and oriented X4 . as documented in the nursing notes for 3/7/19 at 23:49 (11:49 pm).
On 3/13/19, the surveyor could not find any documentation of communication between the facility and the dialysis center. The resident was noted to be receiving dialysis on Monday, Wednesday and Friday of every week.
At 10:45 am on 3/13/19, the surveyor asked the director of nursing (DON) where to locate the documentation of communication between the facility and dialysis for Resident #316. The DON stated, We don't use the communication forms for dialysis and only chart exceptions if there are any noted.
The surveyor notified the administrative team of the above documented findings on 3/13/19 at 2:14 pm.
The surveyor requested and received the facility's policy titled Hemodialysis on 3/14/19 at 9:45 am. The policy read in part, .The Dialysis Communication Form will be initiated prior to sending patient for dialysis .
No further information was provided to the surveyor prior to the exit conference on 3/14/19.
Based on observation, resident and staff interview, facility document review and clinical record review it was determined the facility staff failed to follow the policy for contracted dialysis communication sheets for 2 of 36 residents (Resident #79 and # 316 ).
Findings:
1. Facility staff failed to obtain Resident #79's information/communication sheets from the contracted dialysis facility. The resident's clinical record was reviewed on 3/13/19 at 9:00 AM.
Resident #79 was admitted to the facility on [DATE]. He had diagnoses which included ESRD (end-stage renal disease), hypertension, diabetes and peripheral vascular disease.
The latest MDS (minimum data set) coded the resident as cognitively intact. The resident needed the assistance of at least one staff member for all the ADLS (activities of daily living) with a set-up only to eat.
The latest CCP (comprehensive care plan) reviewed and revised on 3/12/19 documented the resident as needing dialysis due to renal failure. The goal for care was the resident would have immediate intervention should any complications from dialysis occur.
Resident #79's physician's orders, signed and dated 12/29/18, included instructions for dialysis on Monday, Wednesday, Friday at 11:30 am. The staff followed orders to get the resident to the dialysis center three days a week.
The clinical record was reviewed for communication sheets from the facility. No communication with the dialysis center was documented in the record.
On 03/12/19 at 3:16 PM Resident #79 was interviewed about his dialysis treatments. He stated, I go Monday, Wednesday and Friday I don't eat while I'm there because I'm not hungry . I don't carry a dialysis sheet over and back with me.
On 3/13/19 at 9:45 AM the facility DON was asked about the communications with the dialysis center. The DON said they had not been using communication sheets because they didn't find them to be effective. She acknowledged the facility policy directed staff to use the communication forms.
The contract between the facility and the dialysis center, signed and dated 4/29/03, was reviewed for content. The contract included, in part, The parties will mutually develop a written proposal governing specific responsibilities, policies and procedures to be used in rendering dialysis services to residents at the ESRD Dialysis Unit, including, but not limited to, the development and implementation of a resident's care plan relative to the provision of dialysis services. The Facility will provide for the interchange of information useful or necessary for the care of the resident .
The facility policy for Hemodialysis, effective 9/20/18, contained the following: The dialysis communication form will be initiated prior to sending patient for dialysis. A dialysis center's designated form may be used in place of (name of the facility) dialysis communication form. Patient reports received from dialysis center will be uploaded to the patient's EHR (electronic health record).
On 3/13/19 at 4:00 PM the surveyor's findings were shared with the administrator, DON and corporate nurse.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review the facility staff failed to identify irregularities related to medications ...
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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 identify irregularities related to medications for 1 of 36 Residents, Resident #129.
The findings included:
For Resident #129, the pharmacist failed to identify prn (as needed) usage of psychotropic medications for longer than 14 days without being re-evaluated by a physician.
Resident # 129 was admitted to the facility on [DATE]. Diagnoses included but not limited to Alzheimer's disease, dementia, seizure disorder, anxiety, depression, and psychotic disorder.
The most recent MDS (minimum data set) with an ARD (assessment reference date) of 02/13/19 coded the Resident as 3 out of 15 in Section C, cognitive patterns. This is a quarterly MDS.
Resident #129's clinical record was reviewed on 03/13/19. It contained a signed physician's order summary, which read in part Ativan Tablet 1 mg (lorazepam). Give 1 tablet by mouth every 24 hours as needed for Psychosis related to UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOW PSYSIOLOGICAL CONDITION (F29). Given with Haldol 2 mg and Haloperidol Tablet 2 mg. Give 1 tablet by mouth every 24 hours as needed for psychosis related to UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOW PSYSIOLOGICAL CONDITION (F29) given with Ativan 1 mg. These orders contained no stop date. The Haldol was discontinued on 03/04/19.
Resident #129's eMAR (electronic medication administration record) for the month of February was reviewed and contained entries, which read in part Ativan Tablet 1 mg (lorazepam). Give 1 tablet by mouth every 24 hours as needed for Psychosis related to UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOW PSYSIOLOGICAL CONDITION (F29). Given with Haldol 2 mg and Haloperidol Tablet 2 mg. Give 1 tablet by mouth every 24 hours as needed for psychosis related to UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOW PSYSIOLOGICAL CONDITION (F29) given with Ativan 1 mg.
Resident #129's MRR's (medication regimen review) for the months of April 2018-February 2019 were reviewed. The consulting pharmacist had made no recommendations related to the use of the as needed psychotropic medications Haldol and Ativan for longer than 14 days with no stop date on any of the MRR's. The Resident's clinical record contained a Consulation Report from the pharmacist dated 02/15/19 which read in part patient stable on current regimen. Risks outweigh the benefits, but did not speak specifically of the Ativan or Haldol.
The concern of the consulting pharmacist not identifying as needed psychotropic medications in use for longer than 14 days with no stop date was discussed with the administrative team during a meeting on 03/14/19 at approximately 1230.
No further information was provided prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review the facility staff failed to ensure 1 of 36 Residents was free of unnecessar...
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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 1 of 36 Residents was free of unnecessary psychotropic medications, Resident #129.
The findings included:
For Resident #129 the facility staff failed to ensure that the psychotropic medications Ativan and Haldol were not used unnecessarily.
Resident # 129 was admitted to the facility on [DATE]. Diagnoses included but not limited to Alzheimer's disease, dementia, seizure disorder, anxiety, depression, and psychotic disorder.
The most recent MDS (minimum data set) with an ARD (assessment reference date) of 02/13/19 coded the Resident as 3 out of 15 in Section C, cognitive patterns. This is a quarterly MDS.
Resident #129's clinical record was reviewed on 03/14/19. It contained a signed physician's order summary, which read in part Ativan Tablet 1 mg (lorazepam). Give 1 tablet by mouth every 24 hours as needed for Psychosis related to UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PSHYIOLOGICAL CONDITION (F29). Given with Haldol 2 mg and Haloperidol tablet 2 mg. Give 1 tablet by mouth every 24 hours as needed for psychosis related to UNSPECIFIED PSYCHOSIS NOT DUE TO A SUBSTANCE OR KNOWN PHYSIOLOGICAL CONDITION (F29). given with Ativan 1 mg. Order date for these orders was 01/12/18. The Ativan did not have a stop date. The Haldol was discontinued on 03/04/19.
Resident #129's clinical record contained psychiatric progress notes for the months of April, July, and October 2018 with a current medications list. Each progress note listed Haldol and Ativan in the current medications list, and treatment goals to continue current plan, and next appointment in 90 days. The clinical record contained a psychiatric note for December 2018 which read in part .(Resident #129) is at her baseline. She currently lying on her bed. She is calm @ (at) this time but has periods of intense agitation c (with) aggression. She will remain on prn (as needed) Ativan and Haldol to manage periods of aggression. No med adjustments @ this time. The next appointment was listed as 90 days with treatment goals of continue tx (treatment) plan. The Resident's clinical record also contained a psychiatric progress note for February 2019 which read in part Termination of Psychiatric Services. This patient was seen for final assessment today. The patient remains stable. Effective 3/3/19, .(name omitted) will no longer provide psychiatric services at .(facility name omitted). Please refer Resident to your primary care physician. Current medications listed included Ativan and Haldol, with treatment goals to continue treatment plan.
The concern of using as needed psychotropic medications for longer than 14 days and with no stop date was discussed with the administrative team during a meeting on 03/14/19 at approximately 1230.
No further information was provided prior to exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review the facility staff failed to ensure 3 of 36 Reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review the facility staff failed to ensure 3 of 36 Residents were free of significant medication errors, Resident #88, Resident #90, and Resident #7.
The findings included:
1. For Resident #88 the facility staff held the medication Novolog without a physician's order.
Resident #88 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included but not limited to hypertension, neurogenic bladder, diabetes mellitus, quadriplegia, and depression.
The most recent MDS (minimum data set) with an ARD (assessment reference date) of 01/29/19 coded the Resident as 15 of 15 in section C, cognitive patterns. This is a quarterly MDS.
Resident #88's clinical record was reviewed on 03/13/19. It contained a signed physician's order summary, which read in part Novolog Solution 100 units/ml (Insulin Apart). Inject 20 units subcutaneously before meals for dmii (diabetes mellitus type 2). The Resident's eMAR (electronic medication administration record) for the month of February 2019 was reviewed and contained an entry which read in part Novolog Solution 100 units/ml (Insulin Aspart). Inject 20 units subcutaneously before meals for dmii (diabetes mellitus type 2). This entry was coded as 15 on 02/02/19 at 1100, 02/03/19 at 1100, 02/04/19 at 0730, 02/05/19 at 0730, 02/07/19 at 0730, 02/11/19 at 0730, and 02/28/19 at 0730. Chart code 15 is the equivalent of no coverage needed. This entry was also coded as 5 on 02/03/19 at 1600, 02/20/19 at 1100 and 02/23/19 at 0730. Chart code 5 is the equivalent of hold/see progress notes. This entry had not been initialed as having been administered on 02/04/19 at 1100. Resident #88's progress notes were reviewed and the surveyor could not locate any progress notes related to holding the Resident's insulin.
The concern of staff holding the Resident's insulin without a physician's order was discussed with the administrative team during a meeting on 03/13/19 at approximately 1415.
On 03/14/19 at approximately 0830, DON (director of nursing) informed the surveyor that she had reviewed the Resident's eMAR's and confirmed that the insulin had been held. She informed the surveyor that she was going to re-educate staff about not holding medications without a physician's order.
No further information was provided prior to exit.
2. For Resident #90 the facility staff administered the medication Midodrine outside of the physician ordered parameters.
Resident #90 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included but not limited to anemia, hypertension, orthostatic hypotension, urinary tract infection, dementia, hemiplegia, seizure disorder, depression, gastroesophageal reflux disease, and dysphagia.
The most recent MDS (minimum data set) with an ARD (assessment reference date) of 01/30/19 coded the Resident as 15 of 15 in section C, cognitive patterns. This is a quarterly MDS.
Resident #90's clinical record was reviewed on 03/13/19. It contained a signed physician's order summary, which read in part Midodrine HCl Tablet 2.5 mg. Give 1 tablet by mouth three times a day for hypotension. Hold if systolic is greater than 100.
According to Tabor's Medical Dictionary, systolic is the upper number of the blood pressure and measures the pressure exerted when the heart contracts.
Resident #90's eMAR (electronic medication administration record) for the month of February 2019 was reviewed and contained and entry which read in part, part Midodrine HCl Tablet 2.5 mg. Give 1 tablet by mouth three times a day for hypotension. Hold if systolic is greater than 100. This entry was initialed as being administered on 02/01/19 at 0900 with a systolic of 101, 02/03/19 at 2100 with a systolic of 101, 02/08/19 at 0900 with a systolic of 103, 02/10/19 at 0900 with a systolic of 104, 02/10/19 at 1400 with a systolic of 110, 02/11/19 at 2100 with a systolic of 106, 02/13/19 at 1400 with a systolic of 102, 02/16/19 at 1400 with a systolic of 102, 02/19/19 at 2100 with a systolic of 123 and 02/27/19 at 2100 with a systolic of 104. The Resident's eMAR for March was reviewed and contained and entry, which read in part Midodrine HCl Tablet 2.5 mg. Give 1 tablet by mouth three times a day for hypotension. Hold if systolic is greater than 100. This entry was initialed as being administered on 03/03/19 at 2100 with a systolic of 105, 03/04/19 at 0900 with a systolic of 102, 03/07/19 at 0900 with a systolic of 103, 03/10/19 at 0900 with a systolic of 102 and 03/12/19 at 2100 with a systolic of 101.
The concern of administering the Resident's medications outside of the physician ordered parameters was discussed with the administrative team on 03/13/19 at approximately 1415.
No further information was provided prior to exit.
3. For Resident #7 the facility staff failed to administer the medications Catapres-TTS-3 Patch, insulin glargine and meropenem solution per the physician's order.
Resident #7 was admitted to the facility on [DATE]. Diagnoses included but not limited to hypertension, diabetes mellitus, hyperlipidemia, depression, dysphagia, and chronic kidney disease.
The most recent MDS (minimum data set) with an ARD (assessment reference date) of 02/28/19 coded the Resident having both long and short term memory loss with severely impaired cognitive processes for daily decision making. This is a quarterly MDS.
Resident # 7's clinical record was reviewed on 03/13/19. It contained signed physician's order summary, which read in part Catapres TTS-3 Patch Weekly 0.3 mg/24Hr (clonidine HCl). Apply 1 patch transdermally one time a day every Mon for hypertension and remove per schedule. The Resident's eMAR (electronic medication administration record) was reviewed and contained an entry, which read in part Catapres TTS-3 Patch Weekly 0.3 mg/24Hr (clonidine HCl). Apply 1 patch transdermally one time a day every Mon for hypertension and remove per schedule. This entry was coded as 9 on 02/04/19 at 0900 (apply), 02/11/19 at 0859 (remove), 02/11/19 at 0900 (apply) and 02/18/10 at 0859 (remove). Chart code 9 is the equivalent of Other/See progress note. Resident #7's progress notes were reviewed for these dates, and contained entries which read in part, 2/2/2019 09:56 Catapress-TTS-3 Patch Weekly on order, 2/11/2019 08:24 Catapres-TTS-3 Patch Weekly .no patch in place and 2/11/2019 08:30 Catapres-TTS-3 Patch Weekly .awaiting delivery from pharmacy.
According to [NAME] Drug Guide, Catapres-TTS-3 Patch is a medication used to treat high blood pressure.
Resident #7's physician's order summary also contained an order, which read in part Insulin Glargine Solution 100 units/ml. Inject 8 units subcutaneously at bedtime for diabetes. Resident #7's eMAR contained an entry, which read in part Insulin Glargine Solution 100 units/ml. Inject 8 units subcutaneously at bedtime for diabetes. This entry was coded as 9 on 02/09/19 and 02/10/19. Resident #7's progress notes were reviewed for these dates and contained entries which read in part, 2/9/2019 21:21 Insulin Glargine Solution .BS (blood sugar) 77 and 2/10/2019 20:39 Insulin Glargine Solution .on order.
Resident #7's physician's order summary also contained an order, which read in part Meropenem Solution Reconstituted 1 GM. Use 1 gram intravenously two times a day for esbl-urine for 14 administrations. Resident #7's eMAR contained an entry, which read in part Meropenem Solution Reconstituted 1 GM. Use 1 gram intravenously two times a day for esbl-urine for 14 administrations. This entry was coded as 9 on 02/04/19 at 0400. Resident #7's progress notes were reviewed for this date, and the surveyor could not find a corresponding progress note.
According to [NAME] Drug Guide, meropenem is a broad spectrum antibiotic used to treat bacterial infections.
The concern of not administering the Resident's medications per the physician's orders was discussed with the administrative team during a meeting on 03/13/19 at approximately 1415.
No further information was provided prior to exit.
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 and facility document review the facility staff failed to ensure a complete and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review the facility staff failed to ensure a complete and accurate clinical record for 3 of 36 Residents, Resident #129, Resident #1 and Resident #11.
The findings included:
1. For Resident #129 the facility staff failed to maintain a complete record.
Resident #129 was admitted to the facility on [DATE]. Diagnoses included but not limited to Alzheimer's disease, dementia, seizure disorder, anxiety, depression, and psychotic disorder.
The most recent MDS (minimum data set) with an ARD (assessment reference date) of [DATE] coded the Resident as 3 out of 15 in Section C, cognitive patterns. This is a quarterly MDS.
Resident #129's clinical record was reviewed on [DATE]. It contained a signed physician's order summary, which read in part Antianxiety Medication-Monitor for Drowsiness, slurred speech, dizziness, nausea, aggressive/impulsive behavior. Document 'Y if monitored and not of the above observed. N if monitored and any of the above was observed, select chart code 'Other/See Nurses Notes' and progress note findings every shift for bms, Antipsychotic medication-monitor for dry mouth, constipation, blurred vision, disorientation/confusion, difficulty urinating, hypotension, dark urine, yellow skin, N/V (nausea/vomiting), lethargy, drooling, EPS (extra-pyramidal symptoms [tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue]). Document 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/See Nurses Notes' and progress note finding every shift for bms, Behaviors-Monitor for the following: Picking at skin, restlessness (agitation), picking nose until it bleeds, hitting, increase in complaints, biting, kicking, spitting, cussing, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusing care, noncompliance with fluid restrictions, removing wanderguard, taking clothes off. Document Y if monitored and none of the above observed. N if monitored and any of the above was observed, select chart code Other/See Nurses Note every shift for bms, and Interventions utilized before use of psychotropic med/hypnotic med (1:1, redirect, offer cigarette, calm environment, call Daughter, offer snack, offer coffee). Document Y if not required. N if any of the above was utilized, select chart code Other/see Nurses Notes' and progress not interventions every shift for BMS.
Resident #129's eMAR (electronic medication administration record) for February was reviewed and contained entries, which read in part Antianxiety Medication-Monitor for Drowsiness, slurred speech, dizziness, nausea, aggressive/impulsive behavior. Document 'Y if monitored and not of the above observed. N if monitored and any of the above was observed, select chart code 'Other/See Nurses Notes' and progress note findings every shift for bms, Antipsychotic medication-monitor for dry mouth, constipation, blurred vision, disorientation/confusion, difficulty urinating, hypotension, dark urine, yellow skin, N/V (nausea/vomiting), lethargy, drooling, EPS (extra-pyramidal symptoms [tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue]). Document 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/See Nurses Notes' and progress note finding every shift for bms, Behaviors-Monitor for the following: Picking at skin, restlessness (agitation), picking nose until it bleeds, hitting, increase in complaints, biting, kicking, spitting, cussing, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusing care, noncompliance with fluid restrictions, removing wanderguard, taking clothes off. Document Y if monitored and none of the above observed. N if monitored and any of the above was observed, select chart code Other/See Nurses Note every shift for bms, and Interventions utilized before use of psychotropic med/hypnotic med (1:1, redirect, offer cigarette, calm environment, call Daughter, offer snack, offer coffee). Document Y if not required. N if any of the above was utilized, select chart code Other/see Nurses Notes' and progress not interventions every shift for BMS. These entries were all blank on [DATE] and coded with 2 on [DATE] and [DATE] for day shift. Chart coded 2 is the equivalent of drug refused.
The concern of the incorrect documentation was discussed with the administrative team during a meeting on [DATE] at approximately 1415.
No further information was provided prior to exit.
2. For Resident #1 the facility staff failed to ensure a complete clinical record.
Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included but not limited to hypertension, hyperlipidemia, dementia, anxiety, depression, bipolar disorder, psychotic disorder adult failure to thrive and gastroesophageal reflux disease.
The most recent MDS (minimum data set) with an ARD (assessment reference date) of [DATE] coded the Resident as 15 of 15 in section C, cognitive patterns. This is a quarterly MDS.
Resident #1's clinical record was revived on [DATE]. It contained a signed physician's order summary, which read in part atorvastatin calcium tablet 20 mg. Give 1 tablet by mouth at bedtime for elevated cholesterol, clonazepam tablet 0.5 mg. Give 1 tablet by mouth at bedtime for anxiety, ketoconazole shampoo 2%. Apply to scalp topically every evening shift ever Wed, Sat for dry skin, Mirtazapine Tablet 7.5 mg. Give 1 tablet by mouth at bedtime for weight loss, ramelteon tablet 8 mg. Give 1 tablet by mouth at bedtime related insomnia, unspecified, thera tablet (multivitamin). give 1 tablet by mouth at bedtime for supplement, buspirone HCl tablet 5 mg. Give 3 tablets by mouth two times a day for anxiety, calcium carbonate-Vit D-Min tablet 600-400 mg-unit. Give 1 tablet by mouth two times a day related to age-related osteoporosis without current pathological fracture, potassium chloride ER tablet Extended Release 10 MEQ. Give 2 tablets by mouth two times a day for hypokalemia, Prilosec capsule delayed release 20 mg. Give 20 mg by mouth two times a day for ulcer, baclofen tablet 10 mg. Give 0.5 tablet by mouth three times a day related to other muscle spasm, gabapentin capsule 300 mg. Give 1 capsule by mouth three times a day related other chronic pain, pyridostigmine bromide tablet 60 mg. Give 1 tablet by mouth every 8 hours related to other muscle spasm, sucralfate suspension 1 GM/ 10 ml. Give 1 gram by mouth three times a day for gastric protection, and Tylenol extra strength tablet 500 mg. Give 1 tablet by mouth every 8 hours related to other chronic pain.
Resident #1's eMAR (electronic medication record) for the month of February 2019 was reviewed and contained entries which read in part atorvastatin calcium tablet 20 mg. Give 1 tablet by mouth at bedtime for elevated cholesterol, clonazepam tablet 0.5 mg. Give 1 tablet by mouth at bedtime for anxiety, ketoconazole shampoo 2%. Apply to scalp topically every evening shift ever Wed, Sat for dry skin, Mirtazapine Tablet 7.5 mg. Give 1 tablet by mouth at bedtime for weight loss, ramelteon tablet 8 mg. Give 1 tablet by mouth at bedtime related insomnia, unspecified, thera tablet (multivitamin). Give 1 tablet by mouth at bedtime for supplement, buspirone HCl tablet 5 mg. Give 3 tablets by mouth two times a day for anxiety, calcium carbonate-Vit D-Min tablet 600-400 mg-unit. Give 1 tablet by mouth two times a day related to age-related osteoporosis without current pathological fracture, potassium chloride ER tablet Extended Release 10 MEQ. Give 2 tablets by mouth two times a day for hypokalemia, Prilosec capsule delayed release 20 mg. Give 20 mg by mouth two times a day for ulcer, baclofen tablet 10 mg. Give 0.5 tablet by mouth three times a day related to other muscle spasm, gabapentin capsule 300 mg. Give 1 capsule by mouth three times a day related other chronic pain, pyridostigmine bromide tablet 60 mg. Give 1 tablet by mouth every 8 hours related to other muscle spasm, sucralfate suspension 1 GM/ 10 ml. Give 1 gram by mouth three times a day for gastric protection, and Tylenol extra strength tablet 500 mg. Give 1 tablet by mouth every 8 hours related to other chronic pain. None of these entries had been initialed as being administered for 1600, 1700, 2000, 2100 or evening on [DATE].
The concern of the incomplete documentation was discussed with the administrative staff during a meeting on [DATE] at approximately 1415.
No further information was provided prior to exit.
3. The facility staff failed to have a complete and accurate clinical record for Resident #11.
Resident #11 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to heart failure, high blood pressure, diabetes, dementia, depression, Manic Depression and PTSD. On the quarterly MDS (minimum Data Set) with an ARD (Assessment Reference Date) of [DATE], the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 4 out of a possible score of 15. Resident #11 was also coded as requiring extensive assistance of 1 staff member for dressing and personal hygiene and being totally dependent on 1 staff member for bathing.
During the clinical record review and MAR (Medication Administration Record) for [DATE] on [DATE] the surveyor noted the following blanks:
Omeprazole Delayed Release 20 mg (milligram) Give 1 capsule by mouth one time a day at 0600-The box was left blank for the
date of [DATE].
The surveyor notified the administrative team of the above documented findings on [DATE] at approximately 11 am in the conference room.
No further information was provided to the surveyor prior to the exit conference on [DATE].
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** Based on observation, resident and staff interview, facility document review and clinical record review it was determined the fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, facility document review and clinical record review it was determined the facility staff failed to coordinate services with hospice to include a hospice plan of care for 1 of 36 residents (Resident #122.)
Findings:
Facility staff failed to obtain a care plan from Resident #122's hospice provider. The resident's clinical record was reviewed on 3/12/19 at 2:00 PM.
Resident #122 was admitted on [DATE]. Her diagnoses included pulmonary fibrosis, hypertension, congestive heart failure, respiratory failure, anxiety and chronic obstructive pulmonary disease.
The latest MDS (minimum data set) assessment indicated the resident was cognitively intact. She required facility staff assistance with all the ADLS (activities of daily living) with the exception of eating independent with staff set-up.
Resident #122's CCP (comprehensive care plan) documented the resident was on hospice care, but did not detail the provision of services provided by hospice. There was no documentation in the clinical record referring to the hospice care plan or division of services.
Resident #122's physician orders, signed and dated 2/7/19, the resident was enrolled with hospice services on 2/8/19. The physician also included an order, signed and dated on 2/26/19, for hospice to provide physical therapy to evaluate and treat the resident for 3 sessions.
On 3/13/19 at 9:45 AM the DON was asked about the hospice services care plan. The DON said they did not have one at the facility at the current time, but she had called the hospice provider to obtain one.
The facility did have an agreement for the provision of hospice service. The contractual agreement, signed by both the facility administrator and the hospice representative on 12/1/11 contained the following, .Plan of care means with respect to each Hospice Patient, a written care plan established, maintained, reviewed and modified, as necessary, at intervals established by the applicable IDT (hospice interdisciplinary team), which identifies the care and services needed and specifically identifies whether Hospice or the Facility is responsible for performing the respective functions included in the plan of care. The Plan of Care shall include (a) an assessment of such Hospice Patient's needs; (b) identification of the Hospice services, including management of discomfort and symptom relief, appropriate to meet such Hospice Patient's needs and the related needs of the Hospice Patient's Family; and (c) details concerning the scope and frequency of Hospice Services to be provided .
On 3/13/19 at 4:00 PM the surveyor's findings were shared with the administrator, DON and corporate nurse.
CONCERN
(D)
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 and staff interview, the facility staff failed to maintain a hazard free environment.
The findings included:
The doors to the room that accessed the back of the dryers were rust...
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Based on observation and staff interview, the facility staff failed to maintain a hazard free environment.
The findings included:
The doors to the room that accessed the back of the dryers were rusted which allowed for debris from the outside to collect in this room.
On 03/14/19 at 8:19 a.m., the surveyor and the maintenance director checked the area behind the dryers. This area was accessed from the outside by outside doors. Upon opening the doors, the surveyor was able to observe a moderate amount of debris from the outside that had blown in under the doors and through rusted out areas on the doors.
After exiting this room, the surveyor notified the administrator of the issue regarding the debris.
On 03/14/19 at 9:36 a.m., the maintenance director stated he had spoken with the door company and obtained prices for new doors. The maintenance director also stated he had swept out the backside of the dryers.
The administrative staff were notified of the above issue during a meeting with the survey team on 03/14/19 at 12:38 p.m. The administrator verbalized that the new doors had been ordered.
No further information regarding this issue was provided to the survey team prior to the exit conference.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. For Resident #467 the facility staff failed to administer the medication buspirone 5 mg per the physician's order and failed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. For Resident #467 the facility staff failed to administer the medication buspirone 5 mg per the physician's order and failed to remove a Fentanyl patch per physician's order.
Resident #467 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included but not limited to trans-ischemic accident, displaced fracture of left lower leg, encounter for surgical aftercare, hypertension, hyperlipidemia, diabetes mellitus type 2, and fibromyalgia.
Resident #467 is a new admission and the MDS (minimum data set) had not been completed; however Resident #467 is alert and oriented to person, place, time and situation.
Resident #467's clinical record was reviewed on 03/12/19. It contained a signed physician's order summary, which read in part Buspirone HCl Tablet 5 mg Give 1 tablet by mouth three times a day for anxiety. Resident #467's eMAR (electronic medication administration record) for the month of March was reviewed and contained an entry, which read in part Buspirone HCl Tablet 5 mg. Give 1 tablet by mouth three times a day for anxiety. This entry was coded with 9 on 03/06/19 at 1400 and 03/10/19 at 2100, and with 5 on 03/10/19 at 1300. Chart code 9 is equivalent to other/see progress notes and chart code 5 is equivalent to hold/see progress notes. Resident #467's progress notes were reviewed and contained notes, which read in part 3/6/2019 13:17 Buspirone HCl tablet 5 mg. Give 1 tablet by mouth three times a day for anxiety new order. not delivered. and 3/10/2019 22:30 Buspirone HCl 5 mg. Give 1 tablet by mouth three times a day for anxiety awaiting pharmacy.
Surveyor requested and was provided with a copy of a facility policy entitled Medication Shortages/Unavailable Medications, which read in part Procedure 1. Upon discovery that facility has an inadequate supply of a medication to administer to a Resident, facility staff should immediately initiate action to obtain the medication from pharmacy. If the medication shortage is discovered at the time of medication administration, facility staff should immediately take the action specified in Sections 2 or 3 of the Policy 7.0, as applicable. 2. If a medication shortage is discovered during normal pharmacy hours: 2.1 Facility nurse should call pharmacy to determine the status of the order. If the medication has not been ordered, the licensed facility nurse should place the order or reorder for the next scheduled delivery. 2.2 If the next available delivery causes delay or a missed dose in the Resident's medication schedule, facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose.
Surveyor requested and was provided with a list of medications contained in the facility Emergency Medication Supply. The medication Buspirone 5 mg tab was listed as available in the Emergency Medication Supply.
Resident #467's physician's order summary also contained an entry, which read in part 'Fentanyl Patch 72 hour 25 mcg/hr. Apply 1 patch transdermally every 72 hours for pain and remove per schedule. This entry had an order date of 03/10/19 and a discontinue date of 03/12/19. Resident's eMAR contained an entry, which read in part Fentanyl Patch 72 hour 25 mcg/hr. Apply 1 patch transdermally every 72 hours for pain and remove per schedule. This entry was coded 5 on 03/10/19 and 9 on 03/12/19. Resident's progress notes were reviewed and the surveyor could not locate a note for 03/10/19. The progress notes contained a note dated 03/12/19, which read in part Fentanyl patch 72 hour 25 mcg/hr. Apply 1 patch transdermally every 72 hours for pain and remove per schedule patch discontinued.
Surveyor spoke with Resident #467 on 03/13/19 at approximately 1235. Surveyor asked Resident about medications for pain, and Resident stated, That patch they put on me didn't help at all. Surveyor then asked Resident if she currently had a patch on, and Resident stated that she did, and pulled down her top to reveal a patch on her R shoulder. Surveyor then asked LPN (licensed practical nurse) #1 to accompany her to Resident's room to observe the patch. LPN #1 removed the patch and allowed surveyor to observe the patch, which was dated 03/09/19. LPN #1 stated that the patch should have been removed on 03/12/19. Surveyor asked Resident #467 if the facility staff had placed the patch and she stated that it had been put on while she was in the hospital.
The concern of not administering Resident's medications as ordered was discussed with administrative staff during a meeting on 03/13/19 at approximately 1414.
No further information was provided prior to exit.
5. For Resident #115 the facility staff failed to follow physician's orders for the administration of the medications atorvastatin, Centrum tablet, donepezil, latanoprost eye drops, Memantine, mirtazapine, brimonidine tartrate eye drops, docusate sodium liquid, ferrous sulfate, and ipratopium-albuterol.
Resident #115 was admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included but not limited to anemia, hypertension, diabetes mellitus, hyperlipidemia, dementia, hemiplegia, depression, asthma, respiratory failure and dysphagia.
The most recent MDS (minimum data set) with an ARD (assessment reference date) of 02/13/19 coded the Resident as 11 out of 15 in section C, cognitive patterns. This is a quarterly MDS.
Resident #115's clinical record was reviewed on 03/13/19. It contained a signed POS (physician's order summary), which read in part atorvastatin calcium tablet 40 mg. Give 1 tablet via PEG-tube at bedtime for hyperlipidemia, Centrum tablet chewable (multi-vitamins-minerals). Give 1 tablet via PEG-tube at bedtime for supplement, donepezil HCl tablet 10 mg. Give 1 tablet via PEG-tube at bedtime for dementia, latanoprost solution 0.005%. Instill 1 drop in both eyes at bedtime for glaucoma, Memantine HCl tablet 5 mg. Give 1 tablet via PEG-tube in the evening for dementia, mirtazapine tablet 45 mg. Give 1 tablet via PEG-tube at bedtime for or depression, brimonidine tartrate solution 0.2%. Instill 1 drop in both eyes two times a day for glaucoma, docusate sodium liquid 50 mg/5 ml. Give 10 ml via PEG-tube two times a day for constipation, ferrous sulfate liquid. Give 5 ml via PEG-tube three times a day for supplement, and ipratropium-albuterol solution 0.5-2/5 (3) mg/3 ml. 1 inhalation inhale orally three times a day for cough, wheezing for 7 days.
Resident #115's eMAR (electronic medication administration record) for the month of February 2019 was reviewed and contained entries which read in part atorvastatin calcium tablet 40 mg. Give 1 tablet via PEG-tube at bedtime for hyperlipidemia, Centrum tablet chewable (multi-vitamins-minerals). Give 1 tablet via PEG-tube at bedtime for supplement, donepezil HCl tablet 10 mg. Give 1 tablet via PEG-tube at bedtime for dementia, latanoprost solution 0.005%. Instill 1 drop in both eyes at bedtime for glaucoma, Memantine HCl tablet 5 mg. Give 1 tablet via PEG-tube in the evening for dementia, mirtazapine tablet 45 mg. Give 1 tablet via PEG-tube at bedtime for depression, brimonidine tartrate solution 0.2%. Instill 1 drop in both eyes two times a day for glaucoma, docusate sodium liquid 50 mg/5 ml. Give 10 ml via PEG-tube two times a day for constipation, ferrous sulfate liquid. Give 5 ml via PEG-tube three times a day for supplement, and ipratropium-albuterol solution 0.5-2/5 (3) mg/3 ml. 1 inhalation inhale orally three times a day for cough, wheezing for 7 days. None of these medications was initialed as being administered on 02/02/19. The ferrous sulfate and the ipratopium-albuterol was also not initialed as being administered on 02/13/19. The Resident's progress notes were reviewed and the surveyor could not locate any progress notes related to the administration of the medications.
The concern of not administering medications as ordered by the physician was discussed with the administrative team during a meeting on 03/13/19 at approximately 1415.
No further information was provided prior to exit.
6. For Resident #20 the facility staff failed to administer the medication gabapentin per the physician's orders.
Resident #20 was admitted to the facility on [DATE]. Diagnoses included but not limited to anemia, congestive heart failure, hypertension, obstructive uropathy, hyperlipidemia, dementia, Parkinson's disease, depression, bipolar disorder, asthma, and chronic kidney disease.
The most recent MDS (minimum data set) with an ARD (assessment reference date) of 12/11/18 coded the Resident as 15 of 15 in section C, cognitive patterns. This is a quarterly MDS.
Resident #20's clinical record was reviewed on 03/12/19. It contained a signed physician's order summary, which read in part Gabapentin 300 mg capsule. Give 1 capsule by mouth two times a day for neuropathy pain.
Surveyor observed LPN #2 (licensed practical nurse) during a medication pass and pour on 03/12/19 at approximately 0825. LPN #2 was preparing Resident #20's medications. While preparing the medications, LPN #2 informed the surveyor that Resident #20's gabapentin was not available for administration. Surveyor asked LPN #2 what the process was if medications were not available, and LPN #2 stated she would call the pharmacy to order medications, and call the physician.
Surveyor requested and was provided with a copy of a facility policy entitled Medication Shortages/Unavailable Medications, which read in part Procedure 1. Upon discovery that facility has an inadequate supply of a medication to administer to a Resident, facility staff should immediately initiate action to obtain the medication from pharmacy. If the medication shortage is discovered at the time of medication administration, facility staff should immediately take the action specified in Sections 2 or 3 of the Policy 7.0, as applicable. 2. If a medication shortage is discovered during normal pharmacy hours: 2.1 Facility nurse should call pharmacy to determine the status of the order. If the medication has not been ordered, the licensed facility nurse should place the order or reorder for the next scheduled delivery. 2.2 If the next available delivery causes delay or a missed dose in the Resident's medication schedule, facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose.
Surveyor requested and was provided with a list of medications contained in the facility Emergency Medication Supply. The medication gabapentin 100 mg capsule 4 capsules was listed as available in the Emergency Medication Supply.
Surveyor spoke with the staff development coordinator on 03/14/19 at approximately 0850 regarding what training the nurses received regarding medication administration, and specifically medication availability. The staff development coordinator stated that she goes over step-by-step what to do if a medication is unavailable. These steps included checking the medication cart and if not in cart, check the medication room. If the medication cannot be located in the medication room, then check the stat box. If the medication is in the stat box, retrieve it from there, if not, call the pharmacy and order a stat delivery of the medications and call the physician.
The concern of not administering medications as ordered by the physician was discussed with the administrative team during a meeting on 03/13/19 at approximately 1415.
No further information was provided prior to exit.
Based on Resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to follow physician orders for 9 of 36 Residents, Residents #141, 170, 366, 467, 115, 20, 11, 126, and 38.
The findings included:
1. For Resident #141, the facility failed to administer the Residents erythromycin ophthalmic ointment as ordered by the physician.
The clinical record review revealed that Resident #141 had been admitted to the facility on [DATE] and had been readmitted on [DATE]. Diagnoses included, but were not limited to, cerebral infarction due to unspecified occlusion, cerebral edema, hydrocephalus, and respiratory failure.
Section C (cognitive patterns) of the Residents admission MDS (minimum data set) assessment with an ARD (assessment reference date) of 01/24/19 included a BIMS (brief interview mental status) summary score of 15 out of a possible 15 points.
The Residents clinical record included a physicians order for erythromycin ointment 1 application in both eyes two times a day for prophylaxis. The order date was documented as 02/19/19.
A review of the Residents eMARs (electronic medication administration records) revealed that the facility nursing staff had documented a 9 on 02/24, 02/26, 03/01, and 03/05. On 03/06, the nursing staff had documented a 5. Per the preprinted code on the eMARs a 5 equaled Hold/See Progress Notes and a 9 equaled Other/See Progress Notes.
The nursing staff had documented the following progress notes.
02/20/19-Erythromycin Ointment .awaiting med from pharm .
02/23/19-Erythromycin Ointment .on order.
02/24/19-Erythromycin Ointment .backorder.
02/26/19-Erythromycin Ointment .on order.
03/01/19-Erythromycin Ointment .on order.
03/05/19-Erythromycin Ointment .on order.
03/05/19-Erythromycin Ointment .awaiting from pharmacy.
03/06/19-Erythromycin Ointment .awaiting med from pharm. Nurse to follow up with pharm.
This medication had been discontinued on 03/06/19.
On 03/12/19 at 11:55 a.m., the surveyor interviewed RN (registered nurse) #1 regarding the erythromycin. RN ##1 stated she had signed for the medication by mistake, as the medication was on a manufacturer back order and would not have been available for administration.
On 03/12/19 at 12:02 p.m., during a phone interview with pharmacist #1 this pharmacist verbalized to the surveyor that this medication had never been sent to the facility.
03/13/19 at 12:16 p.m., the DON (director of nursing) stated that the Resident was sent to a local hospital and the erythromycin had been sent back to the facility from the hospital. The DON stated the staff development nurse had thrown the erythromycin away because it was from an outside source. The DON stated she did not know why some of the nurses had not administered it.
The administrative staff were notified of the issue regarding the Residents medication during a meeting with the survey team on 03/13/19 at 2:13 p.m.
No further information regarding this issue was provided to the survey team prior to the exit conference.
2. For Resident #170, the facility failed to administer the Residents physician ordered medications magnesium oxide, levothyroxine, and prilosec as ordered.
The clinical record review revealed that Resident #170 had been admitted to the facility 02/28/19 and had ben readmitted on [DATE]. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease, heart failure, muscle weakness, and hypertension.
The clinical record did not include a completed MDS (minimum data set) assessment. However, the Resident was alert and orientated to person and place.
The Residents EHR (electronic health record) included a physicians order for magnesium oxide 250 mg one time a day for laxative.
A review of the Residents eMARs (electronic medication administration records) revealed that the nursing staff had documented a 9 on 03/09, 03/10, and 03/11 for this medication. Per the preprinted code on the eMARs a 9 equaled Other/See Progress Notes. This medication had been signed for as being administered on 03/08 and 03/12.
The nursing staff had documented in the progress notes that this medication was not available for administration on 03/09, 03/10, and 03/11. On 03/11, the facility nursing staff also documented that the pharmacy had been contacted and the medication would come tonight.
On 03/13/19 10:56 a.m., the hall nurse and the surveyor checked the medication cart and the medication was observed to be on the cart. This medication was dated as being delivered to the facility on [DATE].
On 03/11 at 6:00 a.m., the nursing staff documented a 7 for the medications levothyroxine and Prilosec. Per the preprinted code on eMARs a 7 equals Sleeping.
The administrative staff were notified of the issue regarding the Residents medication during a meeting with the survey team on 03/13/19 at 2:13 p.m.
On 3/13/19 at 4:25 p.m., during an interview with the DON the DON stated she would expect the nurse to attempt to wake the Resident up and/or call the practitioner and get the medication time changed if needed.
No further information regarding this issue was provided to the survey team prior to the exit conference.
3. For Resident #366, the facility staff failed to administer the Residents physician ordered medication flonase as ordered by the physician.
The clinical record review revealed that Resident #366 had been admitted to the facility on [DATE]. Diagnoses included, but were not limited to, diverticulosis of large intestine without perforation or abscess with bleeding and muscle weakness.
There was no completed MDS (minimum data set) assessment completed on this Resident. However, the Resident was alert and orientated to self and place.
The Residents EHR (electronic health record) included a physicians order for flonase 1 spray each nostril one time a day for allergies.
A review of the Residents eMARs (electronic medication administration records) revealed that the nursing staff had documented a 9 on 03/10/19 for this medication. Per the preprinted code on the eMARs a 9 equaled Other/See Progress Notes. This medication had been signed for as being administered on 03/08, 03/09, 03/11, and 03/12/19. This same nurse documented in a progress note on 03/10/19 at 8:50 a.m. not avail.
During a phone interview with the pharmacy on 03/13/19 at 10:04 a.m., the customer service manager verbalized to the surveyor that the flonase had been sent to the facility on midnight on 03/07/19 and should have arrived at the facility in the morning hours on 03/08/19.
On 03/13/19 at 10:59 a.m., the surveyor checked the medication cart with LPN (licensed practical nurse) #3. This medication was available for administration on the medication cart.
The administrative staff were notified of the issue regarding the Residents medication during a meeting with the survey team on 03/13/19 at 2:13 p.m.
No further information regarding this issue was provided to the survey team prior to the exit conference.
7. The facility staff failed to follow the physician's orders for Resident #11 in regards to the administration of Cipro.
Resident #11 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to heart failure, high blood pressure, diabetes, dementia, depression, Manic Depression and PTSD. On the quarterly MDS (minimum Data Set) with an ARD (Assessment Reference Date) of 12/4/18, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 4 out of a possible score of 15. Resident #11 was also coded as requiring extensive assistance of 1 staff member for dressing and personal hygiene and being totally dependent on 1 staff member for bathing.
During the clinical record review on 3/12 and 3/13/19, the surveyor noted the following physician order for Resident #11: Cipro 500 mg (milligram) Give 1 tablet by mouth every 12 hours for UTI (Urinary Tract Infection) for 14 administrations until finished. The facility staff began to administer Cipro to the resident on 3/1/19 at 2000 (8 pm) and then 2 times a day (at 8 am and 8 pm) from 3/2/19 to 3/9/19. The total number of administrations of Cipro given to Resident #11 was for 17.
On 3/13/19 at 2:14 pm, the surveyor notified the administrative team of the above documented findings of administrating 17 dosages of Cipro instead of the 14 dosages ordered by the physician.
No further information was provided to the surveyor prior to the exit conference on 3/14/19.
8. The facility staff failed to follow the physician's orders on Resident #126 in regards to administering the medication Omeprazole.
Resident #126 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to heart failure, high blood pressure, urinary tract infection, diabetes, manic depression, and chronic obstructive pulmonary disease. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/12/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #126 was also coded as requiring extensive assistance of 2 staff members for dressing, and 1 staff member for personal hygiene and being totally dependent on 1 staff member for bathing.
The surveyor performed a clinical record review of Resident #126's chart on 3/12/19 through 3/13/19. During this review, the surveyor noted a physician order for Resident #126 to receive Omeprazole 20 mg (milligram) one time a day at 6 am. On 2/26/19 at 600, the box on the MAR (Medication Administration Record) was left blank. Then on 2/19/19 at 0600, the facility staff documented a 7 in the box on the MAR which represents the resident was sleeping.
On 3/13/19 at 2:14 pm, the surveyor notified the administrative team of the above documented findings.
No further information was provided to the surveyor prior to the exit conference on 3/14/19.
9. For Resident #38, facility staff failed to follow physician orders for medication administration.
Resident #38 was admitted to the facility on [DATE] with diagnoses including paraplegia, muscle weakness, chronic pain, neurogenic bowel, hypertension, diabetes mellitus, anxiety, and depression. On the quarterly minimum data set assessment with assessment reference date 12/27/18, the resident scored 15/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care.
During an interview on 3/13/19 at 12:56 PM, the resident mentioned that during her stay, robaxin and gabapentin had both run out with no quick replacement.
Record review revealed that on 3/11 the Lidocaine patch was held (code 5=see note), without a nursing note to document the reason and on 1/10, Fentanyl and Lidocaine patches were both held with no explanation. Fentanyl was coded 5(=hold, see notes) and Lidocaine at 8 and 12 were coded 9(= other see progress notes). There were no progress notes on those dates. Robaxam tablet 500 mg give 1 tablet 4 times daily for muscle relaxer was documented as held awaiting from pharmacy on 3/9 at 9 PM, on 3/10 at 9 AM, 1 PM, and 9 PM and 3/11 at 1 PM and 9 PM.
The administrator and director of nursing were notified of the concern with pain medication administration on 3/12/19.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
4. For Resident #20 the facility staff failed to ensure the medications losartan and lactulose were available for administratio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
4. For Resident #20 the facility staff failed to ensure the medications losartan and lactulose were available for administration.
Resident #20 was admitted to the facility on [DATE]. Diagnoses included but not limited to anemia, congestive heart failure, hypertension, obstructive uropathy, hyperlipidemia, dementia, Parkinson's disease, depression, bipolar disorder, asthma, and chronic kidney disease.
The most recent MDS (minimum data set) with an ARD (assessment reference date) of 12/11/18 coded the Resident as 15 of 15 in section C, cognitive patterns. This is a quarterly MDS.
Resident #20's clinical record was reviewed on 03/12/19. It contained signed physician's order summary, which read in part Lactulose Solution 10 mg/15 ml. Give 15 ml by mouth two times a day for constipation and Losartan Potassium Tablet 25 mg. Give 1 tablet by mouth one time a day for supplement.
Surveyor observed LPN #2 (licensed practical nurse) during a medication pass and pour on 03/12/19 at approximately 0825. LPN #2 was preparing Resident #20's medications. While preparing the medications, LPN #2 informed the surveyor that Resident #20's lactulose and losartan were not available for administration. Surveyor asked LPN #2 what the process was if medications were not available, and LPN #2 stated she would call the pharmacy to order medications, and call the physician. Surveyor asked LPN #2 to let her know when the medications arrived from the pharmacy. On 03/12/18 at approximately 1145 spoke with LPN #2, regarding Resident #20's medications and LPN #2 informed the surveyor that the medications had arrived from the pharmacy and that she had already administered them.
Resident #20's clinical record contained a progress note dated 03/12/19 at 11:15, which read in part Per Md ok to give losartan 25 mg, lactulose 15 ml, and gabapentin @ (at) 11am. Np (nurse practitioner) aware. Resident RP (responsible party) aware.
The concern of the medications not being available for administration was discussed with the administrative team during a meeting on 03/13/19 at approximately 1415.
No further information was provided prior to exit.
5. For Resident #7 the facility staff failed to ensure the medications fluconazole suspension, prevacid solutab, and Nystatin suspension were available for administration.
Resident #7 was admitted to the facility on [DATE]. Diagnoses included but not limited to hypertension, diabetes mellitus, hyperlipidemia, cerebrovascular accident, dementia, hemiplegia, depression, dysphagia, and chronic kidney disease.
The most recent MDS (minimum data set) with an ARD (assessment reference date) of 02/28/19 coded the Resident having both long and short term memory loss with severely impaired cognitive processes for daily decision making. This is a quarterly MDS.
Resident #7's clinical record was reviewed on 03/13/19. It contained a signed physician's order summary, which read in part Fluconazole Suspension Reconstituted 40 mg/ml. Give 5 ml by mouth one time a day for thrush for 10 administrations until finished apply with pink oral swab, Prevacid SoluTab Dispersible 15 mg (Lansoprazole). Give 1 tablet via G-Tube two times a day for GERD (gastroesophageal reflux disorder), and Nystatin Suspension 100000 Unit/ml. Give 5 ml by mouth three times a day for thrush for 21 administrations until finished apply with pink oral swab.
Resident #7's eMAR (electronic medication administration record) was reviewed and contained entries, which read in part Fluconazole Suspension Reconstituted 40 mg/ml. Give 5 ml by mouth one time a day for thrush for 10 administrations until finished apply with pink oral swab, Prevacid SoluTab Dispersible 15 mg (Lansoprazole). Give 1 tablet via G-Tube two times a day for GERD (gastroesophageal reflux disorder), and Nystatin Suspension 100000 Unit/ml. Give 5 ml by mouth three times a day for thrush for 21 administrations until finished apply with pink oral swab. The entry for the fluconazole suspension was coded as 9 on 02/14/19, which is the equivalent of Other/See progress notes. Resident #7's progress notes for 02/14/19 were reviewed and contained a note, which read in part Fluconazole Suspension Reconstituted 40 mg/ml. Give 5 ml by mouth one time a day for thrush for 10 administrations until finished apply with pink oral swab x 10 days will contact pharmacy.
The entry on Resident #7's eMAR for Prevacid was coded with 9 on 02/09/19 at 0900 and 1700, 02/10/19 and 02/11/19 at 1700, and 02/12/19 at 0900. Resident #7's progress notes for these dates were reviewed and contained progress notes, which read in part 2/9/2019 12:31 Prevacid SoluTab Tablet Dispersible 15 mg. Give 1 tablet via G-tube tow times a day for GERD, nausea on order, 2/09/2019 17:21 Prevacid SoluTab Tablet Dispersible 15 mg. Give 1 tablet via G-tube two times a day for GERD, nausea on order, 2/10/2019 Prevacid SoluTab Tablet Dispersible 15 mg. Give 1 tablet via G-tube two times a day for GERD, nausea on order and 2/11/2019 17:27 Prevacid SoluTab Tablet Dispersible 15 mg. Give 1 tablet via G-tube two times a day for GERD, nausea on order.
The entry on Resident #7's eMAR for Nystatin was coded with 5 on 02/06/19 at 0900 and 1400. Chart code 5 is the equivalent of Hold/See progress Note. Resident #7's progress notes were reviewed for this date and contained entries, which read in part 10:50 Nystatin Suspension 100000 Unit/ml. Give 5 ml by mouth three times a day for thrush for 21 administrations until finished apply with pink oral swab call pharmacy to f/u (follow up) with medication delivery, medication is on back order and is not available to sent to facility. NP (nurse practitioner) made aware. and 13:02 Nystatin Suspension 100000 unit/ml. Give 5 ml by mouth three times a day for thrush for 21 administration until finished apply with pink oral swab medication on back order. NP aware. The entry for the Nystatin was coded as 9 on 02/09/19 at 0900, 1400 and 2100, and 02/10/19 at 1400 and 2100. The Resident's progress notes were reviewed for these dates and contained entries, which read in part 2/9/2019 12:30 Nystatin Suspension on order, 2/9/2019 13:43 Nystatin Suspension on order, 2/9/2019 21:21 Nystatin Suspension ON ORDER, 2/10/2019 14:42 Nystatin Suspension .on order, 2/10/2019 20:38 Nystatin Suspension on order.
The concern of the Resident's medication not being available for administration was discussed with the administrative team during a meeting on 03/13/19 at approximately 1415.
No further information was provided prior to exit.
6. For the medication cart on Unit 1 the facility staff failed to place an opened on date on a bottle of eye drops and for the medication cart on Unit 2 the facility staff failed to properly store medications.
Surveyor observed the medication cart on Unit 1 on 03/13/19 at approximately 1045 with LPN #3. The surveyor observed a bottle of a Resident's eye drops with no open on listed on the packaging. LPN #3 stated to the surveyor that she had opened the drops this morning and had just failed to date them, She then dated the packaging for the day's date.
Surveyor observed the medication cart on Unit 2 of the facility with LPN #4. Surveyor observed two oblong maroon colored tablets in the top drawer of the medication cart. LPN #4 stated they were multivitamins, and proceeded to discard them.
Surveyor requested and was provided with a policy entitled General Dose Preparation and Medication Administration which read in part, 3.11 Facility staff should enter the date opened on the label of medications with shortened expiration dates (e.g., insulins, irrigation solution, etc.).
The concern of the not dating the eye drops and not properly storing medications was discussed with the administrative team during a meeting on 03/13/19 at approximately 1415.
No further information was provided prior to exit.
2. The facility staff failed to have a physician ordered medication available for administration to Resident #11.
Resident #11 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to heart failure, high blood pressure, diabetes, dementia, depression, Manic Depression and PTSD. On the quarterly MDS (minimum Data Set) with an ARD (Assessment Reference Date) of 12/4/18, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 4 out of a possible score of 15. Resident #11 was also coded as requiring extensive assistance of 1 staff member for dressing and personal hygiene and being totally dependent on 1 staff member for bathing.
The surveyor noted on 3/14/19 during the clinical record review, Resident #11 had been ordered Tolterodine ER Capsule Extended Release 24 hour 4 milligram 1 tablet by mouth one time a day for overactive bladder. The surveyor also reviewed the MAR (Medication Administration Record) for Resident #11. On 3/12/19 through 3/14/19 at 0900, the facility staff had documented 9 in the box for these dates and times. According to the chart code on the MAR, 9 represents Other-See progress note. The surveyor reviewed the documentation in the nursing notes and there was no documentation on these dates and for this medication for Resident #11.
The surveyor asked the DON (director of nursing) at 10:30 am on 3/14/19 about the issue that had been identified. The DON stated, I don't know unless the medication was not available to be given to the resident.
No further information was provided to the surveyor prior to the exit conference on 3/14/19.
3. The facility staff failed to have a physician order medication available for administration to Resident #126.
Resident #126 was admitted to the facility on [DATE] with the following diagnoses of, but not limited to heart failure, high blood pressure, urinary tract infection, diabetes, manic depression, and chronic obstructive pulmonary disease. On the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/12/19, the resident was coded as having a BIMS (Brief Interview for Mental Status) score of 15 out of a possible score of 15. Resident #126 was also coded as requiring extensive assistance of 2 staff members for dressing, and 1 staff member for personal hygiene and being totally dependent on 1 staff member for bathing.
During the clinical record review on 3/13/19, the surveyor noted the following documentation in the nurses' notes for 3/5/19 22:02 (10:02 pm) Pyridium 100 mg (milligram) Give 1 tablet by mouth two times a day for dysuria for 3 days AWAITING FROM PHARMACY DUE TO NEW ORDER. MEDICATION IS NOT IN THE STAT BOX. (sic).
The administrative team was notified of the above documented findings at 2:14 pm on 3/13/19.
No further information was given to the surveyor prior to the exit conference on 3/14/19.
Based on observation and staff interview, the facility staff failed to ensure physician ordered medications were available for administration, failed to date opened medication, and failed to properly store medications for 5 of 36 Residents (#38, 11, 126, 20, and 7) and on 2 of 5 medication carts.
The findings included:
1. For Resident #38, facility staff failed to ensure medications were available for administration.
Resident #38 was admitted to the facility on [DATE] with diagnoses including paraplegia, muscle weakness, chronic pain, neurogenic bowel, hypertension, diabetes mellitus, anxiety, and depression. On the quarterly minimum data set assessment with assessment reference date 12/27/18, the resident scored 15/15 on the brief interview for mental status and was assessed as without signs of delirium, psychosis, or behaviors affecting care.
During an interview on 3/13/19 at 12:56 PM, the resident mentioned that during her stay, robaxin and gabapentin had both run out with no quick replacement.
Record review revealed that on 3/11 the Lidocaine patch was held (code 5=see note), without a nursing note to document the reason and on 1/10, Fentanyl and Lidocaine patches were both held with no explanation. Fentanyl was coded 5(=hold, see notes) and Lidocaine at 8 and 12 were coded 9(= other see progress notes). There were no progress notes on those dates. Robaxam tablet 500 mg give 1 tablet 4 times daily for muscle relaxer was documented as held awaiting from pharmacy on 3/9 at 9 PM, on 3/10 at 9 AM, 1 PM, and 9 PM and 3/11 at 1 PM and 9 PM.
The administrator and director of nursing were notified of the concern with pain medication administration on 3/12/19.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 2 harm violation(s), $131,313 in fines. Review inspection reports carefully.
- • 88 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
- • $131,313 in fines. Extremely high, among the most fined facilities in Virginia. Major compliance failures.
- • Grade F (10/100). Below average facility with significant concerns.
Bottom line: Trust Score of 10/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Virginia Beach Healthcare And Rehab Center's CMS Rating?
CMS assigns VIRGINIA BEACH HEALTHCARE AND REHAB CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Virginia, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Virginia Beach Healthcare And Rehab Center Staffed?
CMS rates VIRGINIA BEACH HEALTHCARE AND REHAB CENTER's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 69%, which is 22 percentage points above the Virginia average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 80%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Virginia Beach Healthcare And Rehab Center?
State health inspectors documented 88 deficiencies at VIRGINIA BEACH HEALTHCARE AND REHAB CENTER during 2019 to 2025. These included: 2 that caused actual resident harm and 86 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Virginia Beach Healthcare And Rehab Center?
VIRGINIA BEACH HEALTHCARE AND REHAB CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by LIFEWORKS REHAB, a chain that manages multiple nursing homes. With 180 certified beds and approximately 167 residents (about 93% occupancy), it is a mid-sized facility located in VIRGINIA BEACH, Virginia.
How Does Virginia Beach Healthcare And Rehab Center Compare to Other Virginia Nursing Homes?
Compared to the 100 nursing homes in Virginia, VIRGINIA BEACH HEALTHCARE AND REHAB CENTER's overall rating (1 stars) is below the state average of 3.0, staff turnover (69%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Virginia Beach Healthcare And Rehab Center?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.
Is Virginia Beach Healthcare And Rehab Center Safe?
Based on CMS inspection data, VIRGINIA BEACH HEALTHCARE AND REHAB CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Virginia. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Virginia Beach Healthcare And Rehab Center Stick Around?
Staff turnover at VIRGINIA BEACH HEALTHCARE AND REHAB CENTER is high. At 69%, the facility is 22 percentage points above the Virginia average of 46%. Registered Nurse turnover is particularly concerning at 80%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Virginia Beach Healthcare And Rehab Center Ever Fined?
VIRGINIA BEACH HEALTHCARE AND REHAB CENTER has been fined $131,313 across 1 penalty action. This is 3.8x the Virginia average of $34,392. 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 Virginia Beach Healthcare And Rehab Center on Any Federal Watch List?
VIRGINIA BEACH HEALTHCARE AND REHAB CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.