CHARLESTON HEALTHCARE CENTER
For profit - Corporation
150 Beds
COMMUNICARE HEALTH
Data: November 2025
Trust Grade
43/100
#43 of 122 in WV
Photo by Charleston Healthcare Center
Photo by Charleston Healthcare Center
Photo by Bob McCoy
1 / 5 photos
Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Charleston Healthcare Center has a Trust Grade of D, indicating below average performance with some concerns regarding care quality. It ranks #43 out of 122 facilities in West Virginia, placing it in the top half but still showing room for improvement. The facility is on an improving trend, as they reduced their reported issues from 37 in 2023 to 27 in 2024. Staffing is average with a rating of 3 out of 5 stars and a turnover rate of 46%, which is close to the state average. However, the RN coverage is concerning, as it is lower than 75% of other facilities, which might affect the quality of care. There are some serious incidents noted, including a failure to schedule necessary orthopedic appointments for a resident, leading to physical harm, and inadequate management of pressure ulcers that resulted in actual harm to another resident. Additionally, there have been issues with pain management, where residents did not receive appropriate documentation or medication as prescribed. While there are strengths in their quality measures, these weaknesses highlight significant areas that families should consider when researching care options.
- Trust Score
- D
- In West Virginia
- #43/122
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 46% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $12,831 in fines. Lower than most West Virginia facilities. Relatively clean record.
- Skilled Nurses ○ Average
- Each resident gets 34 minutes of Registered Nurse (RN) attention daily — about average for West Virginia. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 95 deficiencies on record. Higher than average. Multiple issues found across inspections.
43/100
Top 35%
Review needed
37 → 27 violations
★★★☆☆
3.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★★
5.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2023: 37 issues
2024: 27 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
3-Star Overall Rating
Near West Virginia average (2.7)
Meets federal standards, typical of most facilities
Staff Turnover: 46%
Near West Virginia avg (46%)
Higher turnover may affect care consistency
Federal Fines: $12,831
Below median ($33,413)
Minor penalties assessed
Chain: COMMUNICARE HEALTH
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 95 deficiencies on record
3 actual harm
Oct 2024
15 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
Based on record review and resident and staff interviews, the facility failed to make orthopedic appointments as directed, provide transportation to appointments, obtain documentation from appointment...
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Based on record review and resident and staff interviews, the facility failed to make orthopedic appointments as directed, provide transportation to appointments, obtain documentation from appointments, and follow directions from those appointments to prevent contractures in Resident #88's left arm and hand following a fall at the facility.
The State Agency (SA) determined physical harm was caused to Resident #88 when the resident developed contractures in her upper left arm and hand following a fall at the facility. The failure to schedule a follow up appointment with Resident #88's orthopedic doctor in a timely manner, provide transportation, obtain the documentation sent from the appointments, and follow the recommendations from the appointments, resulted in the resident developing contractures in her left arm and hand. This will be cited at past non-compliance due to the facility identifying and correcting the issue on 08/04/23.
The facility also failed to administer anticonvulsant and narcotic pain medications, as ordered by the physician to Resident #105, # 51, #79, #494, #93, #75, #64, #23, #101, #3, #60, #48, #495, #52, #91. This will also be cited as past noncompliance.
Resident identifiers: #88, #105, #51, #79, #494, #93, #75, #64, #23, #101, #3, #60, #48, #495, #52, #91. Facility census: 145.
Findings include:
a) Resident #88
At approximately 1:57 PM on 10/28/2024, an interview was conducted with Resident #88. During the interview, the resident was asked about the range of motion in her left arm, due to a fall suffered in the facility on 05/24/2023. During the interview, Resident #88 stated she had fallen out of bed while a Nurse Aide (NA) was providing care to her. She states she broke her upper arm because of the fall. Resident #88 proceeded to state I have a hard time using my hand now. It ' s hard to use it to eat. At this time, Resident #88 took her left hand out from under her blanket and held it up. Resident #88's left hand was observed to be contracted.
At approximately 3:00 PM on 10/29/2024, a review of the Facility reported incidents related to this fall were reviewed. During this review, it was determined the facility did not schedule the follow up appointment for the resident as advised, did not provide transportation to the appointments as needed, and did not ensure all documentation was obtained from the doctor's office, resulting in the resident not getting the treatment she needed, resulting in the development of contractures of her left arm and hand. When the resident went to the orthopedic appoinment on 06/29/24 the facility did not receive follow up information regarding the range of motion exercices recommended by the orthopedist.
The facilities narrative of their investigation reads as follows:
On May 24, (Resident #88's name) sustained a fracture of her left humerus because of a fall. (Resident #88's name) returned to the facility the same day with orders to follow up with ortho in 1-2 weeks. The appointment was not made until 06/09/23 for 06/29/23. The facility obtained documentation from that consult with the follow up appointment date only. No consult report was returned to the facility following this appointment. (Resident #88's name) should have had the next follow up appointment with orthopedics on 07/13/23. The facility did not ensure that this appointment was completed for (Resident #88's name) due to failing to ensure transportation was arranged.
On 8/2/23, occupational therapy identified that (Resident #88's name) had contractures noted to left upper extremity and hand. (Resident #88's name) Had an immobilizer ordered but after investigation it was determined that she frequently was non-compliant with allowing the application of the immobilizer. It was further discovered that the initial orthopedics appointment recommendation was made for range of motion exercises. The facility failed to ensure that this consult documentation was received after the appointment on 06/29/24. As a resultand Resident #88 had not been receiving this range of motion.
As a result of the investigation, the facility substantiated neglect as the facility failed to ensure needed follow up for Resident #88.
At approximately 12:00 PM on 10/30/2024, an interview was conducted with the Administrator and Director of Nursing (DON). During the interview, the Administrator and DON acknowledged the facility failed to ensure a follow up for Resident #88 after the fall. The administrator and DON then supplied the plan the facility put into place to correct the issue.
Education was conducted with the person in charge of scheduling appointments (Medical Records Coordinator) for residents, to ensure they were made in a timely manner and they returned with all of the follow up documentation. Education was also completed with the nursing staff. Furthermore, the DON revealed she has implemented a process to ensure all appointments are completed and documentation has returned with the resident. The policy is as follows:
1. Appointments are placed on the communications tab.
2. Nursing checks appointments and reviews them daily in stand up for the day.
3. Nursing reviews appointments in stand-down to ensure our notes and return notes are completed with any follow up.
4. Any appointment that has not returned before stand-down goes onto the next day follow-up sheet.
c) On 06/15/24, the facility reported an incident to the Office of Health Facility Licensure and Certification (OHFLAC) that occurred on 06/14/24 and was discovered on 06/15/24. Licensed Practical Nurse (LPN) #195 had failed to administer bedtime medications for Residents #105, #51, #79, #494, #93, #75, #64, #23, #101, #3, #60, #48, #495, #52, and #91. This was past non-compliance that began on 06/14/24 and ended 06/29/24.
The incident was investigated by the facility. The five (5) day follow-up report submitted to OHFLAC verified the allegation of failure to administer medications.
The medications that were identified as not given were anticonvulsants and narcotics. The physicain was contacted and did not order the missed dose to be given. Pain assessments were also done and residents did not appear to have been affected by the missed dose.
The written statement by LPN #55 on 06/15/24 stated as follows: On 06/14/24 7p-7a shift I worked with [LPN #195]. She was assigned to B Hall cart. [LPN #55] was unable to log into the computer (PCC) around 5:30 am on 6/15/24. She asked to use my username and password to give her morning meds. I refused and gave her the phone number for IT help in resetting her password. [LPN #55] never reset her password and I realized she did not start morning med pass yet. I asked if she needed help and she gave me her med cart keys and I realized our residents wouldn't have morning meds. Upon starting B Hall med pass I noticed pill packets for 6/14/24 times 2100 and 2200 [9:00 PM and 10:00 PM] unopened on multiple residents. I called the on-call nurse [Registered Nurse #97] and explained the situation. I completed all 6:00 rx [prescription] med pass and reported the situation to the oncoming nurse as well. (Typed as written.)
The verbal statement by LPN #195 taken by the Director of Nursing on 06/16/24 stated as follows: I do not know what happened. I thought I gave all of the medications. It was a busy night but uneventful. The physician was notified regarding the omitted medications. The medications were to be given at the next scheduled dose. Change in condition forms with assessments were completed for all residents with omitted medications. All these residents were assessed for adverse consequences, which included vital signs and assessment for pain levels and behaviors. Frequent assessments for these residents continued through 06/18/24. No resident was found to have experienced harm. All medications, including controlled substances, were accounted for. Interviewable residents were interviewed and reported no pain or other adverse consequences.
LPN #195's employment was terminated. All other nurses received education on medication administration. The education was completed for all nurses on 06/29/24. The education followed the facility's policy and standard procedure titled Medication Administration, with no implementation given. The education included, but was not limited to, observing the five (5) rights of giving medication, to administer medications within the time frame of one hour before and up to one hour after the time ordered, and documentation of medication within accepted standards of nursing practice.
On 10/30/24 at 1:00 PM, the DON was interviewed regarding the matter. She stated the day shift nurse found the evening pill packets in the cart and realized the meds had not been given. LPN #195 was interviewed and stated she thought she had given all the medications. The DON stated LPN #195 had signed out all the omitted medications on the Medication Administration Record (MAR). She stated LPN #195's employment was terminated and she had not worked any shifts at the facility after this incident. The DON stated she was performing daily MAR audits before this incident and the audits continued after this incident. The MAR audits are ongoing.
The following nurses were interviewed on 10/30/24 and were able to correctly state five (5) rights of medication administration as well as the time frame for medication administration and the correct documentation for medication administration.
- LPN #153 at 12:30 PM
- LPN #95 at 12:35 PM
- LPN #84 at 1:28 PM
- LPN #54 at 1:41 PM
Resident #105 was interviewed on 10/30/24 at 1:33 PM and had no complaints about medication administration.
Resident #23 was interviewed on 10/30/24 at 1:38 PM and no complaints about medication administration.
No further information was provided through the completion of the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observations and staff interviews the facility failed to make sure call light was accessible to Resident #120. This was a random opportunity for discovery during the Long-Term Care survey. Fa...
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Based on observations and staff interviews the facility failed to make sure call light was accessible to Resident #120. This was a random opportunity for discovery during the Long-Term Care survey. Facility census: 145. Resident identifier: #120
Findings included:
a) Resident #120
During the initial facility tour on 10/28/24 around 11:45 AM the surveyor observed Resident #120 lying in bed with head elevated, the call light was not within reach of Resident #120. The call light was hanging between the headboard and the mattress. As the surveyor exited the room, the staff entered the room.
Further observation on 10/28/24 around 12:15 PM of Resident #120 laying in the bed after staff left the room revealed the call light was still hanging on the headboard not within reach to Resident #20.
An interview with Unit Manager Registered Nurse (UMRN)# 50 on 10/28/24 at approximately 12:20 PM confirmed the call light was not within reach for Resident #120.
On 10/29/24 at approximately 9:00 AM the Administrator provided a copy of the facility policy. On page two (2) procedure one (1) Section C stated the following: To have a method to communicate needs to staff 1. Call light or bell access will be within reach of the resident as one method to communicate needs to staff.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
Based on record review, resident interview, and staff interview the facility failed to honor Resident #68's choices in their preference to only have female caregivers. This failed practice was found t...
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Based on record review, resident interview, and staff interview the facility failed to honor Resident #68's choices in their preference to only have female caregivers. This failed practice was found true for (1) one of (9) nine residents reviewed for choices during the Long-Term Care Survey Process. Resident identifier: #68. Facility Census: 145.
Findings include:
a) Resident #68
During an interview on 10/29/24 at 1:00 PM, Resident #68 stated, I don't like it when the guys come in to take care of me, I won't let them.
Record review on 10/29/24 at 2:15 PM, for Resident #68 revealed a care plan that reads as follows: Residents prefers female caregivers.
A record review on 10/29/24 at 4:30 PM of the Daily Assignment sheets for EB2 indicated that Resident #68 had a male Nursing Assistant (NA) assigned to her on 10/08/24, 10/09/24, 10/15/24, and 10/23/24.
During an interview on 10/29/24 at 4:40 PM, the Director of Nursing (DON) stated, She usually doesn't like male caregivers, but she will tolerate (NA #44 named). We do the assignments by seniority. So he typically gets the assignment that is left, which is usually that assignment.
During an interview on 10/30/24 at 11:15 AM, Resident #68 stated, (NA #44 named, is assigned to me a lot. I tell him you are not taking care of me.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to complete a thorough investigation of a reported incident and identify an allegation of neglect. The facility did not follow physician...
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Based on record review and staff interview, the facility failed to complete a thorough investigation of a reported incident and identify an allegation of neglect. The facility did not follow physician's orders for Resident #122. This was true for 1(one) of 4 (four) residents reviewed for abuse and neglect. Resident identifier #122. Facility Census 145.
Findings included:
a) A review of the incident report, investigation and five day-follow-up that occurred on 06/16/24 for Resident #122 revealed the following:
Resident # 122 was found in her room with chopped up fruit in her bed by a nurse aide. The resident's brother later reported to the nurse that he had Resident #122 laughing and spitting up chunks of fruit. There was a spoon and empty fruit cup on the floor beside her bed on 06/16/24.
There were (3) three witness statements collected. Witness statements were collected from the nurse aide and Licensed Practical Nurse (LPN) #52 and the assistant cook.
The Assistant [NAME] reported that a nurse called and asked for scrambled eggs for Resident #122 on 06/17/24 and she made them without checking the resident's diet card.
The facility did not substantiate the allegation per five-day follow-up. No further documentation was provided.
b) A review of Resident #122's records on 10/30/24 at 12:05 PM revealed the following:
Diagnoses:
Hemiplegia and hemiparesis following cerebral infarction, aphasia, dysphasia requiring feeding tube, apraxia following cerebral infarction.
Physician's orders:
Start date 1/08/24- Nothing By Mouth (NPO) diet, NPO texture, NPO Consistency for diet type
Start date 6/17/24, Puree texture, thin liquids consistency, pleasure tray diet type
Nurses Notes-
6/16/2024 6:00 pm: Physician order not followed related to diet. All parties aware.
Nurses Note
6/17/2024 12:17 pm: New order obtained per speech therapy, upgrade diet pureed texture, thin liquids for pleasure feeding. All parties aware.
c) During an interview on 10/30/24 at 1:30 PM, the Director of Nursing (DON) stated, The investigation was pertaining to the fruit. We did not substantiate it because we feel her brother brought in the fruit. No staff said that they brought in the fruit. She did not get the eggs. (name) the nurse called down and got eggs for another resident. The statement from the kitchen came into play because we just called the kitchen and said 'Did anyone call down and get extra food and they said (name) did for (Resident #122). The kitchen had the person mixed up. (name) is not working today. If you need her number, I can get it for you.
There was no evidence of the information provided by the DON in the investigation provided by the facility. When the surveyor reviewed the investigation provided by the facility it appeared that the resident had received eggs and the resident's physician orders stated she was NPO.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to make a care plan revision in the area of advanced directives. This failed practice was found true for (1)...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to make a care plan revision in the area of advanced directives. This failed practice was found true for (1) one of (6) six residents reviewed for Advance Directives during the Long-Term Care Survey Process. Resident identifier: #66. Facility census: 145.
Findings Include:
a) Resident #66
A record review on [DATE] at 8:52 AM, revealed that Resident #66's was marked as a Do Not Resuscitate (DNR) on her post form dated [DATE].
Further record review of Resident #66's care plan reads as follows:
Focus:
Resident has a Cardiopulmonary Resuscitation (CPR) code status. Revised on [DATE]
During an interview on [DATE] at 11:00 AM, the Director of Nursing (DON) confirmed that the code status for Resident #66 did not match.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0678
(Tag F0678)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure they provided emergency care in accordance with...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure they provided emergency care in accordance with the resident's advanced directives. Resident #139 had a [NAME] Virginia Post Orders to Health Care (POST) form that specified the resident did not want cardiopulmonary resuscitation (CPR). The resident's care plan had not been updated to reflect this and indicated the resident was a full code. The resident received CPR when they had no pulse and were not breathing. Resident identifier: #139. Facility census: 145.
Findings included:
a) Resident #139
During a medical record rive for resident #139 on [DATE] at approximately 09:45 AM it is identified that the resident had capacity and had completed the [NAME] Virginia Post Orders to Health Care (POST) form on [DATE] which identifies the following:
Section A) Cardiopulmonary Resuscitation Orders. Follow these orders if patient has no pulse and is not breathing.
NO CPR: Do not attempt Resuscitation (May choose any option in Section B.
Section B) Option selected:
Selective treatments. Goal attempt to restore function while avoiding intensive care and resuscitation efforts (ventilator, defibrillation and cardioversion). May use non-invasive positive airway pressure, antibiotics and IV fluids as indicated. Avoid intensive care. Transfer to hospital if treatment needs cannot be met in current location.
During a review of the care plan it is identified that the care plan states Resident is a full code and was initiated on [DATE].
Further review of the medical record muses notes it is identified that on [DATE] Registered Nurse (RN) #49 documented on [DATE] at 9:30 PM that Resident #139 became unresponsive with no pulse or respirations. RN #49 states that the high quality CPR was imitated at that time.
The following sequence of events was identified in RN #49's notes on [DATE] at 09:30 PM, typed as written;
2051: Ambu bag with supplemental oxygen applied.
2052: AED (Automated External Defibrillator) applied.
2055: AD performed a rhythm check, no shock advised. High quality CPR resumed.
2058: Pulse/rhythm check performed, no pulse palpated. No shock advised. High quality CPR resumed;
2059: Peripheral IV access attempted and unsuccessful.
2101: EMS arrived on scene. Pulse/rhythm check performed. No pulse palpated. No shock advised. High quality CPR resumed with EMS taking the lead.
2103: The residents daughter/MPOA notified of the change in condition.
2104: Pulse/rhythm check performed. No pulse palpated. No shock advised. High quality CPR resumed.
2105: Intraosseous access obtained by EMS.
2107: Pulse/rhythm check performed. No pulse palpated. No shock advised. High quality CPR resumed.
2109: EMS charge paramedic confirmed with daughter to end life saving measures.
2114: EMS conferred with their physician (physician name noted) and determined the time of death is 2114.
2145: The residents family arrived at the facility.
On call nurse manager/DON notified. On call medical provider notified. In house medical provider notified. All parties aware.
During an interview with the Director of Nursing on [DATE] at approximately 10:49 AM the DON agreed that the care plan had not been developed and implemented accurately as the resident was a Do Not Resuscitate and the nurses intimated cardiopulmonary resuscitation (CPR) at the time Resident #139 had become unresponsive.
During an interview with the Director of Nursing on [DATE] at approximately 10:49 AM the DON agreed that the care plan was not accurate and that the resident was a Do Not Resuscitate. The DON acknowledge the error that had been made as the nurse immediately intimated cardiopulmonary resuscitation (CPR) at the time Resident #139 had become unresponsive. The DON stated they had already identified the issues and had presented this to their Quality Assurance Committee. Education were completed and an audit was completed of the residents POST status with physician order and updated in the residents chart. This education was completed on [DATE].
The education consisted of Code Status Process: Social Worker obtains the POST form, Social Worker scans form into chart, gives form to the assigned nurse, the nurse obtains the order from the provider, then the nurse puts the status order in PCC (point click care). The POST form then goes into the chart.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation and staff interview, the facility failed to maintain the environment as free of accident hazards as possible. A used razor laying on Resident #53's bathroom sink. This was a rando...
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Based on observation and staff interview, the facility failed to maintain the environment as free of accident hazards as possible. A used razor laying on Resident #53's bathroom sink. This was a random opportunity for discovery. Resident Identifier: #53. Facility Census: 145.
Findings Include:
a) Resident #53
On 10/28/24 at 11:18 AM, a used razor was observed laying on the bathroom sink in Resident #53's room.
On 10/28/24 at 11:20 AM, the Facility Scheduler #19 confirmed the used razor was laying on the bathroom sink. The Facility Scheduler stated, I'll take care of it.
On 10/29/24 at 8:58 AM, the Director of Nursing (DON) was notified and confirmed the used razor should not have been left on the bathroom sink.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and family interview the facility failed to recognize, evaluate, and address the needs ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and family interview the facility failed to recognize, evaluate, and address the needs of each resident at risk for and experiencing dehydration. This failed practice was found true for (1) of (3) residents reviewed for dehydration during the Long-Term Care Survey Process. Resident identifier #68. Facility Census 145.
Findings Include:
a) Resident identifier #68
During the initial interview on 10/28/24 at 12:47 PM, Resident #68 stated, I don't drink the water here. I drink coffee with each meal and I eat Ice chips. They don't always bring me my ice chips. They are getting a little better since I had that intravenous (IV) to get fluids.
Further record review of Resident #68's diagnoses revealed that Resident #68 was diagnosed with a Urinary Tract Infection (UTI) on 09/06/24 that was resolved on 10/05/24. The Hydration risk evaluation dated 10/09/24 did not indicate that Resident #68 had a history of UTI, which would put her at a higher risk for dehydration.
Further record review of Resident #68's diagnosis revealed a diagnosis of depression. The Hydration risk evaluation dated 10/09/24 does not indicate that Resident #68 had depression, which would put her at a higher risk for dehydration.
A review of Resident #68's Nutritional Risk assessment dated [DATE] under section F, question 1e. reads that Resident #68' estimated daily fluids are 1750 cubic centimeter (cc).
A record review on 10/29/24 at 11:15 AM of Resident #68's progress notes, revealed a nurses note dated 10/01/2024 reads as follows:
Received new order to infuse 2 liters of normal saline (NS). Fluid volume depletion. All parties aware
Further record review of Resident #68's Dietary Nutritional assessment dated [DATE] under letter I, question 2, reads that resident has no signs of symptoms of dehydration.
During an interview on 10/29/24 at 2:00PM, The Director of Nursing (DON) stated, We only put fluids in that they have for their meals. We do not track the fluids they get in between.
During an interview on 10/29/24 at 2:10 PM, Licensed Practical Nurse (LPN) #32 stated, She won't drink water. She gets cups of ice and eats them. We give her several a day now. She does get more now then before she had the IV put in for fluids.
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
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
Based on resident interview, staff interview, observation and record review, the facility failed to promptly obtain needed dental services for damaged dentures for Resident #31. The was true for 1 (on...
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Based on resident interview, staff interview, observation and record review, the facility failed to promptly obtain needed dental services for damaged dentures for Resident #31. The was true for 1 (one) of 3 (three) reviewed for dental needs. Resident identifier #31. Facility census: 145.
Finding included:
a) Resident #31
An interview on 10/28/24 at 12:10 PM with resident #31 who reported that he had 2 (two) missing teeth from his upper, front dentures due to eating facility's tough meat. Resident's dentures were observed to have missing 2 (two) front teeth. He stated that the facility was aware that his dentures were broken for over a year and had not yet offered to make an appointment to have them repaired. He reported that he was not having difficulty eating but that he did not like the way they looked.
b) On 10/29/24 an interview with Medical Records Coordinator #150 reported that nurses would give her a consult assessment when a resident was in need of a dental appointment, and she would follow up with business office for insurance options, schedule appointment and the resident's dentures would be available after payment was received. She reported that she had not received a consultation to schedule dental/denture appointment for Resident # 31 and was not aware that he had broken dentures.
c) On 10/29/24 at 11:52 AM, a review of resident's care plan stated that he has dentures and that two teeth are broken off the top plate. Stated no pain or trouble. Provide oral care as needed. Complete oral assessment as needed. Dental consult as needed.
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 F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
Based on record review, staff interview and resident interview the facility failed to meet resident's nutritional needs by serving Resident #31 food he was allergic to. This is true for three (3) of 1...
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Based on record review, staff interview and resident interview the facility failed to meet resident's nutritional needs by serving Resident #31 food he was allergic to. This is true for three (3) of 13 residents review for food preferences. Resident identifier: #31, #68, and #10. Facility census: 145.
Findings included:
a) Resident #31
On 10/28/24 at 12:10 PM an interview with Resident #31 who reported that he was allergic to lemon and the facility continues to serve him lemon products. He reported that some of his dietary cards reflect that he was allergic to lemon and other cards stated that he was allergic to only lemonade. Resident reported that when he consumes lemon products he would break out in hives.
b) On 10/28/24 a review of resident's records revealed the following:
Resident #31's care plan and medical records reveal that he was allergic to lemon.
Resident # 31's dietary cards revealed the that the resident's card stated following and that he was served food containing lemon on these days:
08/19/23- Allergies: Lemon, Lemon Bar
09/13/23- Allergies: Lemonade, Lemon Bar
09/16/23- Allergies: Lemonade, Steamed Broccoli Florets with Lemon-1/2 cup
10/23/24- Allergies: Lemonade, Lemon cake with Lemon Icing
c) On 10/30/24 at 10:05 AM an interview with Food Service Director in regards to resident #31's allergies. He reported that the dietary cards were made from a 3rd party company that take meal tracker data from Point Click Care to develop each resident's meals. He acknowledged that some dietary cards stated allergy to lemon and some showed the allergy to be lemonade. He also acknowledged that the resident's meal cards for the following dates showed the resident was served lemon products:
08/19/23- Allergies: Lemon, Lemon Bar
09/13/23- Allergies: Lemonade, Lemon Bar
09/16/23- Allergies: Lemonade, Steamed Broccoli Florets with Lemon-1/2 cup
10/23/24- Allergies: Lemonade, Lemon cake with Lemon Icing
b) Resident #68
During an interview on 10/30/24 at 10:40 AM, Resident #68 stated, I am allergic to eggs. They still send them to me. Sometimes the Nurses take them off my tray. Here is my ticket from breakfast.
An observation on 10/30/24 at 10:40 AM, revealed a breakfast meal ticket for Resident #68 in bold red letters: Allergies: egg. Below the red print it reads what the resident received for breakfast which was: baked cheese omelet, sausage patty, cold cereal, English muffin, jelly and margarine.
A record review on 10/30/24 at 11:00 PM, of resident # 68's allergies revealed that she did have an allergy to eggs.
During an interview on 10/30/24 at 11:15 AM, Resident #68 stated, Well I can eat eggs in stuff, but I just don't eat them whole because it makes my stomach cramp. I have always taken the flu shot and it does not bother me.
During an interview on 10/30/24 at 11:30 AM, The Corporate Dietary Manager stated, We found the issue. It isn't pulling over to our meal tracker. We are working on the problem. If the kitchen staff see an allergy to eggs on her meal ticket, they do not send her eggs.
During an interview on 10/30/24 at 11:40 AM, Nursing Assistant (NA )#30 stated, There have been eggs on the resident tray before and I just took them off.
c) Resident #10
On 10/28/24 at 12:10 PM Resident #10 stated she does not like eggs and they keep sending eggs.
On 10/29/24 at 8:50 AM record review of two (2) Dietary History/Food Preferences, one dated 09/25/25 and the other dated 10/24/25 both have Resident #10's dislikes listed as egg, chicken and fish.
Review of Resident #10's meal tickets for the following dates show her menu for the day included eggs, chicken or fish.
10/26/24
breakfast: baked cheese omelet
dinner: breaded fish on a bun
10/27/24
breakfast: scrambled eggs
lunch: chicken Alfredo
dinner: BBQ chicken thigh
10/29/24
breakfast: scrambled eggs with cheese
dinner: BBQ chicken thigh
The above findings were confirmed with the Director of Nursing on 10/29/24 at 11:54 AM.
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 F0808
(Tag F0808)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure resident's diet was followed per physician's orders fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure resident's diet was followed per physician's orders for Resident #122. This is true for 1(one) of 13 residents reviewed for food. Resident identifier #122. Facility Census 145.
Findings included:
a) A review of incident report, investigation and five day-follow-up that occurred on 06/16/24 for resident #122 revealed the following:
Resident # 122 was found in her room with chopped up fruit in her bed by Nurses Aide. The resident's brother later reported to the nurse that he had resident #122 laughing and spitting up chunks of fruit. There was a spoon and empty fruit cup in the floor beside her bed on 06/16/24.
There were (3) three witness statements collected. That of the Nursed Aide and Licensed Practical Nurse #52 who found fruit and spoon but did not know how resident obtained it. The Assistant [NAME] was the last witness statement obtained and it was reported that a nurse called and asked for scrambled eggs for resident #122 on 06/17/24 and she made them without checking the resident's diet card.
The facility did not substantiate the allegation per five-day-follow-up. No further documentation was provided.
b) A review of resident's records on 10/30/24 at 12:05 PM revealed the following:
Diagnosis List in Point Click Care-
Resident # 122 had a diagnosis of hemiplegia and hemiparesis following cerebral infarction, aphasia, dysphasia requiring feeding tube, apraxia following cerebral infarction.
Physician's orders-
Start date 1/08/24- Nothing By Mouth (NPO) diet, NPO texture, NPO Consistenency for diet type
Start date 6/17/24, Puree texture, thin liquids consistency, pleasure tray diet type
Nurses Notes-
6/16/2024 6:00 pm: Physician order not followed related to diet. All parties aware.
Nurses Note
6/17/2024 12:17 pm: New order obtained per speech therapy, upgrade diet ro pureed texture, thin liquids for pleasure feeding. All parties aware.
c) During an interview on 10/30/24 at 1:30 PM, the Director of Nursing (DON) stated, The
investigation was pertaining to the fruit. We did not substantiate it because we feel her brother
brought in the fruit. No staff said that they brought in the fruit. She did not get the eggs. [NAME]
the nurse called down and got eggs for another resident. The statement from kitchen came in to
play because we just called the kitchen and said did anyone call down and get extra food and
they said [NAME] did for (resident #122). The kitchen had the person mixed up. [NAME] is not working
today. If you need her number I can get it for you.
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 observatio and staff interview the facility failed to ensure they, prepared and served food under sanitary conditions. This has the potential to affect all residents of the facility who recei...
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Based on observatio and staff interview the facility failed to ensure they, prepared and served food under sanitary conditions. This has the potential to affect all residents of the facility who received an oral diet. Facility census:145.
Findings included:
a) During an observation of the lunch meal service in dining Room EB1 10/28/24, Resident # 90 had an egg sandwich. She took a bite and bit down onto a piece of foil which was inside the sandwich. During an interview with Dietary Director #20, he acknowledged the piece of foil and stated he would find out how it happened to be in her sandwich.
During an observation of dining room EB2 lunch service on 10/29/24, there were three (3) beverage serving containers on a cart. These were being used to serve drinks to residents during the lunch service. These three containers were not labeled or dated for expiration. The outside of the containers did not appear to be clean.
During an interview with Dietary Director #20, he identified the beverages as tea, fruit juice and punch. He acknowledged the containers should be labeled and dated.
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** b) Resident #75
During a medical record review on [DATE] at approximately 1:27 PM PM for Resident #75, it is identified the res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b) Resident #75
During a medical record review on [DATE] at approximately 1:27 PM PM for Resident #75, it is identified the resident was care planned to have anxiety.
It was further identifeid that the resident had an order for anxiety side effect monitoring and an order for Buspirone hcl oral tablet 10 mg to be given 2 (two) times a day for anxiety.
A review of the physician diagnoses did not identify a diagnosis of anxiety.
During an interview with the Director of Nursing (DON), on [DATE] at approximately 2:00 PM, the DON agreed that the resident should have a diagnosis of anxiety.
b) Resident #139
During a medical record rive for resident #139 on [DATE] at approximately 09:45 AM it was identified that the resident had capacity and had completed the [NAME] Virginia Post Orders to Health Care (POST) form on [DATE] which identifies the following:
Section A) Cardiopulmonary Resuscitation Orders. Follow these orders if patient has no pulse and is not breathing.
NO CPR: Do not attempt Resuscitation
During a review of the care plan it was identified that the care plan indicated the resident was a full code and was initiated on [DATE].
Further review of the medical record muses notes it is identified that on [DATE] Registered Nurse (RN) #49 documented on [DATE] at 9:30 PM that Resident #139 became unresponsive with no pulse or respirations. RN #49 states that the high quality CPR was imitated at that time.
The following sequence of events was identified in RN #49's notes on [DATE] at 09:30 PM, typed as written;
2051: Ambu bag with supplemental oxygen applied.
2052: AED (Automated External Defibrillator) applied.
2055: AD performed a rhythm check, no shock advised. High quality CPR resumed.
2058: Pulse/rhythm check performed, no pulse palpated. No shock advised. High quality CPR resumed;
2059: Peripheral IV access attempted and unsuccessful.
2101: EMS arrived on scene. Pulse/rhythm check performed. No pulse palpated. No shock advised. High quality CPR resumed with EMS taking the lead.
2103: The residents daughter/MPOA notified of the change in condition.
2104: Pulse/rhythm check performed. No pulse palpated. No shock advised. High quality CPR resumed.
2105: Intraosseous access obtained by EMS.
2107: Pulse/rhythm check performed. No pulse palpated. No shock advised. High quality CPR resumed.
2109: EMS charge paramedic confirmed with daughter to end life saving measures.
2114: EMS conferred with their physician (physician name noted) and determined the time of death is 2114.
2145: The residents family arrived at the facility.
On call nurse manager/DON notified. On call medical provider notified. In house medical provider notified. All parties aware.
During an interview with the Director of Nursing on [DATE] at approximately 10:49 AM the DON agreed that the care plan did not match the resident's POST form.
Based on record review and staff interview, the facility failed to maintain a complete and accurate record regarding Resident #34's assistance for meals and Resident #75's diagnosis of anxiety. This was true for two (2) of 41 residents reviewed during the survey process. Resident identifiers: #34 and #75. Facility Census: 145.
Findings Include:
a) Resident #34
On [DATE] at 12:02 PM, a record review was completed for Resident #34. The review found the resident was ordered nothing by mouth (NPO) and received a tube feeding for nutrition which was Jevity 1.5 83ml (milliliters)/hr (hour) for 17 hours.
The resident was noted to be dependent for all meal and fluid intake. The review, also, found documentation on the September, 2024 and October, 2024 medication administration record (MAR) indicating the resident was independent, set up only, one (1) person physical assistance and two (2) + ( plus) persons physical assist.
The September, 2024 MAR indicated 28 times, the resident ranged from independent to 2+ persons physical assistance. The October, 2024 MAR indicated 42 times, the resident ranged from independent to 2+ persons physical assistance.
On [DATE] at 1:05 PM, the Director of Nursing (DON) was notified. The DON confirmed the resident was dependent for all meals; and, did receive all nutrition and fluid intake via tube feeding.
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
Based on record review and staff interview the facility failed to ensure residents had care plans developed for as of area of concern. Resident #68 had suffered fluid volume depletion and did not have...
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Based on record review and staff interview the facility failed to ensure residents had care plans developed for as of area of concern. Resident #68 had suffered fluid volume depletion and did not have a care plan focus area for dehydration. Resident identifier: #68. Facility census: 145.
Findings included:
a) Resident # 68
During the initial interview on 10/28/24 at 12:47 PM, Resident #68 stated, I don't drink the water here. I drink coffee with each meal and I eat Ice chips. They don't always bring me my ice chips. They are getting a little better since I had that intravenous (IV) to get fluids.
Further record review of Resident #68's diagnoses revealed that Resident #68 was diagnosed with a Urinary Tract Infection (UTI) on 09/06/24 that was resolved on 10/05/24. The Hydration risk evaluation dated 10/09/24 did not indicate that Resident #68 had a history of UTI, which would put her at a higher risk for dehydration.
Further record review of Resident #68's diagnosis revealed a diagnosis of depression. The Hydration risk evaluation dated 10/09/24 does not indicate that Resident #68 had depression, which would put her at a higher risk for dehydration.
A record review on 10/29/24 at 11:15 AM of Resident #68's progress notes, revealed a nurses note dated 10/01/2024 reads as follows:
Received new order to infuse 2 liters of normal saline (NS). Fluid volume depletion. All parties aware
Further record review revealed that there is no care plan in place for dehydration or for at risk of dehydration.
During an interview on 10/29/24 at 2:10 PM, The Director of Nursing (DON) confirmed that risk for dehydration was not on Resident #68's care plan.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
c) Resident #130
During a tour of the facility on 10/28/24 at 11:35 AM it was identified that Resident #130's breathing treatment with mouth piece was observed to be still connected to oxygen and lay...
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c) Resident #130
During a tour of the facility on 10/28/24 at 11:35 AM it was identified that Resident #130's breathing treatment with mouth piece was observed to be still connected to oxygen and laying on the bedside chair without a protective barrier for infection control.
During an interview with Registered Nurse RN #158 on 10/28/24 at 11:40 PM, RN #158 stated that the respiratory therapist had just been in there and turned off the treatment. Stated that the therapist should have placed the mouth piece back inside the bag.
b) Resident #132
On 10/30/24 at 8:55 AM, an observation of Licensed Practical Nurse (LPN) #153 was made during medication administration for Resident #132. LPN #153 dropped four (4) pills on the medication cart with no barrier in place. The medication dropped was Eliquis (blood thinner), Losartan Potassium (high blood pressure, and two (2) Lasix (diuretic) pills. At this time, LPN #153 went to the medication room to retrieve the new medication.
On 10/30/24 at 9:05 AM, LPN #153 returned to the medication cart and dropped one (1) of the Lasix pills on the barrier; however, LPN #153 picked the pill up with a bare hand and placed the pill in the medication cup. After Surveyor intervention, LPN #153 stated, I didn't realize I did that .I'll get some new medication to replace these.
On 10/30/24 at 9:08 AM, Unit Manager (UM) #148 was notified. UM #148 stated, okay .thank you for letting me know.
On 10/30/24 at approximately 2:30 PM, the Director of Nursing (DON) was notified. The DON stated, I'm sure she was nervous .but she shouldn't have picked up the pill with her bare hand.
Based on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. These were random opportunities that had the potential to affect more than a limited number of residents. Resident identifiers: #132 and #130. Facility census: 145.
Findings included:
a) On 10/30/24 at 10:02 AM an inspection of the laundry room was made with the Assistant Executive Director accompanying the survey.
In the dirty area of the laundry room, where dirty laundry was brought and sorted, five (5) mop heads were noted to hanging on hooks. Laundry room worker #176 stated the mop heads were clean. She stated they could not go into the dryer so they had been hung there to dry after washing. She stated she realized clean items should not be drying in the dirty laundry area, but that she did not have anywhere else to hang them.
May 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
.
Based on record review and staff interview, the facility failed to complete a thorough investigations of Resident #75 allegations of abuse. The facility failed to maintain documentation that alleged...
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.
Based on record review and staff interview, the facility failed to complete a thorough investigations of Resident #75 allegations of abuse. The facility failed to maintain documentation that alleged violations were thoroughly investigated. This was true for one (1) of three (3) resdients reviewed for abuse. Resident Identifiers: Resident #75 Facility Census: 148.
Findings include:
a) Resident #75
A review of the facility reportable records log on 05/07/24 at 9:56 AM, revealed an alleged incident occurring on 03/06/24 involving Resient #75 was unsubstantiated.
The reporting form dated 03/06/24 read as follows:
Alleged Victim: ( Name of Resident #75)
Alleged Perpetrator: (Name of Nurse Aide (NA) #57)
Allegation:
Date of Incident: unknown
Time of incident: unknown
Date this report completed: 03/16/24
Describe incident/injuries: An allegation of abuse was reported this date.
A record review on 05/07/24 at 1:45 PM, found Resident #75 had a Brief Interview for Mental Status (BIMS) score of 00 on the quarterly Minimum Data Set (MDS) for ARD (assessment reference date) of 03/11/24. BIMS score of 00 is the lowest score attainable, indicating Resident #75 is not cognitively intact.
During an interview on 05/07/24 at 2:21 PM, the Administrator stated a nurse came to me and said she heard chatter concerns that NA # 57 was being verbally abusive to Resident #75. Then I reported it to the Social worker and she started the initial investigation. No written statement was obtained from the nurse who initially reported it to me. That is on me. I will own it, I will not fight it. She acknowledged the alleged verbal abuse was not investigated thoroughly.
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
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to ensure a discharge summary was completed by the physician f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to ensure a discharge summary was completed by the physician for the basis for the discharge for one (1) of three (3) residents reviewed for a discharge to home. Resident identifier: #151. Facility Census: 148
Findings include:
a) Resident #151
A medical record review was completed on 05/08/24 at 10:30 AM. The record review revealed Resident #151 was discharged to home on [DATE].
A discharge note (nurse note) dated 04/25/24 at 10:51 AM read as follows:
piatient being discharged home today, this nurse did complete body audit on patient and no new skin issues noted, went over discharge instructions with patient and doughtier both verbalized understanding, order received to give patient 36 Norco 5-325, medications called in to mountaineer drug per patient request, patient leaving facility via wheelchair with family.
The record did not reflect a physician discharge note was completed for the date of discharge.
During an interview on 05/07/24 at 3:38 PM the Director of Nursing (DON) acknowledged the physician did not complete a discharge summary note on Resident #151. The DON stated she reviewed the charts of other discharged residents and found that the physician had completed the physician discharge notes at time of discharge.
Jan 2024
10 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 and staff interview the facility failed to ensure the residents residing in room [ROOM NUMBER] was treated ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to ensure the residents residing in room [ROOM NUMBER] was treated with respect and dignity when a housekeeper failed to obtain the residents permission before entering the room and talked on her cell phone the entire time, she was in the resident's room. This was a random opportunity for discovery. Resident Identifier: room [ROOM NUMBER]. Facility Census: #141
a) room [ROOM NUMBER]
On 01/23/24 at 9:42 AM Housekeeper #170 was observed going into room [ROOM NUMBER] while talking on her teal-colored phone. This housekeeper opened the door and walked into the room without knocking. Housekeeper #170 was observed talking on her phone while in the room and remained on her phone when she exited the room.
Housekeeper #170 was stopped upon exiting the room and was asked about knocking on doors before opening and walking in the room. Housekeeper #170 said, It does not matter if you knock or not most of these people here either can't hear or can't talk so it does not matter. Housekeeper #170 remained on her phone the whole time.
The above incident was discussed with the Director of Nursing on 01/23/24 at 11:19 AM and no further information was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to revise a care plan to indicate skin issues were healed for Resident #73, #40 and #31. This is true for three (3) of five (5) resident...
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Based on record review and staff interview, the facility failed to revise a care plan to indicate skin issues were healed for Resident #73, #40 and #31. This is true for three (3) of five (5) residents reviewed under the care area of pressure ulcers. Resident identifiers: #73, #40 and #31. Facility Census: 141.
Findings included:
a) Resident #73
On 01/22/24 at 11:00 AM, a record review was completed for Resident #73. A review of the care plan indicated the resident had excoriation to the bilateral buttock. The weekly skin assessments were reviewed indicating the resident currently had no skin issues.
On 01/22/24 at 3:00 PM, the Director of Nursing (DON) was interviewed and was asked, does the resident have any skin issues? The DON stated, the care plan is incorrect .the resident does not have any skin issues.
b) Resident #40
On 01/22/24 at 11:25 AM, a record review was completed for Resident #40. A review of the care plan indicated the resident had open MASD (moisture-associated skin damage). The weekly skin assessments were reviewed indicating the resident had no skin issues currently.
On 01/22/24 at 3:00 PM, the Director of Nursing (DON) was interviewed and was asked, Does the resident have any skin issues? The DON stated, The care plan is incorrect .the resident does not have any skin issues.
c) Resident #31
On 01/22/24 at 11:45 AM, a record review was completed for Resident #31. A review of the care plan indicated the resident had MASD to inner buttocks. The weekly skin assessments were reviewed indicating the resident had no skin issues currently.
On 01/22/24 at 3:00 PM, the Director of Nursing (DON) was interviewed and was asked, Does the resident has any skin issues? The DON stated, the care plan is incorrect .the resident does not have any skin issues.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility record review and staff interview the facility failed to administer medication as prescribed by the physician,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility record review and staff interview the facility failed to administer medication as prescribed by the physician, failing to offer the Respiratory syncytial virus (RSV) vaccine when available, failed to complete neuro checks, failed to notify physician of no bowel movement, failed to notify physician of resident requesting to go to the emergency room, no protocol for bowel regiment, failed to follow physicians' orders. These were random opportunities for discovery. Resident identifiers: #16, #14, #59, #75, #126, #147, #60, 18, and #145. Facility census 142.
Findings included:
a) Resident #147
Record review on 01/22/24 at 10:00 AM found that on 12/27/23 at 09:30 PM, according to a nurse progress note, Resident #147 had an elevated blood glucose level of 660. The nurse administered the ordered dose of insulin (18 units). There was no nurse note completed at that time of the Physician being notified. However, there is a progress note on 12/27/23 at 9:33 PM from Telehealth Physician which states: cover with accu checks and sliding scale, give 6 units more. Obtain BMP (Basic Metabolic Panel) in the AM, increase Lantus to 20 units from 18 units. There was no order placed in Point Click Care for the additional 6 units of insulin ordered.
Further record review found there was no change in condition assessment completed for this elevated blood glucose.
This was confirmed with the Director of Nursing on 01/23/24 at 10:10 AM at which time she stated there should have been a change in condition report filed for this elevated glucose.
b) Failure to notify Physician
b-1) Resident #147
On 01/15/24 at 9:02 AM, a record review found a nursing note written on 12/28/23 at 09:02 AM, which states the resident, and her daughter was requesting to be transferred to the local emergency room for further evaluation after an elevated blood glucose (660) was obtained the prior evening. The note states the nurse explained to the resident she did not have a Physicians order to send her out at this time and explained the Against Medical Advise (AMA) Policy to the resident and her daughter.
There was no documentation that the nurse had paged a Physician for an order to transfer the resident to the emergency room. When the resident left, there was no documentation the Physician had been notified she had left the facility.
On 12/28/23 at 10:52 AM a progress notes by Social Worker #27 states: Licensed Social Worker (LSW) called Adult Protective Services (APS) for referral relating to leaving facility AMA, Referral intake number provided.
During an interview with Social Worker #27 on 01/23/24 at 10:00 AM, she states she does know the AMA policy and doesn't know anything about this situation, she was only going off the progress note from the nurse on 12/28/23 at 9:02 AM, and according to residents rights, she has the right to request to go to the emergency room (ER).
This was confirmed with the Director of Nursing on 01/23/24 at 3:10 PM. No further information was provided prior to exiting the facility on 01/24/24 at 2:00 PM.
b-2) Resident # 7
A record review on 01/23/24 at 09:25 AM, found Resident #7 did not have a bowel movement (BM) 01/11/24, 01/12/24 or 01/13/24. She did not have an order for the BM Protocol which normally reads:
Bowel protocol step 1: If no BM in 3 days initiate bowel protocol. as needed for Constipation If no BM on day 3 give MOM (1200 mg/15 ml) 30 cc x 1 dose.
Bowel protocol step 2: If no BM in 8 hours (after MOM) give Dulcolax (10 mg) suppository. as needed for Constipation per rectum
Bowel protocol step 3: If no BM 8 hours after Dulcolax suppository give Fleets enema (ready to use saline laxative 4.5 fl oz). as needed for Constipation per rectum. If no results from step 3 notify the physician for additional orders.
Standard practice of care is to notify the Physician of no BM for 3 days with no BM protocol orders present. There is no documentation of the Physician being notified of this change in condition.
This was confirmed with the Director of Nursing on 01/23/24 at 03:10 PM.
b-30) Resident #10
A record review on 01/23/24 at 09: 50 AM, found Resident #10 did not have a BM for three days on 12/18/23, 12/29/23, 12/30/23 and again on 01/04/24, 01/05/24, 01/06/24 or 01/07/24. She did not have an order for the BM Protocol which normally reads:
Bowel protocol step 1: If no BM in 3 days initiate bowel protocol. as needed for Constipation If no BM on day 3 give MOM (1200 mg/15 ml) 30 cc x 1 dose.
Bowel protocol step 2: If no BM in 8 hours (after MOM) give Dulcolax (10 mg) suppository. as needed for Constipation per rectum
Bowel protocol step 3: If no BM 8 hours after Dulcolax suppository give Fleets enema (ready to use saline laxative 4.5 fl oz). as needed for Constipation per rectum. If no results from step 3 notify the physician for additional orders.
Standard practice of care is to notify the Physician of no BM for 3 days with no BM protocol orders present. There is no documentation of the Physician being notified of this change in condition.
This was confirmed with the Director of Nursing on 01/23/24 at 3:10 PM.
c) Failure to follow Physicians orders
c-1) Resident #60
On 01/23/24 at 02:20 PM, a record review found Resident #60 was readmitted to the facility on [DATE]. found readmission Resident #60 was ordered to have vital signs every shift for 72 hours then Daily. According to documentation on the Weights and Vitals Summary, there were no vital signs obtained on the following shifts.
01/10/24 3-11 shift
01/11/24 3-11 shift
This was confirmed with the Director of Nursing on 01/23/24 at 03:10 PM.
c-2) Resident #147
On 01/23/24 at 02:20 PM, record review shows that Resident #147 has an order for Accu checks before meals and at bedtime for diabetes, notify physician for blood sugar less than 60 or greater than 400. The accu checks were scheduled for 7:00 AM, 11:00 AM, 4:00 PM and 9:00 PM.
Further review of the Weights and Vitals Summary for Resident #147 found the Physicians order was not followed when the facility failed to obtain blood glucose on 12/27/23 at 0:00 PM.
This was confirmed with the Director of Nursing on 01/23/24 at 03:10 PM and no further information was provided.
c-3) Resident #147
On 02/23/24 at 2:20 PM a record review found Resident #147 had an order for insulin Lispro (Humalog) injection solution 100 units/milliliter (ml): inject four (4) units subcutaneous before meals for diabetes (DM). Review of the medication administration record (MAR) found this order was not followed prior to the evening meal on 12/26/23 at 4:30 PM. According to the Chart Codes, the nurse documented NC, which is coded as No insulin coverage required.
Resident #147 also has an order for insulin Lispro (Humalog) injection solution 100 units/ml; inject eighteen (18) units subcutaneous two times a day (9:00 AM and 9:00 PM). According to review of the MAR, the 12/26/23 9:00 PM dose was not administered as ordered. According to the Chart Codes, the nurse documented 9, which is coded as see nurse note. According to the nurse progress note, the insulin was not available from the pharmacy. However, the insulin (Humalog) was available in the cubex.
This was confirmed with the Director of Nursing on 01/23/24 at 03:15 PM at which time she stated, This was not a sliding scale order, the four (4) units of insulin should have been administered as ordered and the Humalog is available in the cubex.
c-4) Resident #18
On 01/23/24 at 2:10 PM, a record review found Resident #18 had an order for the bowel protocol which read:
Bowel protocol step 1: If no BM in 3 days initiate bowel protocol.
as needed for Constipation If no BM on day 3 give MOM by mouth (1200 mg/15 ml) 30 cc x 1 dose.
Bowel protocol step 2: If no BM in 8 hours (after MOM) give Dulcolax (10 mg) suppository.
as needed for Constipation per rectum
Bowel protocol step 3: If no BM 8 hours after Dulcolax suppository give Fleets enema (ready to use saline laxative 4.5 fl oz).
as needed for Constipation per rectum. If no results from step 3 notify the physician for additional orders.
A further review of Resident #18's medical record found Resident #18 did not have a did not have a BM on 01/07/24, 01/08/24 and 01/09/24 which should have required the bowel protocol step #1 be initiated. The record was void of any documentation indicating the bowel protocol was initiated.
This was confirmed with the Director of Nursing on 01/23/24 at 03:10 PM at which time she agreed the bowel protocol should have been initiated and was not.
c-5) Resident #147
On 01/23/24 at 01:20 PM record review shows Resident #147 has a progress note from the Telehealth Physician on 12/27/23 at 09:33 PM stating the following: C/w (cover with) accu checks and sliding scale, give 6 units more .
Further record review shows there was no order placed in Point Click Care, nor a nurse progress note indicating the additional six (6) units of insulin was administered.
This was confirmed with the Director of Nursing on 1/23/24 at 3:05 PM at which time she agreed that there is no documentation to indicate the additional six (6) units of insulin was administered as ordered.
d) Resident #147
On 01/22/24 at 02:45 PM record review shows that Resident #147 had an elevated blood glucose of 660 on 12/27/24 at 9:30 PM. The nurse administered the ordered insulin eighteen (18 units) and received a new order from the Telehealth Physician to administer an additional six (6) units of insulin.
Standard practice of care is to re check a blood glucose level one hour after administering insulin when the original blood glucose level was elevated. Documentation showed that Resident #147 did not have another blood glucose level checked until 12/28/23 at 06:38 AM.
This was confirmed with the Director of Nursing on 1/23/24 at 3:05 PM at which time she agreed the blood glucose should have been re checked on 12/27/23 one (1) hour after administering the resident's ordered insulin.
e) Neurological checks
e-1) Resident #145
On 01/23/24 at 3:02 PM, a record review found Resident #145 had an unwitnessed fall on 10/16/23 at 1:00 AM. According to the Neurological Checks Policy all unwitnessed falls are to have neurological (neuro) checks performed every 15 minutes X 4, then every hour X 4, then daily X 4.
Review of Resident #145's neuro checks for this fall shows neuro checks were performed every 15-minute X 4 checks. The remaining eight (8) neurological checks were not performed.
This was confirmed with the Director of Nursing on 01/24/24 at 08:45 AM and no further information was provided.
e-2) Resident #146
On 01/23/24 at 03:02 PM, a record review found Resident #146 had two (2) unwitnessed falls on 10/21/23, one at 06:15 AM and one at 11:30 PM. According to the Neurological Checks Policy all unwitnessed falls are to have neurological (neuro) checks performed every 15 minutes X 4, then every hour X 4, then daily X 4.
Review of Resident #146's fall at 06:15 AM shows that seven (7) of the neurological checks were not performed and the fall at 11:30 PM, eight (8) of the neurological checks were not performed.
This was confirmed with the Director of Nursing on 01/24/24 at 08:45 AM and no further information was provided.
f) Resident #75
On 01/22/24 at 12:15 PM, a record review was completed for Resident #75. A review of the Medication Administration Audit report from 01/12/24 through 01/22/24 found late administration times for the following physician's orders:
--01/15/24 Coreg 12.5mg (milligram) two times daily, scheduled for 10:00 AM, administered at 12:22 PM, which is 2 hours and 22 minutes late
--01/15/24 Plavix 75mg daily, scheduled for 10:00 AM, administered at 12:22 PM, which is 2 hours and 22 minutes late
--01/15/24 Norvasc 10mg daily, scheduled for 10:00 AM, administered at 12:22 PM, which is 2 hours and 22 minutes late
--01/15/24 Neurontin 100mg two times daily, scheduled at 10:00 AM, administered at 12:23 PM, which is 2 hours and 23 minutes late
--01/15/24 Hydralazine 25mg two times daily, scheduled at 10:00 AM, administered at 12:23 PM, which is 2 hours and 23 minutes late
--01/15/24 Senna S 8.6-50mg daily, scheduled for 10:00 AM, administered at 12:23 PM, which is 2 hours and 23 minutes late
--01/15/24 Lasix 20mg daily, scheduled for 10:00 AM, administered at 12:23 PM, which is 2 hours and 23 minutes late
--01/15/24 Potassium Chloride 20meq (milliequivalent) every other day, scheduled at 10:00 AM, administered at 12:23 PM, which is 2 hours and 23 minutes late
--01/16/24 Lasix 20mg daily, scheduled for 10:00 AM, administered at 12:11 PM, which is 2 hours and 11 minutes late
--01/16/24 Senna S 8.6-50mg daily, scheduled for 10:00 AM, administered at 12:11 PM, which is 2 hours and 11 minutes late
--01/16/24 Hydralazine 25mg two times daily, scheduled at 10:00 AM, administered at 12:11 PM, which is 2 hours and 11 minutes late
--01/16/24 Neurontin 100mg two times daily, scheduled at 10:00 AM, administered at 12:11 PM, which is 2 hours and 11 minutes late
--01/16/24 Norvasc 10mg daily, scheduled at 10:00 AM, administered at 12:11 PM, which is 2 hours and 11 minutes late
--01/16/24 Plavix 75mg daily, scheduled at 10:00 AM, administered at 12:11 PM, which is 2 hours and 11 minutes late
--01/16/24 Coreg 12.5mg two times daily, scheduled at 10:00 AM, administered at 12:11 PM, which is 2 hours and 11 minutes late
--01/22/24 Coreg 12.5mg two times daily, scheduled at 10:00 AM, administered at 12:03 PM, which is 2 hours and 3 minutes late
--01/22/24 Plavix 75mg daily, scheduled at 10:00 AM, administered at 12:03 PM, which is 2 hours and 3 minutes late
--01/22/24 Norvasc 10mg daily, scheduled at 10:00 AM, administered at 12:03 PM, which is 2 hours and 3 minutes late
--01/22/24 Neurontin 100mg two times daily, scheduled at 10:00 AM, administered at 12:03 PM, which is 2 hours and 3 minutes late
--01/22/24 Hydralazine 25mg two times daily, scheduled at 10:00 AM, administered at 12:03 PM, which is 2 hours and 3 minutes late
--01/22/24 Senna S 8.6-50mg daily, scheduled at 10:00 AM, administered at 12:03 PM, which is 2 hours and 3 minutes late
--01/22/24 Lasix 20mg daily, scheduled at 10:00 AM, administered at 1:03 PM, which is 2 hours and 3 minutes late
--01/22/24 Carafate Oral Suspension 10ml (milliliter) four times daily, scheduled at
10:00 AM, administered at 12:03 PM, which is 2 hours and 3 minutes late
On 01/22/24 at 3:00 PM, the Director of Nursing (DON) was notified and confirmed the administration was late. The DON stated, we are working on getting things corrected.
g) Resident #126
On 01/22/24 at 12:15 PM, a record review was completed for Resident #126. A review of the Medication Administration Audit report from 01/12/24 through 01/22/24 found late administration times for the following physician's orders:
--01/14/24 Hydroclorothiazide (HCTZ) 25mg two times daily, scheduled at 2:00 PM, administered at 5:46 PM, which is 3 hours and 46 minutes late
--01/14/24 Metaxalone 800mg every 8 hours, scheduled at 2:00 PM, administered at 5:46 PM, which is 3 hours and 46 minutes late
--01/14/24 Carbidopa-Levodopa 25-100mg three times daily, scheduled at 2:00 PM, administered at 5:46 PM, which is 3 hours and 46 minutes late
--01/19/24 Famoidine 10mg daily, scheduled at 10:00 AM, administered at 10:46 PM, which is 12 hours and 46 minutes late
--01/19/24 Carbidopa-Levodopa 25-100mg three times daily, scheduled at 10:00 AM, administered at 10:45 PM, which is 12 hours and 45 minutes late
--01/19/24 Miralax 17gr (gram) daily, scheduled at 10:00 AM, administered at 10:46 PM, which is 12 hours and 46 minutes late
--01/19/24 Heparin Injection 40mg/0.4ml daily, scheduled at 10:00 AM, administered at 10:45 PM, which is 12 hours and 45 minutes late
--01/19/24 Senna S 8.6-50mg two times daily, scheduled at 10:00 AM, administered at 10:46 PM, which is 12 hours and 46 minutes late
--01/19/24 HCTZ 25mg two times daily, scheduled at 10:00 AM, administered at 10:46 PM, which is 12 hours and 46 minutes late
--01/19/24 Metaxalone 800mg every 8 hours, scheduled at 10:00 AM, administered at 10:46 PM, which is 12 hours and 46 minutes late
--01/19/24 Carbidopa-Levodopa 25-100mg three times daily, scheduled at 10:00 AM, administered at 10:46 PM, which is 12 hours and 46 minutes late
--01/20/24 Carbidopa-Levodopa 25-100mg three times daily, scheduled at 10:00 AM, administered at 5:16 PM, which is 7 hours and 16 minutes late
--01/20/24 Famotidine 10mg daily, scheduled at 10:00 AM, administered at 5:16 PM, which is 7 hours and 16 minutes late
--01/20/24 Senna S 8.6-50mg two times daily, scheduled at 10:00 AM, administered at 5:16 PM, which is 7 hours and 16 minutes late
--01/20/24 HCTZ 25mg two times daily, scheduled at 10:00 AM, administered at 5:16 PM, which is 7 hours and 16 minutes late
On 01/22/24 at 3:00 PM, the Director of Nursing (DON) was notified and confirmed the administration was late. The DON stated, we are working on getting things corrected.
h) RSV immunization
A review of the facility documents regarding immunizations, found zero (0) out of 141 residents had been provided educational information about the risk and benefits of receiving the RSV vaccination.
On 01/23/24 at 11:25 AM, Infection Preventionist (IP) stated she was not aware she needed to do anything about the RSV vaccine. She went on to say she just started this job as IP in September.
h-1) The Centers for Disease Control and Prevention (CDC)
Respiratory syncytial virus, or RSV, is a common respiratory virus that usually causes mild, cold-like symptoms. Most people recover in a week or two, but RSV can be serious. Infants and older adults are more likely to develop severe RSV and need hospitalization. Vaccines are available to protect older adults from severe RSV. Monoclonal antibody products are available to protect infants and young children from severe RSV.
CDC recommends RSV vaccines to protect adults ages 60 and older from severe RSV, using shared clinical decision-making.
According to the CDC the RSV vaccine was made available on early August of 2023.
In general, simultaneous administration of vaccines remains a best practice. Providers should continue to simultaneously administer the vaccines for which a patient is eligible, including COVID-19, influenza, and pneumococcal vaccines. Simultaneous administration of RSV vaccine with other vaccines for older adults is also acceptable. When deciding whether to simultaneously administer other vaccines with RSV vaccine on the same day, providers should consider whether the patient is up to date with recommendations for currently recommended vaccines, the feasibility of administering additional vaccine doses later, risk for acquiring vaccine-preventable disease, vaccine reactogenicity profiles, and patient preferences.
Above information was taken from the website: Centers for Disease Control and Prevention
i) Resident #16
A review of the facility documents called, Medication Admin Audit Report, found that on the following days Resident #16 did not receive her medication within the standard practice time frame.
On 01/08/24 the medication Reglan was ordered to be given four (4) times a day for nausea, possible gastroparesis. The scheduled time to be given was 9:00 AM but was not given until 11:37 AM. The next dose was scheduled to be given at 1:00PM and was not given until 4:00 PM.
j) Resident #14
A review of the facility document called, Medication Admin Audit Report, found on the following days Resident #16 did not receive her medication within the standard of practice time frame.
On 01/12/24 Lantus Solostar Insulin was scheduled to be given at 9:00 PM and was not given until 01/13/24 at 4:39 AM.
On 01/12/24 Reglan was scheduled to be given at 9:00 PM and was not given until 01/13/24 at 4:39 AM.
On 01/12/24 Melatonin (given for insomnia) was scheduled to be given at 9:00 PM and was given at 4:39 AM on 01/13/24.
On 01/12/24 Oxycodone was scheduled to be given at 9:00 PM and was not given until 4:39 AM on 01/13/24. This medication was given again on 01/13/24 at 6:00 AM.
On 01/12/24 Hydroxyzine HCL (given for anxiety and to be given at bedtime) was scheduled to be given at 9:00 PM, was not given until 01/13/24 at 4:36 AM.
Zanaflex to be given three (3) times a day for neck pain. This was scheduled to be given on 01/12/24 at 10:00 PM and was not given until 01/13/24 at 4:39 AM.
Gabapentin to be given every eight (8) hours. This was scheduled for 01/12/24 at 10:00 PM and was not given until 4:39 AM on 01/13/24. This medication was given again on 01/13/24 at 6:00 AM. There were not eight (8) hours between times it was given.
Hydralazine was ordered to be given every eight (8) hours for hypertension. On 01/12/24 it was scheduled for 10:00 PM and was not given until 4:39 AM on 01/13/24. This medication was given again on 01/13/24 at 6:00 AM. There were not eight (8) hours between times it was given.
On 01/23/24 at 2:10 PM, the Director of Nursing (DON) was asked if she had reviewed the Medication Administration Audit forms which was provided to the survyor? The DON said yes. DON was asked if she was aware of the medication that was given late. The DON said yes and that the nurses were told to call the physician and document the physician gave an order to give late.
On 01/23/24 at 5:00 PM the DON was asked to find the nursing notes which correspond with the dates and times of the medication mentioned above.
On 01/24/24 at 10:00 AM the DON reported there were not any nursing notes about the late medications and could not provide any information on if the physician was made aware of the late medications.
k) Resident #14 medications not available
A review of the medical record for Resident #14 found many nursing notes stating medications were not available for administration. The notes were as follows:
Resident #14 was admitted to the facility on [DATE].
On 12/28/23 at 4:17 PM Licensed Practical Nurse (LPN) #180 wrote the medication Reglan cannot be administered because the medication was not available. This medication is used to relieve the symptoms of slow stomach emptying in people with diabetes.
LPN #180 wrote the medication Reglan could not be administered on 12/28/23 at 1:01 PM due to not being available.
On 01/04/24 at 6:23 PM LPN #73 wrote the medication Epoetin Alfa was unavailable and was reordered. This medication is used to help your body make more red blood cells (treatment for anemia).
On 01/05/24 at 10:32 PM Unit Manager #183 wrote the medication Lantus SoloStar was not available to administer and was reordered. This medication is used to control the levels of glucose in the blood.
Also, at this time on 01/05/24 UM #183 wrote the medication used for urinary health called Tamsulosin was also not available.
Also, the medication Ropinirole used for tremors was not available at the same time as the above mentioned medication.
On 01/18/24 at 3:14 PM, LPN #30 wrote the medication Epoetin Alfa was again not available.
On 01/19/24 at 11:23 PM Registered Nurse (RN) #124 wrote the following nursing note: Typed as written:
Lantus Solostar subcutaneous Solution Pen-injector 100 units/ml.
Inject 18 units subcutaneously at bedtime for DM medication not on hand. Med fridge checked. Medication reordered.
On 01/23/24 at 2:10 PM, the DON was asked about the medications not being available and she said it may take time to get them here from the pharmacy if they are new admits. A review of the medical chart found Resident #14 was out of the facility on 01/02/24 for a few hours in the early part of that day but returned before midnight of 01/02/24.
l) Resident #59
Resident #59 was admitted to the facility on [DATE].
Nursing notes revealed that the following medication were not available on the following dates and times:
-- On 01/20/24 at 5:40 AM, Levothyroxine used for hypothyroidism was not available.
--On 01/20/24 at 3:42 PM, Levothyroxine was not available.
--On 01/20/24 at 4:58 PM, Abacavir Sulfate is an antiretroviral used to treat HIV to keep the viral load down, was unavailable
--On 01/20/24 at 10:25 PM Etravirine is an antiretroviral medication and was not available.
--On 01/21/24 at 12:58 AM dronabinal used for appetite stimulate was not available.
--On 01/22/24 at 4:36 PM, Abacavir Sulfate is an antiretroviral used to treat HIV to keep the viral load down was not available.
--On 01/23/24 at 10:36 AM, Abacavir Sulfate is an antiretroviral used to treat HIV to keep the viral load down was not available.
--On 01/23/24 at 10:37 AM, Etravirine is an antiretroviral medication and was not available.
--On 01/23/24 at 10:37 AM, Dolutegravir Sodium, an anti-viral was not available.
--On 01/23/24 at 10:36 AM, Etravirine is an antiretroviral medication and was not available.
During an interview, with the DON on 01/23/24 at 4:10 PM, the DON stated, Sometimes it takes a while for the pharmacy to deliver the mediation.
According to HIV. Gov, Missing doses of HIV medicines can reduce their usefulness and increase the possibility of developing drug resistance, which makes certain HIV drugs lose their effectiveness.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
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Based on medical record review and staff interview the facility failed to have a care plan addressing the provision of meals before, during and/or after dialysis treatments. This was true for one (1...
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Based on medical record review and staff interview the facility failed to have a care plan addressing the provision of meals before, during and/or after dialysis treatments. This was true for one (1) of one (1) resident reviewed for dialysis treatment during a complaint survey. Resident identifier:#68. Facility census: 141.
Findings included:
a) Resident #68.
Medical record review of Resident #68's medical record found a physician's order for: Dialysis every Tuesday, Thursday, and Saturday with chair time at 6:40 am.
Continued review of the residents (resident's) dialysis care plan found there was no provision of meals before, during and/or after dialysis treatments.
During an Interview with the Director of Nursing (DON) on 1/24/24 at 10:23 AM, she verified there was no dialysis meal plan for dialysis days in Resident #68's care plan.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
.
Based on record review and staff interview, the facility failed to ensure medical records were accurate and complete. This is true for two (2) of three (3) residents reviewed under the care area of ...
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Based on record review and staff interview, the facility failed to ensure medical records were accurate and complete. This is true for two (2) of three (3) residents reviewed under the care area of discharges. Resident Identifiers: #66 and #31. Facility Census: 141.
Findings Include:
a) Resident #66
On 01/23/24 at 11:00 AM, a record review was completed for Resident #66. The review found the resident had been transferred to an acute care facility on 01/23/24 at 9:20 AM. However, the transfer form indicates the resident was transferred on 12/19/23 at 9:27 AM.
On 01/23/24 at 2:20 PM, the Director of Nursing was interviewed and was asked when the resident got transferred to the acute care facility. DON stated the transfer date on the form was incorrect. The DON stated, I have never noticed that before .the documentation is showing the last time the resident was sent out to the acute care facility.
b) Resident #31
1) On 01/23/24 at 11:45 AM, a record review was completed for Resident #31. The review found the resident had been transferred to an acute care facility on 12/07/23 at 10:00 PM. However, the transfer form indicates the resident was transferred on 02/22/20 at 9:50 AM.
On 01/23/24 at 2:20 PM, the Director of Nursing was interviewed and asked when did the resident get transferred to the acute care facility? DON stated the transfer date on the form was incorrect. The DON stated, I have never noticed that before .the documentation is showing the last time the resident was sent out to the acute care facility.
2) On 01/23/24 at 12:00 PM, a record review was completed for Resident #31. The review found the resident had been transferred to an acute care facility on 01/03/24 at 5:26 PM. However, the transfer form indicates the resident was transferred on 12/07/23 at 10:26 PM.
On 01/23/24 at 2:20 PM, the Director of Nursing was interviewed and asked when did the resident get transferred to the acute care facility? DON stated the transfer date on the form was incorrect. The DON stated, I have never noticed that before .the documentation was showing the last time the resident was sent out to the acute care facility.
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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
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Based on observation and staff interview, the facility failed to ensure the resident environment remains as free of accident hazards as possible. This was a random opportunity for discovery and had ...
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Based on observation and staff interview, the facility failed to ensure the resident environment remains as free of accident hazards as possible. This was a random opportunity for discovery and had the potential to affect a limited number of residents. Facility census: 141
Findings included:
a) During a tour of the facility on 1/23/24 at 1:24 PM the egress directly in front of the emergency exit door on unit EB2 off from the dining room and activity area was fully blocked by large dietary carts and a large trash can. During an interview with the Activities Director (AD) #19 on 1/23/24 at 1:27 PM, AD#19 acknowledged the emergency door exit was completely blocked and acknowledged this was not safe in the event of an emergency for evacuation. AD #19 immediately began moving the items away from the blocked emergency 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
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
.
Based on observation and staff interview the facility failed to prepare food in accordance with professional standards for food service safety related to, sanitary conditions and the prevention of f...
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Based on observation and staff interview the facility failed to prepare food in accordance with professional standards for food service safety related to, sanitary conditions and the prevention of foodborne illness. This has the potential to affect all residents that get their nutrition from the kitchen. Facility census: 141.
Findings include:
a) Kitchen
Tour of the kitchen on 1/23/24 at 10:00 AM with the Dietary Manager found the steam table and lids and plate warmer was heavily soiled, with grease build up, and old food debris. Continued tour revealed 2 maintenance workers, working in the kitchen on the plate warmer without hair coverings.
During an interview on 1/23/24 at 10:00 AM the Dietary Manager, confirmed the steam table with lids and plate warmer was heavily soiled, with grease build up, and old food debris. She also verified the Maintenance workers were working on the plate warmer in the food preparation area without hair coverings.
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
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
.
Based on observation and staff interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment an...
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Based on observation and staff interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This failed practices was a random opportunity for discovery while observing medication pass. Resident identifiers: #120. Facility census 141.
Findings include:
a) Resident #120
On 01/23/23 at 8:40 AM Licensed Practical Nurse (LPN) #108 was pulling medication for Resident #120 and dropped a pill on the med-cart. There was not a barrier on the cart and LPN #108 picked up the pill without donning a glove and put the pill in the cup with the other medications. LPN #108 gave all of the pills in the cup to Resident #120.
This is the list of medications given:
Fexofenadine 180 mg
Metoprolol 50 mg
Myrbetrig 25 mg
Valsartan 160 mg
When asked, LPN #108 agreed she should have not picked the pill up with a bare hand.
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 F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on facility record review and staff interview the facility failed to offer the Pneumococcal vaccine when eligible. This ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on facility record review and staff interview the facility failed to offer the Pneumococcal vaccine when eligible. This was true for four (4) out of five (5) reviewed for immunizations. Resident identifiers: #143, #19, #100, and #120. Facility census: 141.
Findings include:
a) Pneumococcal vaccine
Resident #143 was admitted on [DATE] and a review of the medical records found this resident received Pneumonia vaccine 23 on 10/12/12.
Resident #19 was admitted on [DATE] and a review of the medical records revealed Resident #19 received the following Pneumococcal vaccines. The PREVNAR (PVC) 13 was given on 09/2016, Pneumococcal (PNX) on 12/2009, Pneumococcal Polysaccharide (PPSV 23) on 05/2015.
Resident #100 was admitted on [DATE] and had nothing listed for pneumococcal vaccines.
Resident #120 was admitted on [DATE] and did not have anything listed as past vaccinations.
On 01/23/24 at 11:15 AM, the IP was asked about the four (4) residents mentioned above and their pneumococcal vaccines. It was pointed out that all residents were eligible for the PVC 20. The IP left to review their histories and returned on 01/23/24 at 2:02 PM and confirmed all the residents mentioned above should have been offered the PVC 20.
The CDC recommends giving the PVC 20 if it has been five (5) years or more since PVC 13 or PVC 23 has been given.
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
Staffing Information
(Tag F0732)
Could have caused harm · This affected most or all residents
.
Based on observation and staff interview, the facility failed to ensure the Daily Staffing Posting information was accurate and current and the facility failed to maintain the Daily Staffing Posting...
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Based on observation and staff interview, the facility failed to ensure the Daily Staffing Posting information was accurate and current and the facility failed to maintain the Daily Staffing Posting data for a minimum of 18 months. This was a random opportunity for discovery and had the potential to affect all resident currently residing at the facility. Facility Census 141
Findings included:
a) Accurate and current data
On 1/23/24 (01/23/24) at 10:00 AM, during a review of the facilities Daily Staffing Posting and the Daily Punches data for all direct care staff, the following discrepancies were identified with the total number of direct care hours being reported on the Daily Staffing Posting for 11/03/23, 11/16/23 and 1/19/24.
-- 11/03/23 Daily Punches data for all direct care staff was 413.25 hours and the Daily Staffing Posting reported a total of direct care hours being 443.25, an inaccuracy of 30 hours.
-- The 11/16/23 Daily Punches data for all direct care staff was 430.25 hours and the Daily Staffing Posting reported a total of direct care hours being 507.75 hours, an inaccuracy of 77.5 hours.
-- The 1/19/24 Daily Punches data for all direct care staff was 383 hours and the Daily Staffing Posting reported a total of direct care hours being 457.25, an inaccuracy of 74.25 hours.
During an interview with the Administrator on 1/23/24 at 11:05AM, the Administrator denied knowing why the direct care staff hours would be different and stated both the Daily Staffing Posting Forms and the Daily Punches Data come from the same system. She further stated there was nothing else she could provide to explain why the Daily Staffing Posting Form is reflecting inaccurate direct care staff hours for 11/03/23, 11/16/23 and 1/19/24. No further information was provided.
b) Accurate and current data
On 1/23/24 at 11:10AM during an interview with the Administrator, the Unit Manager RN (Registered Nurse) and the Unit Manager LPN (Licensed Practical Nurse) Daily Punches Data was reviewed as this data identifies the entire shifts for the Unit manager RN and Unit Manager LPN to be solely direct care.
A request was made for supportive documentation for the Unit Manager RN and the Unit Managers LPN which identifies the specific hands on care they provided for their entire shifts on 11/03/23, 11/16/23 and 1/19/24. The Administrator replied she already had this conversation with other surveyors during the facilities previous survey. She stated she had told them she is permitted to use their daily scheduled hours towards the direct care hours even though they are categorized as administrative staff.
On 1/23/24 at 1:15 PM, the Labor Classification/ Job Title section of the Centers for Medicare & Medicaid Services- Electronic Staffing Data Submission- Payroll-Based Journal- Long-Term Care Facility- Policy Manual Version 2.6 was reviewed with the Administrator. This section defines that the Labor Classification/Job Title Reporting shall be based on the employee's primary role and their official categorical title. It is understood that most roles have a variety of non-primary duties that are conducted throughout the day (e.g., helping out others when needed). Facilities shall still report just the total hours of that employee based on their primary role. CMS recognizes that staff may completely shift primary roles in a given day. For example, a nurse who spends the first four hours of a shift as the unit manager, and the last four hours of a shift as a floor nurse. In these cases, facilities can change the designated job title and report four hours as a nurse with administrative duties, and four hours as a nurse (without administrative duties). The Administrator acknowledged her understanding and left the room.
At 11:40AM on 1/23/24, the Administrator provided a job description for a Unit Manager upon hire. No further information was provided for the requested supportive documentation for the specific hands on care task performed by the Unit Manager RN and Unit Manager LPN's for the reported shifts identified in the Daily Punches data for 11/03/23, 11/16/23 and 1/19/24.
c) Maintain the posted daily nurse staffing data for a minimum of 18 months
During an interview with the DON on 1/24/24 at 10:18AM the Daily Staffing Posting that is updated in real time with the staffing call-outs/illnesses was requested for review for 11/03/23, 11/16/23 and 01/19/24.
On 1/24/24 at 10:51 the Administrator stated the scheduler was not there yet, but she would get it. On 1/24/24 at 12:00 PM the Administrator returned with a printed duplicate copy of the Daily Staffing Posting which had already been provided to the surveyor. Upon review, the Daily Staffing Posting provided did not identify the staff absences due to call-outs/illnesses as requested for 11/03/23, 11/16/23 and 01/19/24.
Per the Administrators request it was clarified the original Daily Staffing Form document that was posted would have written altered changes which were made in real time to identify any staff absences due to call-outs/illnesses. These staff absences for call-outs/illnesses are identified in the facility Daily Attendance Reports for 11/03/23, 11/16/23 and 1/19/24. The Administrator stated the scheduler enters any changes marked on the original Daily Staffing Postings into the computers data system and updates the total staffing hours on the Daily Staffing Postings for the previous shifts. The Administrator further stated that they do not keep the original Daily Staffing Postings, which reflects the written altered changes that were made in real time to identify any staff absences due to call-outs/illnesses. It was further acknowledged the updated Daily Staffing Posting did not identify actual staff absences due to call-outs/illnesses.
Nov 2023
7 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
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Based on observation and staff interview, the facility failed to provide a dignified dining experience for Resident #8. This was a random opportunity for discovery. Resident Identifier: #8. Facility...
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Based on observation and staff interview, the facility failed to provide a dignified dining experience for Resident #8. This was a random opportunity for discovery. Resident Identifier: #8. Facility Census:143.
Findings Included:
a) Resident #8
On 11/06/23 at 12:24 PM, multiple residents were being observed during the noon meal. Licensed Practical Nurse (LPN) #155 was observed standing while feeding Resident #8.
On 11/06/23 at 12:35 PM, the Assistant Executive Director #76 was notified and confirmed no one should be standing while feeding a resident.
No further information was obtained during the survey process.
.
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
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
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Based on interview, record review and policy review the facility failed to make prompt efforts to resolve a grievance and to keep the resident notified of progress toward a resolution. This was true...
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Based on interview, record review and policy review the facility failed to make prompt efforts to resolve a grievance and to keep the resident notified of progress toward a resolution. This was true for two (2) of four (4) grievances reviewed during the complaint survey. Resident identifiers: #1. Facility census: 143.
Findings Included:
a) Policy Review
Record review of the facility's policy titled, Resident Grievance, showed:
-The Grievance Official shall complete an investigation of the Resident Grievance.
-The grievance review will be completed in a reasonable time frame consistent with the type of grievance.
-The Grievance Official will meet with the resident and inform the resident of the result of the investigation and how the resident's grievance was resolved or will be resolved, if applicable.
b) Hearing Aids
During an interview on 11/06/23 at 12:55 pm, Resident #1 verified her Hearing Aids were missing.
On 11/05/23 at 3:00 PM during an interview with Resident #1's Medical Power of Attorney stated that the facility lost her Hearing Aids in February 2023, and they have never replaced them. She stated she has reported the hearing aids missing multiple times to the Social Worker and Business office Manager.
A record review of grievances found a grievance form filled out on 2/23/23 reporting Resident #1's missing hearing aids. The recommendation on the form revealed Patient has insurance to cover replacement if not found, Center will facilitate as needed. The resolution marked resolved, Facility will replace them.
Continued review revealed an invoice sent from (A local hearing aide provider) for 2 hearing aids on 04/26/2023.
Subsequent record review found an Internal Check Request dated 10/17/23 to the (A local hearing aid provider).
During an interview on 11/06/23, at 3:38 PM the Business Office Manager stated she was aware Resident #1 was missing her hearing aids and had not received them yet. She stated, she requested a check in October 2023 to replace the hearing Aids.
b) Dentures
During a complaint investigation about missing dentures on 11/06/23 revealed, Resident #1 had top dentures in place with no lower dentures. Resident #1 verified her lower dentures were missing.
On 11/05/23 at 3:00 PM during an interview Resident #1s Medical Power of Attorney stated, the facility lost her lower dentures about a year ago, and they have never replaced them. She stated she has reported the dentures missing multiple times to the Social Worker and Business office Manager.
Medical record review on 11/07/23, showed a Long-Term Care Evaluation dated 10/01/22 Nutrition section confirmed, Resident #1 had Upper and Lower Dentures.
During an interview on 11/06/23, at 3:38 PM the Business Office Manager stated, she was aware Resident #1 was missing her bottom dentures for about a year. She stated the BOM prior to her, was working on filling out forms for a Rep Payee and funding to get the lower dentures replaced. She continued to state she also has had multiple conversations with Resident #1's Medical Power of Attorney about the missing Dentures.
No other information was provided prior to the end of the survey on 11/07/23 at 4:00 PM.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to remove the use of hearing aids for Resident #1 in the Minimum Data Set (MDS). This is true for one (1) of eight (8) residents reviewe...
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Based on record review and staff interview, the facility failed to remove the use of hearing aids for Resident #1 in the Minimum Data Set (MDS). This is true for one (1) of eight (8) residents reviewed during the survey process. Resident identifier: #1. Facility Census: 143.
Findings included:
a) Resident #1
On 11/07/23 at 12:00 PM, a record review was completed for Resident #1. The review found the MDS with the assessment reference date (ARD) of 10/16/23 was incorrect regarding hearing, speech, and vision in Section B. Section B stated the resident had moderate difficulty hearing and the use of hearing aids. However, the resident's hearing aids had not been used since February 2023 because they were lost at the facility.
On 11/07/23 at 1:20 PM, the MDS Registered Nurse (RN) #126 confirmed the MDS with an ARD of 10/16/23 was incorrect. The MDS RN #126 stated, I thought the hearing aids had been replaced .she went out for an appointment.
No further information was obtained during the survey process.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
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Based on record review, and staff interview, the facility failed to ensure a Resident had a person-centered comprehensive care plan developed and implemented to meet his / her preferences and goals ...
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Based on record review, and staff interview, the facility failed to ensure a Resident had a person-centered comprehensive care plan developed and implemented to meet his / her preferences and goals and address the resident's physical needs. This practice had the potential to effect more than a limited number of Residents. Resident identifier: #1. Facility census 143.
Findings Included:
a) Resident #1
An observation during a complaint investigation about missing dentures on 11/06/23 revealed Resident #1 had top dentures in place.
Medical record review on 11/07/23, showed a Long-Term Care Evaluation dated 10/01/22 Nutrition section:
--Upper and Lower Dentures
Further review of Resident #1's medical record revealed the care plan (an overview of resident care for nursing staff) did not contain an intervention for Dentures.
During an interview, on 11/07/23 at 1:21 PM, the Minimum Data Set Nurse (MDS-N) #126, confirmed the facility failed to develop a care plan related to dental or denture care for Resident #1. She verified Resident #1's care plan was incomplete without dental or denture care.
No other information was provided prior to the end of survey on 11/07/23 at 4:00 PM
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to revise a comprehensive care plan for Resident #1. This is true for one (1) of eight (8) residents reviewed during the survey proces...
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Based on record review and staff interview, the facility failed to revise a comprehensive care plan for Resident #1. This is true for one (1) of eight (8) residents reviewed during the survey process. Resident identifier: #1. Facility Census: 143.
Findings Included:
a) Resident #1
On 11/06/23 at 2:00 PM, a record review was completed for Resident #1. The review found the care plan listed a focus area of potential for communication problem due to patient having hearing problems. The interventions listed are as follows:
--Change batteries to hearing aids as needed.
--Ensure patient has hearing aids in (Bilateral) ears.
However, the resident's hearing aids had been missing since February 2023.
On 11/07/23 at 1:20 PM, the Minimum Data Set (MDS) Registered Nurse (RN) #126 confirmed the care plan had not been revised since the loss of the resident's hearing aids. The MDS RN #126 stated, I thought the hearing aides had been replaced .she went out for an appointment.
No further information was obtained during the survey process.
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 F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
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Based on observation, resident interview, staff interview, and record review the facility failed to ensure proper treatment related to a hearing impairment for one (1) of two (2) resident in the car...
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Based on observation, resident interview, staff interview, and record review the facility failed to ensure proper treatment related to a hearing impairment for one (1) of two (2) resident in the care area of communication / sensory. Resident identifier: #1. Facility census: 143.
Findings include:
a) Resident #1
During an interview on 11/06/23 at 12:55 Pm, Resident #1 verified her Hearing Aids were missing.
On 11/05/23 at 3:00 PM during an interview with Resident #1s Medical Power of Attorney stated, the facility lost her Hearing Aids in February 2023, and never replaced them. She stated she had reported the hearing aids missing multiple times to the Social Worker and Business office Manager.
A record review of grievances found a grievance form filled out on 02/23/23 reporting Resident #1's missing hearing aids. The recommendation on the form revealed, Patient has insurance to cover replacement if not found, Center will facilitate as needed. The resolution was marked resolved, Facility will replace them.
Continued review revealed an invoice sent from (A local Hearing Aide Provider) for 2 hearing aids on 04/26/2023.
Subsequent record review found an Internal Check Request dated 10/17/23 to the (Name of a local hearing aid provider).
During an interview, on 11/06/23, at 3:38 PM, the Business Office Manager stated she was aware Resident #1 was missing her hearing aids and had not received them yet. She stated, she requested a check in October 2023 to replace the hearing Aids.
No other information was provided prior to the end of survey on 11/07/23 at 4:00 PM.
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 F0790
(Tag F0790)
Could have caused harm · This affected 1 resident
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Based on record review, and staff interview, the facility failed to assist with replacing a Resident's missing Lower dentures in a timely manner. This is true for one (1) of two (2) reviewed for mis...
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Based on record review, and staff interview, the facility failed to assist with replacing a Resident's missing Lower dentures in a timely manner. This is true for one (1) of two (2) reviewed for missing dentures. Resident identifier: #1. Facility census 143.
Findings included:
a) Resident #1
An observation during a complaint investigation about missing dentures on 11/06/23 found Resident #1 had top dentures in place with no lower dentures. Resident #1 verified her lower dentures were missing.
On 11/05/23 at 3:00 PM, during an interview Resident #1's Medical Power of Attorney stated, the facility lost her lower dentures about a year ago, and they had never replaced them. She stated she had reported the dentures missing multiple times to the Social Worker and Business office Manager.
Medical record review on 11/07/23, showed a Long-Term Care Evaluation dated 10/01/22 Nutrition section confirmed, Resident #1 had Upper and Lower Dentures.
During an interview on 11/06/23, at 3:38 PM the Business Office Manager stated, she was aware Resident #1 was missing her bottom dentures for about a year. She stated the BOM prior to her, was working on filling out forms for a Rep Payee and funding to get the lower dentures replaced. She continued to state she had multiple conversations with Resident #1's Medical Power of Attorney about the missing Dentures.
No other information was provided prior to the end of survey on 11/07/23 at 4:00 PM.
Sept 2023
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
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to making prompt efforts to resolve a grievance and to keep the resident notified of progress toward resolution. This is true for one (2) of th...
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Based on interview and record review the facility failed to making prompt efforts to resolve a grievance and to keep the resident notified of progress toward resolution. This is true for one (2) of three (3) reviewed during a complaint Survey. Resident identifier: #70. Facility census: 141.
Findings included:
a) Resident #70
During an interview with Resident #70 on 09/05/23 at 2:20 PM she revealed she did not get his showers as they were scheduled. She stated that most of the time her family must call and complain before she receives showers. She stated her son had to call today because she had not received her shower today. At 2:29 PM during this interview two (2) Nurse Aids entered the room and told Resident #70 they were there to take her to the shower.
Medical record review revealed, Resident #70's shower schedule and preference was two (2) times weekly.
A continued record review of Resident #70's Quarterly 06/09/23 Minimum Data Set (MDS), found the resident's brief interview for mental status was fifteen (15) the highest score obtainable. MDS section G (Functional Status) indicates Total Dependence with bathing. MDS Section E (Behaviors) also indicated Resident #70 does not reject care.
On 02/01/22 a record review of grievances from March 2023 through current revealed No concerns form Resident #70 or Resident #70 family regarding not receiving showers was documented.
During an interview with Social Services #117 on 09/06/23, at 3:42 pm, she stated that she has received multiple complaints and concerns from Resident #70 and Resident #70's Family members about her not receiving showers. SS #117 verified a grievance form was filled out.
Interview on 09/06/23 at 4:11 PM with the Director of nursing verified they have tried working with the resident and family about Resident #70's grievance about missing showers, many times.
No other information was provided prior to the end of the survey on 09/07/23.
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
Based on observation, staff interview, and operation policy the facility failed to report alleged violation related to, neglect and report the results of all investigation to the proper authorities wi...
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Based on observation, staff interview, and operation policy the facility failed to report alleged violation related to, neglect and report the results of all investigation to the proper authorities within a prescribed time frame. This is true for one (1) of three (3) allegations of abuse. Resident identifier: #70. Facility census: 141
Findings included:
a) Resident #70
Record review of the facility's policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, showed:
Neglect: Neglect is the failure of the facility, its employees, or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional destress .
-Investigation of an incident:
-An event may not be perceived by staff to constitute resident abuse, neglect, or misappropriation of resident property; however. If a resident, family member or visitor perceives an event to be abuse, neglect, or misappropriation, the facility must report the event.
-The Executive Director / Designee will report appropriate incidents to Adult Protective services (APS), Office of Health Facility Licensure & Certification (OHFLAC) and State or regional Long-Term Care Ombudsman, and other local authorities, including but not limited to local law enforcement (if appropriate), as required by state law.
-Allegations of resident abuse, neglect, and misappropriation of resident property, where the alleged perpetrator is nurse aide whose identity is known, are to be immediately reported to OHFLAC's Nurse Aide Program.
Findings included:
a) Resident #70
During an Interview with Resident #70, on 09/05/23 at 2:20 PM, she revealed that she does not get his showers as scheduled. She stated most of the time her family must call and complain before she received showers. She stated her son had to call today, because she had not received her shower today. At 2:29 PM during this interview two (2) Nurse Aids entered the room and told Resident #70 they were there to take her to the shower.
Medical record review revealed, Resident #70's shower schedule and preference was two (2) times weekly.
A continued record review of Resident #70's Quarterly 06/09/23 Minimum Data Set (MDS), found the resident's brief interview for mental status was fifteen (15) the highest score obtainable. MDS section G (Functional Status) indicates Total Dependence with bathing. MDS Section E (Behaviors) also indicated Resident #70 does not reject care.
On 02/01/22 a record review of grievances from March 2023 through current revealed No concerns form Resident #70 or Resident #70 family regarding not receiving showers was documented.
During an interview with Social Services # 117 on 09/06/23, at 3:42 pm, she stated that she has received multiple complaints and concerns from Resident #70 and Resident #70's Family members about her not receiving showers. SS #117 verified No grievance form was filled out, no investigation or reportable was completed.
On 09/07/23 at 9:20 AM the Administrator and Director of Nursing (DON) verified there was no documentation showing Resident #70 received showers as scheduled.
Interview on 09/06/23 at 4:30 PM with the Administrator verified no reportable was completed.
No other information was provided prior to the end of the survey on 09/07/23.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on, Resident Interview, staff interview, and operation policy the facility failed to investigate an alleged violation related to, neglect, report the results of all investigation to the proper a...
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Based on, Resident Interview, staff interview, and operation policy the facility failed to investigate an alleged violation related to, neglect, report the results of all investigation to the proper authorities within a prescribed time frames. This is true for one (1) of three (3) allegations of abuse. Resident identifier: #70. Facility census: 141.
Findings Included:
Record review of the facility's policy titled, Abuse, Neglect, Exploitation & Misappropriation of Resident Property, showed:
Neglect: Neglect is the failure of the facility, its employees, or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional destress.
-Investigation of an incident:
-An event may not be perceived by staff to constitute resident abuse, neglect, or misappropriation of resident property; however. If a resident, family member or visitor perceives an event to be abuse, neglect, or misappropriation, the facility must report the event.
-The Executive Director / Designee will report appropriate incidents to Adult Protective services (APS), Office of Health Facility Licensure & Certification (OHFLAC) and State or regional Long-Term Care Ombudsman, and other local authorities, including but not limited to local law enforcement (if appropriate), as required by state law.
-Allegations of resident abuse, neglect, and misappropriation of resident property, where the alleged perpetrator is nurse aide whose identity is known, are to be immediately reported to OHFLAC's Nurse Aide Program.
Findings Included:
a) Resident #70
During an Interview with Resident #70 on 09/05/23 at 2:20 PM she revealed that she does not get his showers per scheduled. She stated that most of the time her family must call and complain before she receives showers. She stated that her son had to call today, because she had not received her shower today. At 2:29 PM during this interview two (2) Nurse Aids entered the room and told Resident #70 they were there to take her to the shower.
Medical record review revealed, Resident #70's shower schedule and preference is two (2) times weekly.
A continued record review of Resident #70's Quarterly 06/09/23 Minimum Data Set (MDS), found the resident's brief interview for mental status was fifteen (15) the highest score obtainable. MDS section G (Functional Status) indicates Total Dependence with bathing. MDS Section E (Behaviors) also indicated Resident #70 does not reject care.
On 02/01/22 record review of grievances from March 2023 through current revealed No concerns form Resident #70 or Resident #70 family regarding not receiving showers was documented.
During an interview with Social Services (SS) Employee #117 on 09/06/23, at 3:42 pm, she stated that she received multiple complaints and concerns from Resident #70 and Resident #70's Family members about her not receiving showers. SS #117 verified a grievance form was filled out, no investigation or reportable was completed.
On 09/07/23 at 9:20 AM the Administrator and Director of Nursing (DON) verified there was no documentation showing Resident #70 received showers as scheduled.
Interview on 09/06/23 at 4:30 PM with the Administrator verified no reportable was completed.
No other information was provided prior to the end of the survey on 09/07/23.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, record review, resident and staff interview, the facility failed to assist dependent Residents with activities of daily living (ADL's) in accordance with the Residents assessed n...
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Based on observation, record review, resident and staff interview, the facility failed to assist dependent Residents with activities of daily living (ADL's) in accordance with the Residents assessed needs for care. This was true for two (2) of three (3) residents reviewed for ADL care. Resident identifiers: #70 and #124. Facility census: 141.
Findings Included:
a) Resident #70
During an interview with Resident #70 on 09/05/23 at 2:20 PM she revealed that she does not get his showers per scheduled. She stated that most of the time her family must call and complain before she receives showers. She stated that her son had to call today, because she had not received her shower today. At 2:29 PM during this interview two (2) Nurse Aids entered the room and told Resident #70 they were there to take her to the shower.
Medical record review revealed, Resident #70's shower schedule and preference is two (2) times weekly.
A continued record review of Resident #70's Quarterly 06/09/23 Minimum Data Set (MDS), found the resident's brief interview for mental status was fifteen (15) the highest score obtainable. MDS section G (Functional Status) indicates Total Dependence with bathing. MDS Section E (Behaviors) also indicated Resident #70 does not reject care.
A review of Resident #70's Care Plan revealed,
Focus:
-Resident requires assistants with Activities of Daily Living (ADLs)
--Refuses showers and bed baths at times.
Revision on 05/11/2023
Goal:
--Resident will complete upper body ADL's daily after set up of supplies and assistance as needed through next review.
Interventions:
-- Bathing assist x1.
A continued review of Resident #70s ADL documentation found:
Four (4) Shower documented given for the month of June 2023.
No Refusals noted for the month of June 2023.
Two (2) Shower documented given for the month of July 2023.
No Refusals noted for the month of July 2023.
Six (6) Showers documented given for the month of August 2023.
No Refusals noted for the month of August 2023.
On 09/07/23 at 8:50 AM the Director of Nursing (DON) verified there was no documentation showing Resident #70 received showers as scheduled.
b) Resident #124
Observation on 09/05/23, at 12:30 PM in the dining room found Resident #124 with long chin hair and oily hair.
During an interview with Resident #124 on 09/05/23, at 1:25PM she stated that she does not want to have hair on her face and does not get showers often.
A continued record review of Resident #124's Quarterly 06/20/23 Minimum Data Set (MDS), found the resident's brief interview for mental status was twelve (12) meaning moderately impaired cognition. MDS section G (Functional Status) indicates physical help with transfers with bathing. MDS Section E (Behaviors) also indicated Resident #124 does not reject care.
A continued review of Resident #70s ADL documentation found:
One (1) Shower documented given for the month of June 2023.
No Refusals noted for the month of June 2023.
Three (3) Shower documented given for the month of July 2023.
No Refusals noted for the month of July 2023.
Four (4) Showers documented given for the month of August 2023.
No Refusals noted for the month of August 2023.
One (1) Showers documented given on 09/04/23.
No Refusals noted for the month of September 2023.
On 09/07/23 at 9:20 AM the Administrator and Director of Nursing (DON) verified there was no documentation showing Resident #124 received showers as scheduled.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, and record review, the facility failed to provide care and treatment in acco...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, and record review, the facility failed to provide care and treatment in accordance with physician's orders for one (1) of seven (7) residents reviewed. Resident #85 experienced a delay in diagnostic testing and the facility failed to ensure the physician had knowledge of the delay in services. Resident identifier: #85. Census: 141.
Findings included:
a) Resident #85
An interview, with Resident #85, on 09/05/23 at 11:45 AM, revealed the resident had fallen in the facility in July 2023 and sustained an ankle fracture.
Resident #85, was noted to have a brief Interview for Mental Status (BIMS of 15, identified on the 02/03/23 comprehensive assessment). A BIMS of 15 noted the resident was cognitively intact. Further interview, with Resident #85, revealed there was a long period of time from when the fall occurred until the ankle was X-rayed.
A record review showed, Resident #85 had a witnessed fall on 07/03/23 at 22:00 hours (10:00 PM). At this time the physician was notified of an order obtained for a STAT Xray, on an emergent basis, of the extremity by portable Xray.
Further record review noted the Xray was not obtained until 07/04/23 at 4:42 PM. The progress notes showed Resident #85 was transported to the hospital on [DATE] at 22:00 hours (10:00 PM) for Xray results indicating a displaced fracture of the lower leg.
An interview, with the Administrator, on 09/06/23 at 3:13 PM, revealed the Portable Xray service was notified on 07/03/23 but did not reach the facility until 4:42 PM on 07/04/23 and verified there was no evidence the staff consulted with the physician, since there was a delay in implementing the order.
An interview, with the Director of Nursing (DON), on 09/06/23 at 4:10 PM, verified the order should have been carried out on an immediate basis, however, when the service was delayed, the physician should have been consulted and there was no evidence this had occurred.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview, the facility failed to ensure a complete and accurate medical record. Specifically, shower documentation. This practice affected one (1) of three (3...
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Based on medical record review and staff interview, the facility failed to ensure a complete and accurate medical record. Specifically, shower documentation. This practice affected one (1) of three (3). Resident identifier #70. Facility census: # 141.
Findings included:
a) Resident #70
During an Interview with Resident #70 on 09/05/23 at 2:20 PM she revealed that she did not get showers as scheduled. She stated most of the time her family must call and complain before she received a shower. She stated her son had to call today, because she had not received her shower. At 2:29 PM during the interview two (2) Nurse Aides entered the room and told Resident #70 they were there to take her to the shower.
Medical record review revealed, Resident #70's shower schedule and preference was two (2) times weekly.
A continued record review of Resident #70's Quarterly 06/09/23 Minimum Data Set (MDS), found the resident's brief interview for mental status was fifteen (15) the highest score obtainable. MDS section G (Functional Status) indicates Total Dependence with bathing. MDS Section E (Behaviors) also indicated Resident #70 does not reject care.
A review of Resident #70s ADL documentation found documentation of a shower given on 09/05/23 at 12:54 PM prior to the time of this surveyor's interview and observation of two (2) Nurse Aids taking her to the shower.
Interview on 09/06/23 at 4:30 PM with the Administrator verified the documentation of the shower was 12:54 PM.
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 F0868
(Tag F0868)
Could have caused harm · This affected 1 resident
Based on facility documentation and staff interview the facility failed to have a certified Infection Preventionist (IP) attend and participate in the Quality Assessment and Assurance (QAA) meetings t...
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Based on facility documentation and staff interview the facility failed to have a certified Infection Preventionist (IP) attend and participate in the Quality Assessment and Assurance (QAA) meetings that worked at least part time in the facility. This failed practice had the potential to affect all residents residing at the facility. Facility Census: 141.
Findings included:
a) QAA
Record review of the facility's documentation of QAA Meeting Agenda and Minutes revealed no IP attended the meeting since May 2023.
During an Interview 09/06/23 at 1:38 PM Director of Nursing (DON) Stated that she and the assistant Director of Nursing (ADON) document all infections for residents in the facility, neither are IP certified. She continued to say that the facility has not had an IP since May 2023, she stated that the corporate consultant is available if they need her, she works at the corporate office.
No other information was provided prior to the end of the survey on 09/07/23.
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 and interview the facility failed to maintain compliance with an effective pest control program that would ensure that the facility is free of pests and rodents for one (1) out of...
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Based on observation and interview the facility failed to maintain compliance with an effective pest control program that would ensure that the facility is free of pests and rodents for one (1) out of three (3) medication supply rooms. This failed practice has the potential to affect more than an isolated number of residents within the facility. Facility census: 141.
Findings included:
a) Medication Supply Room Observation
An observation was conducted on 09/06/23 at 8:46 a.m. on Complex Transitional Care Unit #1 (CTC1) of the medication supply room. Staff #118 was present during the observation.
The medication supply room was dirty, and trash was overflowing in the garbage can. The counter tops were dirty with dust and stains on them. The floor had spills and stains on it.
There was a dead spider on the floor and spider droppings, cobwebs, and spider eggs behind the door.
When asked how often the room was cleaned Staff #118 stated at least once a week or more if needed. There were three (3) large boxes of outdated medications sitting in the room with an open lid. When ask how often is medication disposed of Staff#118 stated, We have a company that comes and picks them up periodically and the pharmacist also disposes of medication. Staff #118 concurred that the room was messy and that there were spider droppings, cobwebs, and spider eggs behind the door.
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 F0882
(Tag F0882)
Could have caused harm · This affected most or all residents
Based on facility documentation and staff interview the facility failed to have a certified Infection Preventionist (IP) that worked at least part time in the facility. This failed practice had the po...
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Based on facility documentation and staff interview the facility failed to have a certified Infection Preventionist (IP) that worked at least part time in the facility. This failed practice had the potential to affect all residents residing at the facility. Facility Census: 141.
Findings included:
a) Infection Preventionist
Record review of the facility's documentation of Infection control practices found the facility was unable to provide an Infection Control Preventionist Certification or documentation for an IP that worked at least part time in the facility.
During an Interview 09/06/23 at 1:38 PM Director of Nursing (DON) Stated that she and the assistant Director of Nursing (ADON) document all infections for residents in the facility, neither are IP certified. She continued to say that the facility has not had an IP since May 2023, she stated that the corporate consultant is available if they need her, she works at the corporate office.
No other information was provided prior to the end of the survey on 09/07/23.
May 2023
7 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 F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview, the facility failed to ensure personal privacy during medical treatments for one (1) resident observed during a random opportunity for discovery. Lab work w...
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Based on observation and staff interview, the facility failed to ensure personal privacy during medical treatments for one (1) resident observed during a random opportunity for discovery. Lab work was drawn when Resident #87 was observed at a community dining table, on the unit, while eating breakfast. Resident Identifier: Resident #87 . Census: 149
Findings included:
a) Policy Review
A review of the Policy, titled: Resident's Rights, #NS1021-00, noted a resident's right to privacy would be respected during treatment, medication or care that was being administered included having no treatment, medication or care performed in common areas, unless requested by the resident. This included not receiving treatment in hallways, dining rooms or other common areas.
b) Resident #87
An observation, on 05/03/23 at 08:16 AM, revealed Phlebotomist #100 was observed to come to the unit (EB2) , approaching Resident #87 and informed the resident her doctor had ordered for them to check her red blood cells and a CMP (Complete Metabolic Panel). Resident #87 stated she was eating and did not want any blood taken. Resident #87 was seated at the dining room table adjacent to the nursing station eating breakfast with other residents.
Phlebotomist #100 proceeded to apply a tourniquet to Resident #87's arm. At this time, the surveyor requested Licensed Practical Nurse (LPN #171) to intervene. LPN #171 then asked for Resident #87 to be assisted to her room and verified privacy for the procedure had not been maintained.
An interview with the Administrator, on 05/03/23 at 09:20 AM, confirmed it was the policy of the facility to provide privacy during treatments and residents should not have had blood drawn at the dining table.
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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
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
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Based on record review, facility concern log review, resident interview, family interview, and staff interview, the facility failed to make prompt efforts to resolve grievances, and failed to ensure...
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Based on record review, facility concern log review, resident interview, family interview, and staff interview, the facility failed to make prompt efforts to resolve grievances, and failed to ensure that all grievance decisions, included the date the grievance was received, a summary of pertinent findings or conclusions regarding the resident's concern and any corrective action taken or would be taken as a result of the grievance and the date a written decision was made for two (2) residents reviewed. This was found true during a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident identifiers: Resident #30 and #13. Census: 149.
Findings included:
a) Resident #30
A record review for Resident #30, showed a progress note, dated 03/06/23, in which a nursing assistant had notified the nurse, Resident #30 was angry during the previous shift, because the resident was cleaned, dressed and got up in wheelchair at 6 AM and took her to living area table. At this time, it was noted Resident #30 did not want that nursing assistant in her room.
A review of the grievance log for March 2023, did not contain record of the complaint being made, the name of the person reporting, who the complaint had been assigned to and summary of resolution with the date and discussion with the resident or responsible parties involved to ensure resolution of the problem alleged.
A family interview, on 05/01/23 at 12:35 PM, confirmed complaints had been made to the facility but the complaints had not been resolved to satisfaction. Complaints included staffing concerns, not putting pajama pants on the resident after incontinence care had been reported to the facility as concerns.
An interview with the Administrator, on 05/02/23 at 03:14 PM and 03:47 PM, confirmed not all complaints were documented. The administrator stated she was afraid some of the complaints had been missed. It was stated further, by the Administrator during the interviews, revealed improvement was needed in how the facility was handling concerns. The concerns should have been logged in, however, there had been a period of time a guest relations employee was not doing complaints and that could have been the problem.
b) Resident #13
An interview with Resident #13, on 05/01/23 at 11:46 AM, revealed there had been a complaint made to the facility regarding not being changed, due to incontinence, for a long period of time. Resident #13 confirmed the complaint had been reported to facility staff. It was also noted during the interview, Resident #13 had complained to Nursing and Administrative staff, about nursing assistants turning off the call light and not returning to assist with care.
A record review noted Resident had a brief interview for mental status exam (BIMS) on 04/15/23 at a level 15, which indicated the resident was cognitively intact. The comprehensive assessment, dated 04/15/23, showed the resident did require extensive assistance from staff for activities of daily living care (ADLS).
A review of the grievance log showed no evidence of a concern.
An interview with the Administrator , on 05/03/23 at 09:20 AM, provided a statement with no date or resident name, noting Verbal one on one education for staff to provide care immediately when requested and stated the statement pertained to Resident #13's issue with staff.
During the interview, the Administrator confirmed , there was no name on the paper, proving this did pertain to Resident #13's concern and no date proving the date the education was provided.
It was also confirmed, there was no evidence of a follow-up with the resident with a resolution and if the concern had been resolved.
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CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
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Based on review of facility documentation of reportable incidents, and staff interview, the facility failed to ensure evidence, in the response to allegations of abuse/neglect, that all alleged viol...
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Based on review of facility documentation of reportable incidents, and staff interview, the facility failed to ensure evidence, in the response to allegations of abuse/neglect, that all alleged violations were thoroughly investigated for one (1) of three (3) reportable incidents reviewed. This was true for an allegation of neglect, which was made on an anonymous basis, which was not thoroughly investigated.
Census: 149.
Findings included:
A review of the Reportable log for April 2023, noted on 04/10/23, an anonymous complaint was made. Further review of the report, dated 04/10/23 showed an anonymous caller alleging a resident, on the 2nd floor of the long-term care unit had not been changed or provided a bath. Additionally, the allegation made alleged the resident had not been provided mouth care and none of the patients in the room had been cared for. The caller stated a nursing assistant had helped clean up the family member.
A review of the facility's investigation showed no evidence a thorough investigation had been completed. A review of the narrative of investigative report dated 04/14/23, showed the facility had documented interviews that had been conducted with interview-able residents but failed to include those residents that were unable to be interviewed. Additionally, there was no evidence the facility had documented staff statements when the allegation noted there was a staff member that assisted in cleaning up the resident when the allegation was made. Further review of the investigation, conducted by facility staff, showed no evidence of assessments for all residents, who required assistance with Activities of Daily living (ADL) tasks who would have been at risk.
An interview with the administrator on 05/03/23 at 02:22 PM, revealed there was no evidence non- interviewable residents were included in the investigation and stated she was in agreement they should have been assessed for abuse and neglect as well.
During the interview, the Administrator verified a seasoned nursing assistant (NA) was interviewed but no other staff members were questioned, however, no documentation was kept and this information was not included in the summary of the investigation or in the five (5) day follow up information.
On 05/03/23, at 02:24 PM, the Administrator confirmed, after speaking with the Social Services Director, no other residents were included in the investigation except the residents that were able to be interviewed.
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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
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Based on observation, record review, resident interview and staff interview, the facility failed to provide an environment free from accident hazards over which it had control. The facility failed t...
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Based on observation, record review, resident interview and staff interview, the facility failed to provide an environment free from accident hazards over which it had control. The facility failed to ensure medications were not kept at the bedside unless it was determined it was safe for a resident to self-administer the medications. Resident identifier: Resident #103. Facility census: 149.
Findings included:
a) Resident #103
An observation, on 05/01/23 at 11:42 AM, revealed Resident #103 laying in bed with a medicine cup containing pills on her bedside table.
An interview with Resident #103, on 05/01/23 at 11:42 AM, verified the resident does not self- administer her own medications.
An interview with Licensed Practical Nurse (LPN #195) on 05/01/23 at 11:44 AM, verified Resident #103 did have medications left at the bedside. LPN #195 verified the medications were Resident #103's morning medications ordered by the physician. LPN #196 revealed she had left them there and should not have done so.
An interview with the Director of Nursing (DON) on 05/02/23 at 08:45 AM, verified she was aware of LPN #195 leaving medications unattended at the bedside without ensuring supervision of the administration. The DON stated it was the policy of the facility for all staff administering medications to supervise the medication administration pass.
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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
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Based on record review and staff interview, the facility failed to ensure medical records for each resident were accurately documented for two (2) of five (5) records reviewed during the complaint i...
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Based on record review and staff interview, the facility failed to ensure medical records for each resident were accurately documented for two (2) of five (5) records reviewed during the complaint investigation. The facility failed to document complete meal consumption records of Resident #30, who had been identified as a weight loss risk and failed to document correct resuscitation status in the progress notes for Resident #150. Resident identifiers: Resident #30 and #150. Census: 149.
Findings included:
a) Resident #30
A record review for Resident #30, showed a current care plan approach to monitor food intake due to an issue of weight loss. A review of the meal consumption documentation for 04/2023 was reviewed and found documentation of the meal consumption records were incomplete.
There was no evidence meal consumption records were maintained for the following dates and meals served:
A review of the meal consumption records for 04/03/23, 04/04/23, 04/24/23, 04/26/23, and 04/29/23, showed no evidence meal consumption for Resident #30 was documented for all three (3) meals on those days.
A review of the meal consumption records for 04/06/23 , 04/08/23 and 04/11/23 showed no evidence the meal consumption for Resident #30 was documented for the dinner meals on those days.
A review of the meal consumption records for 04/13/23 showed no evidence the meal consumption for Resident #30 was documented for the breakfast meal intake.
A review of the meal consumption records for 04/15/23 showed no evidence the meal consumption for Resident #30 was documented for the dinner meal intake.
A review of the meal consumption records for 04/17/23 showed no evidence the meal consumption for Resident #30 was documented for the breakfast or dinner meal intake.
An interview with the Director of Nursing (DON) on 05/02/23 at 02:01 PM, confirmed documentation of meal consumption records for Resident #30 were incomplete and staff should have included meal consumption for all meals for those time frames.
b) Resident #150
A record review for Resident #150 showed a progress note written on 03/17/23 at 06:10 PM , documenting the resident had a code status of DNR indicating the resident would not be resuscitated in the event the resident was found with no pulse.
A review of Resident #150's physician orders noted no current order for Do Not Resuscitate and no directive as such noted under an Advance Directive.
An interview with the DON on 05/02/23 at 09:55 AM, verified the progress note did indicate the resident would not be resuscitated. The DON confirmed it was documented in error and the resident would have been resuscitated if found with no pulse.
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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
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
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Based on observation, review of menus, and staff interview, the facility failed to ensure food items noted on the menus were served to residents or a suitable substitution made. Facility staff faile...
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Based on observation, review of menus, and staff interview, the facility failed to ensure food items noted on the menus were served to residents or a suitable substitution made. Facility staff failed to provide meal items consistent with the menus prepared. This was found during a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident identifiers: Resident #31, #4, #149 and #78. Facility census: 149.
Findings included:
a) Resident #31
An observation of the breakfast meal, on 05/02/23 at 07:55 AM, revealed Resident #31 was provided one (1) ham slice, one (1) slice of toast and a scrambled egg.
A review of the meal tray card noted resident was supposed to receive milk, hot cereal and orange juice. There were no documented preferences or dislikes to the items not served on the tray.
During the observation on 05/02/23 at 07:55 AM, Resident #31 requested staff to provide orange juice and tea for the meal.
b) Resident #4
An observation of the breakfast meal on 05/03/23 at 07:50 AM, found Resident #4 received one biscuit with gravy and a scoop of hash brown potatoes.
Review of the tray card for this meal, showed Resident #4 was supposed to receive 2/3 cup of vanilla yogurt, hot cereal, chocolate milk, and orange juice.
An interview with the Administrator on 05/03/23 at 10:18 AM, confirmed the resident did not receive what was on the tray card, there were no dislikes noted, and the staff should have served the additional items listed on the tray card.
c) Resident #149
An observation, on 05/03/23 at 08:10 AM, found Resident #149 received one (1) biscuit with gravy and juice. Resident #149 was observed to have consumed these items and was licking his plate. At this time, there was no staff present. The surveyor asked Resident #149 if he preferred to have additional food items in which he responded yes. On 05/03/23 at 08:15 AM, the staff assisting (Activity Director #193) provided an additional biscuit with gravy and hash brown potatoes. Resident #149 consumed 100 percent of these items.
Review of the tray card for Resident #149, showed the resident was supposed to receive two (2) biscuits, hot cereal, hash browns, milk and orange juice.
An interview with the Administrator, on 05/03/23 at 10:29 AM, confirmed Resident #149 was not provided food items in accordance with the menu and resident's tray card.
d) Resident #78
An observation of the breakfast meal on 05/03/23 at 09:30 AM, for Resident #78, revealed the resident received one (1) biscuit with gravy, a scoop of hash brown potatoes and chocolate milk.
A review of the tray card and menu for breakfast on 05/03/23, noted the resident was supposed to receive oatmeal and orange juice in addition to the menu items provided.
An interview on 05/03/23 at 09:20 AM, with the Administrator revealed Resident #78 was not provided food items consistent with preferences, the menu and what was listed on the tray card, and those menu items omitted should have been provided to the resident for breakfast.
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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
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
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Based on observation, and staff interview, the facility failed to establish and maintain an effective infection prevention and control program designed to provide a sanitary environment and to help ...
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Based on observation, and staff interview, the facility failed to establish and maintain an effective infection prevention and control program designed to provide a sanitary environment and to help prevent the development and transmission of communicable diseases and infections. This was true during a random opportunity of discovery , the facility failed to serve meals in a sanitary manner by placing dirty meal trays in the cart with trays that had yet to be served. This practice had the potential to affect more than a limited number of residents residing in the facility. Resident Identifiers: Resident #141. Census: 149.
Findings included:
An observation, on 05/03/23 at 08:40 AM, revealed Nursing Assistant (NA #128) carried a tray that had been picked up after a resident had consumed the breakfast meal and placed it back in the meal cart. At this time, there was a tray for Resident #141, that had not been served, as well as three additional trays waiting to be served.
An interview, with NA #128, on 05/03/23 at 08:40 AM, confirmed the tray that had been placed on the cart was a tray a resident had completed. When asked if dirty trays were to be mixed with trays yet to be served, NA #128 stated I messed up and should not have put those together. NA #128 confirmed there were trays that had not been served still in the cart.
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Mar 2023
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation and staff interview, the facility failed to ensure the residents environment was clean and homelike envir...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation and staff interview, the facility failed to ensure the residents environment was clean and homelike environment. The intake vents in the satellite kitchens on the first and second floors of the CTC units were covered with gray/brown dust. In addition, the room labeled Spa (shower room on second floor East [NAME] (EB) 2) found multiple used towels scattered on the floor and equipment, used gloves, and unlabeled personal hygiene items (shampoo, lotion). These were random opportunities for discovery. Facility census: 149.
Findings included:
a) Satellite Kitchens
An observation of the air intake vents during the lunch meal service on 03/27/23 at 12:41 PM on the first and second floor of the [NAME] Transition Care (CTC) satellite kitchens found were covered with gray/brown dust.
In an interview with the Maintence Director on 03/29/23 at 10:57 AM confirmed the vents were dirty and needed cleaned. He stated the vents are cleaned monthly and were due to be cleaned either on the 30th or 31st of March. The Maintence Director stated he may need to consider cleaning intake vents twice a month.
b) Second Floor SPA (Shower Room EB-2)
A tour of the spa (shower room) on 03/27/23 at 10:15 pm with the Assistance Director of Nursing (ADON) found the following cleanliness issues:
-- A soiled towel laying on a shower bed and a dirty towel hanging over the grab bar in the toilet area of the spa.
-- On the back of the toilet was multiple used gloves. The gloves were turned inside out. Gloves turn in side when properly doffed after use.
-- Multiple bottles of used and unlabeled soaps and lotions.
-- A used gloved was laying on the towel rack.
--- An uncapped disposal razor was found in the floor.
The ADON stated I will need to get all this cleaned up.
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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 F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
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The facility failed to accurately account for all controlled substance medication belonging to Resident #8. The nurse withdrew two (2) Oxycodones from the Cubex (The Cubex is the system used by the ...
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The facility failed to accurately account for all controlled substance medication belonging to Resident #8. The nurse withdrew two (2) Oxycodones from the Cubex (The Cubex is the system used by the facility to store emergency medications to use while waiting for the Pharmacy to deliver the regular stock of medications) on 03/28/23 at 12:28 am. The nurse failed to ensure one (1) of the two (2) pills was administered to Resident #8. This was a random opportunity for discovery and was only true for Resident #8. Resident identifier: #8. Facility census: 149.
Findings included:
a) Resident #8
During an interview with Resident #8 at approximately 10:00 am she stated she was experiencing pain in her back. Registered Nurse (RN) #150 was made aware of Resident #8's complaints of pain upon the surveyor exiting Resident #8's room.
An interview with RN #150 at 11:25 am on 03/29/23, confirmed he had given the resident two (2) Tylenol at 10:05 am on 03/29/23. He stated, the Tylenol was not effective and he was going to pull an oxycodone from the Cubex to administer to the resident.
A review of Resident #8's Medication Administration Record (MAR) in the afternoon of 03/29/23 found the following dates and times when Resident #8 was administered oxycodone 5-325:
-- 03/25/23 at 2:20 PM.
-- 03/28/23 at 12:31 am
-- 03/29/23 at 11:30 am.
A review of the controlled substance logs for the Oxydcodone 5-325 found the medication was signed out on a log for the 03/25/23 and 03/29/23 doses. The dose administered on 03/28/23 was not recorded on a controlled substance log.
At approximately 11:30 am on 03/29/23 the Director of Nursing was asked to provide documentation to show the Oxycodone administered at 12:31 am on 03/28/23 was pulled from the Cubex. This was requested as a way to ensure the dose documented on 03/28/23 was available to be administered as documented on the MAR. The medication if administered would have had to be pulled from the Cubex because Resident #8's supply of this medication had not arrived from the pharmacy.
At 12:42 PM on 03/29/23 the Assistant Director of Nursing #120 provided a report which showed what medications had been pulled from the Cubex for Resident #8. The report contained two (2) transactions for Resident #8's oxycodone. The first transaction was on 03/28/23 at 12:28 am. During this transaction Licensed Practical Nurse (LPN) #140 removed two (2) Oxycodones 5-325 milligrams.
LPN #140 documented on the MAR administration of one (1) pill to the resident at 12:31 am on 03/28/23. The ADON #120 was asked to provide the controlled substance log for the remaining pill for this transaction. He indicated LPN #140 had not logged either pill into the controlled substance log book. He described the facility's process as, If the nurse pulls more pills than will be administered at the next scheduled dose they should log the medication into the controlled substance log book so an accurate accounting of the medication can be achieved.
ADON #120 was then asked where this pill was since it was not documented as administered on the MAR. He stated, I don't know its not on the medication cart. The nurse stated she gave it to her at 6:30 am on 03/29/23 but it is not documented as administered on the MAR.
A review of the facility's policy Titled Medication Ordering and Receipt under Policy 3.5 Emergency Boxes and On-site Stores found the following: .7. When ordered, the nurse accesses the On-Site Stores and removes only the prescribed medications needed. Only remove the amount of medication needed for the next scheduled dose.
ADON #120 confirmed the nursing staff consistently removes more medication than needed for the next scheduled dose because the process is so lengthy. He indicated this is the reason they should be logged in the controlled substance log because not every pill removed will be administered at the next scheduled dose.
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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
Staffing Information
(Tag F0732)
Could have caused harm · This affected 1 resident
.
Based on observation and staff interview, the facility failed to include the facility census on the daily staff postings. This had the potential to affect a limited number of residents. Facility cen...
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Based on observation and staff interview, the facility failed to include the facility census on the daily staff postings. This had the potential to affect a limited number of residents. Facility census: 149.
Findings included:
a) Daily Staff Postings
An observation on 03/26/23 at 9:33 AM found the Daily Staff posting did not included the facility census. After reviewing the staffing sheets from 03/13/23 until 03/27/23 found there were no staffing sheets which included the census. Data requirements according to the Centers for Medicare and Medicaid Services(CMS) the facility must post the resident census on a daily basis on the staffing sheets.
On 03/27/23 at 9:16 AM the Director of Nursing (DON) confirmed the daily staffing sheets did not have the census on them. The DON corrected the sheets to include the census.
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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
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The facility failed to establish and/or implement a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and determines tha...
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The facility failed to establish and/or implement a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This was true for Resident #8 and was a random opportunity of discovery. Resident Identifiers: Resident #8. Facility Census: 149.
Findings included:
a) Resident #8
During an interview with Resident #8 at approximately 10:00 am she stated the she was experiencing pain in her back. Registered Nurse (RN) #150 was made aware of Resident #8's complaints of pain upon the surveyor exiting Resident #8's room.
An interview with RN #150 at 11:25 am on 03/29/23, confirmed he had given the resident two (2) Tylenol at 10:05 am on 03/29/23. He stated, the Tylenol was not effective and he was going to pull an oxycodone from the Cubex to administer to the resident.
A review of Resident #8's Medication Administration Record (MAR) in the afternoon of 03/29/23 found the following dates and times when Resident #8 was administered oxycodone 5-325:
-- 03/25/23 at 2:20 PM.
-- 03/28/23 at 12:31 am
-- 03/29/23 at 11:30 am.
A review of the controlled substance logs for the Oxydcodone 5-325 found the medication was signed out on a log for the 03/25/23 and 03/29/23. The dose administered on 03/28/23 was not recorded on a controlled substance log.
At approximately 11:30 am on 03/29/23 the Director of Nursing was asked to provide documentation to show the Oxycodone administered at 12:31 am on 03/28/23 was pulled from the cubex.
At 12:42 PM on 03/29/23 the Assistant Director of Nursing #120 provided a report which showed what medications had been pulled from the Cubex for Resident #8. The report contained two (2) transactions for Resident #8's oxycodone. The first transaction on 03/2823 at 12:28 am. During this transaction Licensed Practical Nurse (LPN) #140 removed two (2) Oxycodones 5-325 milligrams.
LPN #140 documented on the MAR administration of one (1) pill to the resident at 12:31 am on 03/28/23. The ADON was asked to provide the controlled substance log for the remaining pill for this transaction. He indicated LPN #140 had not logged either pill into the controlled substance log book. He described the facility's process as, If the nurse pulls more pills than will administered at the next scheduled dose they should log the medication into the controlled substance log book so an accurate accounting of the medication can be achieved.
ADON #120 was then asked where this pill was since it was not documented as administered on the MAR. He stated, I don't know its not on the medication cart. The nurse stated she gave it to her at 6:30 am on 03/29/23 but it is not documented as administered on the MAR.
A review of the facility's policy Titled Medication Ordering and Receipt under Policy 3.5 Emergency Boxes and On-site Stores found the following: .7. When ordered, the nurse accesses the On-Site Stores and removes only the prescribed medications needed. Only remove the amount of medication needed for the next scheduled dose.
ADON #120 confirmed the nursing staff consistently removes more medication than needed for the next scheduled dose because the process is so lengthy. He indicated this is the reason they should be logged in the controlled substance log because not every pill removed will be administered at the next scheduled dose.
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CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on resident interview, observation, record review and staff interview, the facility failed to ensure they honored each r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on resident interview, observation, record review and staff interview, the facility failed to ensure they honored each residents food preferences related to their religious beliefs. The facility also failed to ensure food was served using the required serving size to each resident. This failed practice has the potential to affect more than an isolated number of residents. Resident identifier: #12. Facility Census: 149.
Findings included:
a) Resident #12
During an interview with Resident #12 at 8:40 am on 03/29/23, the resident stated she is Catholic and they are currently in Lent (Lent, in the Christian church, is a period of penitential preparation for Easter. In Western churches it begins on Ash Wednesday, six and a half weeks before Easter, and provides a 40-day period for fasting and abstinence (Sundays are excluded), in imitation of Jesus Christ ' s fasting in the wilderness before he began his public ministry.) The common practice of Resident #12 is to eat no meat on Fridays during Lent. Lent for the year 2023 began on 02/22/23 and will end on 04/06/23. Resident #12 stated I have told them over and over to not bring me meat on Fridays. She stated, they bring me sausage for breakfast, meatloaf and BBQ pork. She stated, I have told nursing, therapy and dietary. She further explained her family has to bring her food on Friday because they have not honored her religious restrictions on food.
A review of Resident #12's medical record found a social service assessment and an activities assessment both of which were completed on admission. Each of the assessments identified the resident as being Catholic.
Further review of Resident #12's medical record found a Diet History/Food Preferences assessment completed shortly after Resident #12's admission on [DATE]. This form indicated the resident did not have any cultural, ethnic, or religious requests.
An interview with Culinary Supervisor #127 on 03/29/23 at 10:28 AM confirmed she is the person who speaks to the residents about their dietary preferences. She provided a hand written form which she uses to gather information before putting it into the electronic medical record. She provided a form which was dated 02/28/23 and had Resident #12's name written at the bottom of the form. The form contained a section which read, Ethnic/Religious Preferences there was a single line drew out from this question. When asked what that indicated Culinary Supervisor #127 stated, I did not ask her that question. That is why her answer is not written in there. She stated, I need to start asking all the questions. She reviewed Resident #12's meal tickets for the three (3) previous Fridays and confirmed Resident #12 was served meat on at least two (2) of the three (3) meals each day.
b) Serving Size
On 03/27/23 at 12:41 PM the Assistant Dietary Manager (ADM) #52 was observed using a stainless steel basting spoon to serve the Kielbasa. ADM #52 looked at a resident meal ticket and it showed a a green handled #8 utensil was to be used to serve the resident the correct amount of Kielbasa. ADM #52 stated that the #8 utensil was on back order. After looking in a drawer, the ADM #52 found the correct #8 serving utensil.
The beans had a red handled seving utensil and the ADM #52 stated that this should also be a green #8 but they only had a red handle scooper which was one (1) ounce less than the green #8 therefore the residents were receiving an inadequate serving.
In an interview with the Dietary Director (DD) on 03/27/23 at 1:24 PM stated that all size serving utensils had been on backorder but they were delivered and she distributed the serving utensils to all satellite kitchens as well as the main kitchen. She stated that there was no reason for not using the correct serving utensil
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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 F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on resident interview, record review, and staff interview, the facility failed to interview a resident to determine food...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on resident interview, record review, and staff interview, the facility failed to interview a resident to determine food preferences. This was true of one (1) of two (2) residents reviewed for food preferences. Resident identifier: #1. Facility census: 149.
Findings included:
a) Resident #1.
Interview with Resident #1 at approximately 10:30 AM on 03/27/23 found the resident was admitted to the facility on [DATE]. The resident said she often gets foods she doesn't like. She said she was unaware she could request a substitute if she didn't like the menu. She said, I can not eat any kind of spicy foods, like Mexican food and sausage. The resident said she rarely eats the foods served because she doesn't like the food or can't eat the food because it upsets her stomach.
At 12:50 PM on 03/27/23, the resident was observed eating lunch in her room. She had eaten her mixed vegetables. She had Kielbasa which she had not touched. She said, I can't eat Kielbasa, it upsets my stomach. It doesn't like me. She said the facility frequently serves sausage for breakfast which she can't eat.
At 12:55 PM on 03/28/23, cook #35 was in the kitchen of the CTC unit. [NAME] #35 said the kitchen has been short staffed so residents haven't been asked what they want for meals. [NAME] #35 said when no one is in the CTC unit, the food is just sent up from the main kitchen.
Review of the most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/21/23 found the Resident's Brief Interview for Mental Status (BIMS) indicated the resident had a score of 15. A score of 15 is the highest score obtainable and indicates the Resident is cognitively intact.
At approximately 10:35 AM on 03/28/23, the Culinary Director (CD) #52 checked her computer system and said she had not talked to the Resident about her food preferences. CD #52 said she had been out on sick leave for the last 2 weeks and was a little behind. CD #52 also confirmed an order for a nutritional supplement had not been entered into the computer for Resident #1. She said she didn't know why a supplement had been ordered. The surveyor and the CD went to the resident's room to enquire about her food preferences.
At 4:20 PM on 03/28/23, the Director of Nursing said the registered dietician added the house supplement when she realized the resident wasn't eating well. According to the DON, the resident has not been weighed because she refuses weights so the facility has not determined the Resident has had an actual weight loss.
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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
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, staff interview and observation the facility failed to administer medications within the defined time ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, staff interview and observation the facility failed to administer medications within the defined time frames of the physician order for Resident #8 and Resident #12. The facility also failed to administer a physician ordered supplement for Resident #1. This was true for three (3) sampled residents reviewed during a complaint investigation. Resident identifier: #8, #12 and #1. Facility census: 149.
Findings included:
a) Resident #8
A review of Resident #8's Medication Administration Audit report from 03/16/23 the date of her admission until the time of this review found on the following dates and times Resident #8's medication was administered later than one (1) hour past the scheduled administration time:
The following medications were scheduled to be administered at 9:00 AM on 03/17/23 and was not administered until 12:26 PM on 03/17/23:
-- Calcitriol .
-- sulfasalazine
--Vitamin B Complex
-- Protonix
-- Prolia Subcutaneous Solution
-- Colestipol hCI Oral Tablet
-- Metoprolol Tartrate
-- Hydroxychloroquine Sulfate
The following medications were scheduled to be administered at 9:00 AM on 03/18/23 and was not administered until 10:25 AM on 03/18/23:
-- Calcitriol .
-- sulfasalazine
--Vitamin B Complex
-- Protonix
-- Colestipol hCI Oral Tablet
-- Metoprolol Tartrate
-- Hydroxychloroquine Sulfate
The following medications were scheduled to be administered at 9:00 AM on 03/24/23 and was not administered until 6:24 PM on 03/24/23:
-- Calcitriol .
-- sulfasalazine
--Vitamin B Complex
-- Protonix
-- Colestipol hCI Oral Tablet
-- Metoprolol Tartrate
-- Hydroxychloroquine Sulfate
The following medications were scheduled to be administered at 10:00 AM on 03/24/23 and was not administered until 6:24 PM on 03/24/23:
-- House shake Daily
-- Magnesium Oxide
The following medications were scheduled to be administered at 9:00 AM on 03/26/23 and was not administered until 11:03 AM and 11:04 AM on 03/26/23:
-- Calcitriol .
-- sulfasalazine
--Vitamin B Complex
-- Protonix
-- Colestipol hCI Oral Tablet
-- Metoprolol Tartrate
-- Hydroxychloroquine Sulfate
-- Stress Plus Zinc Oral Tablet
-- Modular Protein
The following medications were scheduled to be administered at 9:00 PM on 03/17/23 and was not administered until 1:37 AM on 03/18/23:
-- Astrovastatin
-- Colestipol hCI Oral Tablet
-- Protonix
-- sulfasalazine
The following medications were scheduled to be administered at 9:00 PM on 03/19/23 and was not administered until 4:54 AM on 03/20/23:
-- Astrovastatin
-- Colestipol hCI Oral Tablet
-- Protonix
-- sulfasalazine
The following medications were scheduled to be administered at 9:00 PM on 03/20/23 and was not administered until 11:13 PM on 03/20/23:
-- Astrovastatin
-- Colestipol hCI Oral Tablet
-- Protonix
-- sulfasalazine
The following medications were scheduled to be administered at 9:00 PM on 03/25/23 and was not administered until 11:42 PM on 03/25/23:
-- Astrovastatin
-- Colestipol hCI Oral Tablet
-- Protonix
-- sulfasalazine
An interview with the Director of Nursing on 03/27/23 at 3:40 PM confirmed the medications noted above were administered more than a hour after the scheduled time of administration.
b) Resident #12
A review of Resident #12's Medication Administration Audit report from 02/2/7/23 the date of her admission until the time of this review found on the following dates and time Resident #12's medication was administered later than one (1) hour past the scheduled administration time:
The following medications were scheduled to be administered at 10:00 PM on 03/03/23 and was not administered until 11:27 PM on 03/03/23:
-- Fluticasone Propionate
-- Lantus Solostar Solution
-- Pregabelin Oral Capsule
-- Magnesium Oxide
-- Montelukast Sodium
-- Eliquis
The following medications were scheduled to be administered at 10:00 PM on 03/10/23 and was not administered until 11:23 PM on 03/10/23:
-- Fluticasone Propionate
-- Lantus Solostar Solution
-- Pregabelin Oral Capsule
-- Magnesium Oxide
-- Montelukast Sodium
-- Eliquis
The following medications were scheduled to be administered at 9:00 PM on 03/14/23 and was not administered until 3:52 AM on 03/15/23:
-- Fluticasone- salmeterol Aersol Powder breath
The following medications were scheduled to be administered at 10:00 PM on 03/14/23 and was not administered until 3:52 AM on 03/15/23:
-- Fluticasone Propionate
-- Lantus Solostar Solution
-- Pregabelin Oral Capsule
-- Magnesium Oxide
-- Montelukast Sodium
-- Eliquis
An interview with the Director of Nursing on 03/27/23 at 3:40 PM confirmed the medications noted above were administered more than a hour after the scheduled time of administration.
c) Resident #1
Record review found the resident was admitted to the facility on [DATE].
On 03/22/23 an order was written for the resident to receive a House Supplement, 4 ounces, two (2) times a day at 10:00 AM and 8:00 PM.
On 03/27/23 at approximately 10:00 AM, when asked about the house supplement, the resident said, I have received maybe 2 of those things since I have been here, someone told me they were strawberry milkshakes, what are those supposed to be for anyway? The surveyor explained that usually a house supplement is ordered if a resident has lost weight or may not be eating well. She replied, That's me, I can't eat the food and I feel like I have lost a lot of weight, if I had known that, I might have drank them.
Review of the most recent admission minimum data set (MDS) with an assessment reference date (ARD) of 03/21/23 found the resident scored 15 on the Brief Interview for Mental Status exam (BIMS.)
A score of 15 is the highest score obtainable and indicates the resident is cognitively intact.
At 10:40 AM on 03/28/23 the Culinary Director (CD) said the kitchen had not received an order for the resident to have a house supplement. Or if we did, no one has entered it into the system yet. The CD said the kitchen staff sends the house shakes up to the resident's unit.
The Surveyor and the CD went to the resident's room to determine if the Resident had been receiving the house supplement. Upon arrival, the resident was receiving a bed bath. The surveyor and the CD waited in the dining area until the shower was completed. At approximately 10:50 AM, the resident said she did not receive a house supplement today.
At 10:55 AM on 03/28/23, the resident's nurse aide (NA) #125 said she had already passed all the house supplements and Resident #1 did not have a house supplement with her name on it. She picked up a black storage container sitting on the nurses station, turned it upside down and said, See there is nothing left in here, I passed all my snacks and (name of Resident #1) didn't have anything.
Observation of the medication administration record (MAR) in the electronic medical record at approximately 11:05 PM on 03/28/23, found the resident's nurse had signed the medication administration record (MAR) indicating the resident received the supplement and drank 100%.
At 12:08 PM on 03/28/23, the resident's Licensed Practical Nurse (LPN) #128 was found in the hallway just outside the resident's room with the medication cart. When asked if she had given Resident #1 her house supplement, LPN #128 said, I offered it but she doesn't drink them, she didn't want it today.
Upon observation of the electronic medical MAR record shortly after the interview with the LPN, the Medication Administration Record (MAR) had been changed to reflect 0% for the amount of the house supplement consumed. Observation of the MAR at 11:05 AM on 03/28/23 noted the resident drank 100% of the house supplement.
At 12:35 PM, on 03/28/23, the administrator was asked to provide the electronic copy of the MAR with the date and time the percentage of the house supplement had been changed.
At 2:10 PM on 03/28/23, the Administrator provided a report of the administration history report.
LPN #128 made an entry at 9:30 AM, regarding the house supplement. This entry was struck out by LPN #128 and a new entry for the house supplement was made at 12:12 PM on 03/28/23. The new entry changing the amount of the supplement consumed from 100% to 0% was made 4 minutes after LPN #128 told the surveyor the resident didn't want the house supplement and didn't drink it.
At 4:20 PM on 03/28/23, the Director of Nursing (DON) said the registered dietician added the house supplement when she realized the resident wasn't eating well. According to the DON, the resident has not been weighted because she refuses weights. The DON said she talked with LPN #128. LPN #128 said she asked the nurse aide (NA) if she had passed all her snacks and the NA said, yes, so she put down the Resident consumed 100% of the house supplement. The DON said she told LPN #128, she needed to check to see if the Resident actually received a house supplement and if she did LPN #128 needed to verify for herself how much of the house supplement the resident actually drank. She said LPN #128 just assumed the resident received a house supplement. The administrator was present and said she had suspended LPN #128 and all staff were receiving an inservice on false documentation.
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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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, record review and staff interview the facility failed to ensure the resident environment over which it h...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, record review and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. The facility failed to ensure medication carts were locked when not under the supervision of the nurse. For Resident #8 and Resident #1 the facility failed to adequately communicate to all staff the residents transfer status to ensure they were transferred safely. This failed practice has the potential to affect more than a limited number of Residents. Resident Identifiers: #8 and #1. Facility Census: 149.
Findings Included:
a) Medication cart
Initial tour of the facility on 03/26/23 beginning at 9:23 PM, found the medication cart and the treatment cart was unlocked and unattended on the CTC ([NAME] Transitional Care Unit) First Floor. At 9:28 PM, Licensed Practical Nurse( LPN) #92, emerged from the restroom. LPN #92 confirmed she was the only nurse on the unit and was in the restroom at the time of our entrance. She then confirmed her carts were left unlocked and unattended. She proceeded down the hall and locked both carts.
b) Resident #8
A review of Resident #8's medical record on the morning of 03/29/23 found the following information regarding Resident #8's transfer status. The care plan and [NAME] both indicated Resident #8 was to be transferred with total mechanical lift with a two (2) person staff assist. However, the initial nursing assessment dated [DATE] indicated the resident was to be transferred with minimum assist with a gait belt; may use walker for transfers.
An observation on 03/29/23 at at approximately 11:00 am found Resident #8 needed assistance to go from the bed to the wheelchair. Nurse Aide (NA) #174 entered the room to assist the resident. The resident was transferred from the bed by NA #174 using a one person physical assist and no gait belt. The resident was transferred with no issues.
During an interview with the Director of Nursing (DON) at 11:48 am on 03/29/23, the DON was asked why the [NAME] and the resident care plan stated the resident was to be transferred via a mechanical lift when the initial nursing assessment clearly assessed the resident as only needing minimal assistance of one (1) staff member. The DON stated, I am not sure how the mechanical lift got to the care plan and [NAME]. She indicated the typical process is nursing will assess them on admission and initiate the care plan and the [NAME] to relay to the nurse aides how to transfer the resident. She continued, then the restorative nurse will label the resident door with a sticker which will also let the nurse aides now how to transfer the resident.
An interview with LPN #155, the restorative nurse, at 12:08 PM on 03/29/23 confirmed there was no sticker on Resident #8's door to alert the nurse aides on how to transfer the resident. She stated, There was a miscommunication between me and the guest relations director as to who was going to but the sticker on the door. When asked if she could explain why the care plan and [NAME] did not match the initial assessment she stated, I have no idea why that would have happened.
No further information was obtained prior to the completion of the survey.
c) Resident #1
During an interview with the resident at approximately 10:00 AM on the morning of 03/27/23, the resident said she had a broken left leg and was not able to walk. She was concerned that she might never be able to return home if she did not learn to walk. The resident said everyone else seems to know all about me, everyone but me. She was unsure as to what her treatment plan for the broken leg was going to be. I don't know what I need to do to get out of here. She said, I started to just leave here because I don't feel like there is a plan and I don't think I'm getting any help. I am like a dodo bird just lying here. I have to Google up stuff.
Review of the most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/21/23 found the Resident's Brief Interview for Mental Status (BIMS) indicated the resident had a score of 15. A score of 15 is the highest score obtainable and indicates the Resident is cognitively intact.
Record review found the resident was discharged from the hospital on [DATE] with a diagnosis of: broken femur and fracture of the distal end of left femur. The discharge documentation noted the resident was to be non-weight bearing on the left lower extremity. The resident was admitted to the facility on [DATE].
On 03/22/23 a physician's order was written for 2 assist with a gait belt for transfers.
The prior physician's order from 03/14/23 noted the resident was to be transferred with a mechanical lift and assistance of 2 staff members.
At 12:45 PM on 03/27/22 the Certified Occupational Therapy Assistant (COTA) #200 and the Physical Therapy Assistant (PTA) #214 were interviewed regarding the resident's therapy and her plans for therapy services. Both staff members stated the resident can not bear weight on her left leg. COTA #200 said the resident requires much cuing to ensure she doesn't put weight on her left leg. She forgets and wants to put weight on that leg. She used a walker to transfer with us and it's all we can do to get her from the bed to the wheelchair.
Review of the visual/bedside [NAME] report, (the guidance used by nurse aides) noted the following instructions for transferring: Resident requires 2 assistance with transfers with gait belt. There was no mention the resident could not bear weight on her left leg.
Review of the admission nursing assessment dated [DATE], found the resident was to use a total mechanical lift (Hoyer) for all transfers.
A fall risk assessment completed on 03/22/23 found the resident was to have a total mechanical lift for all transfers.
A second fall risk assessment completed on 03/29/23 also indicated the resident was to have a total mechanical lift for all transfers.
On 03/27/23 at 1:45 PM, the Director of Nursing (DON) stated it isn't clear who changed the original orders from a mechanical lift which requires the assistance of 2 staff members to a gait belt. She believed the supervisor of therapy came to an IDT (interdisciplinary team) meeting and probably said 2 therapists are able to transfer the resident. She confirmed there is no guidance to the nurse aides to let them know the resident can not bear weight on her left leg at this time.
On 03/29/23 at 12:40 PM, the DON confirmed the fall risk assessments indicated the resident should be transferred with a mechanical lift and 2 staff members and not a gait belt with 2 staff members. The most recent fall risk assessment does not match the instructions provided to the nurse aides on the [NAME].
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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
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation and staff interview, the facility failed to insure food was prepared and distributed in accordance with p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation and staff interview, the facility failed to insure food was prepared and distributed in accordance with professional standards for food service safety. The cook did not have a hair restraint while in the kitchen area of the CTC unit. In addition, temperatures were not consistently taken on unit pantries and the refrigerators and microwaves were in need of cleaning.These were random opportunities for discovery and had the potential to affect more than an isolated number of residents. Facility census: 149.
Findings included:
a) Observation of the CTC unit
According to the current standards of practice such as the Food Code of the FDA, food service staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent hair from contacting food.
Observation of the CTC kitchen area on 03/28/23 at 10:40 AM, found employee #147 a cook was in the kitchen area preparing for the noon meal. [NAME] #147 did not have a hair restraint. The culinary director was present during the observation. CD #52 was asked if [NAME] #147 should be wearing a hair restraint while in the kitchen area? CD #52 then told [NAME] #147 to get a hair net.
Cook #147 donned a hair restraint (hair net) while standing in the kitchen area. [NAME] #147 only placed the hair net on the top part of her head down to her ears. [NAME] #147 had many shoulder length braids which remained outside the hair restraint.
At 12:10 PM on 03/28/23, the administrator observed [NAME] #147 in the kitchen area of the CTC with the hair net still on the top of her head. Her many braids remained outside the hair net. The administrator said she would take care of it.
b) Nourishment Room Refrigerators
Observations of all nourishment rooms in the facility on 03/26/23 beginning at 9:55 PM and concluding at 10:37 PM found the facility staff was not completing daily temperature checks for the Refrigerators and Freezers both in the morning and in the evening.
-- The temperature log in the East [NAME] pantry on the first floor was missing the following temperature readings:
Refrigerator Log
The AM checks on 03/14/23, 03/15/23, 03/22/23, 03/24/23, 03/25/23 and 03/26/23.
The PM checks on 03/13/23, and 03/21/23.
Freezer Log
The AM checks were missing on 03/14/23, 03/15/23, 03/22/23, 03/24/23, 03/25/23 and 03/26/23.
The PM checks were missing on 0313/23 and 03/21/23.
-- The temperature log in the East [NAME] pantry on the second floor was missing the following temperature readings:
Refrigerator Log
The AM checks on 03/19/23, 03/24/23, 03/25/23, and 03/26/23.
The PM check on 03/13/23.
Freezer Log
The AM checks on 03/25/23 and 03/26/23.
-- The Temperature log in the CTC ([NAME] Transitional Care Unit) on the first floor was missing the following temperature readings:
Refrigerator Log
The PM checks on 03/03/23, 03/05/23, 03/06/23, 03/07/23, 03/10/23, 03/11/23, 03/12/23, 03/17/23, 03/21/23, and 03/24/23.
Freezer Log
The PM checks on 03/03/23, 03/05/23, 03/06/23, 03/07/23, 03/10/23, 03/11/23, 03/12/23, 03/17/23, 03/21/23, and 03/24/23.
-- The temperature log in the CTC unit on the second floor was missing the following temperature readings:
Both the Refrigerator and Freezer logs were missing the PM reading for the entire month beginning on 03/01/23 and continuing through 03/25/23.
On the night of 03/26/23 the surveyor obtained pictures of the temperature logs in each pantry excluding the CTC unit Second floor. When the surveyor returned to the facility the following day and went to retrieve copies of all the logs it was found someone at the facility had filled in all the missing dates. With the exception of the CTC 2 pantry which was still missing all the PM checks.
During an interview with the Nursing Home Administrator on 03/27/23 beginning at 1:53 PM she was asked to observe the photographs taken on the night of 03/26/23 and compare them to the logs received by the surveyor today. She agreed the logs were not complete on the night of 03/26/23 and it appeared someone had filled in the missing temperatures erroneously .
c) Pantry Refrigerators/Microwaves
During the initial tour on 03/26/23 at 9:30 PM observations of the refrigerators and microwaves on First floor and second floor pantries were unclean. Food debris were scraped off of the microwave in the second floor pantry. The refrigerator had a spilled substance in the bottom of the refrigerator.
On 03/28/23 at 12:46 PM, an interview with the Dietary Director revealed the Dietary Department was responsible for the cleaning of the unit pantries refrigerators and microwaves. The Dietary Director was informed of observations of the microwaves and refrigerators on each unit and stated that she would clean them today. At 4:35 PM when passing the Dietary Director in the hallway stated that all of the refrigerators and microwaves were now clean.
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Mar 2023
5 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
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to ensure the resident/resident representative was pro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to ensure the resident/resident representative was provided a written notice for an acute hospital transfer. This was true for one (1) of three (3) residents reviewed for hospital transfers. Resident identifier: Resident #147. Facility census: 146.
Findings Included:
a) Resident #147
A medical record review on 02/27/23 at 11:30 AM revealed Resident #147 was transferred to the hospital on [DATE]. The record did not reflect that the resident/resident representative was provided with a written Notice of Transfer, indicating the reason for transfer, the effective date of transfer, the location to which the resident was transferred.
During an interview on 02/27/23 at 12:31 PM, the Medical Records Clerk #40 stated there was no Notice of Transfer sent to the Resident or Residents representative.
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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 F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review, policy review and staff interview, the facility failed to provide evidence a Bed Hold Notice w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review, policy review and staff interview, the facility failed to provide evidence a Bed Hold Notice was given to residents/resident representatives when transferred to the hospital. This was true for one (1) of three (3) hospital transfers reviewed during the complaint survey. Resident identifier: #147. Facility census: 57.
Findings Included:
A review of the facility policy titled Bed Hold Policy with no date found the following.
Policy:
.It is the intent of this facility to obtain the proper authorization to hold a resident bed when the resident returns to the hospital or goes on a leave.
The bed hold authorization form may be signed prior to the patient leaving the building, or within 24 hours of the resident leaving the facility or the following business day if the resident leaves on the weekend or a holiday.
Procedure:
1. In the event a resident returns to the hospital or goes on a leave, the following process will be followed by the facility:
a. The Admissions Director or designee will notify the resident and/or responsible party of the days available under their Medicaid benefits or the private pay cost associated with holding the bed will be explained, within 24 hours of the patient leaving the facility, or the following business day if the patient leaves on a weekend or holiday.
b. The nurse or designee will obtain the residents or responsibly party's signature on the bed hold authorization form each time the resident leaves on bed hold. If the bed hold authorization form cannot be signed prior to the resident leaving and needs to be mailed, it must be mailed certified return receipt requested by the Business office Manager or designee
a) Resident #147
A medical record review on 02/27/23 at 11:30 AM, revealed Resident #147 was transferred to the hospital on [DATE]. The record did not reflect that the resident/resident representative was provided with a written Bed Hold authorization.
During an interview on 02/27/23 at 12:31 PM, the Medical Records Clerk #40 stated there was no Bed Hold Authorization sent to the Resident or Residents representative.
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CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
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Based on medical record review and staff interview, the facility failed to ensure the accuracy of a Minimum Data Set (MDS) Assessment (MDS) for a resident being discharged . This was true for one (1...
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Based on medical record review and staff interview, the facility failed to ensure the accuracy of a Minimum Data Set (MDS) Assessment (MDS) for a resident being discharged . This was true for one (1) of three (3) reviewed for transfers to the hospital during the complaint survey. Resident Identifier: #147. Facility Census: 146.
Findings Included:
a) Resident #147
Resident #147's medical records revealed a discharge MDS with an Assessment Reference Date (ARD) of 01/24/23. The MDS revealed Section A titled Identification Information, Section A0310 titled type of assessment, Section F titled Entry/discharge reporting: Coded 11. Discharge assessment -return anticipated.
During an interview on 02/27/23 at 12:44 PM, the Administrator stated Resident #147 wanted to leave here, there was no redirecting him. The unit he was admitted to was not a secure unit with wander guards, so we sent him for a psychiatric evaluation. Adult Protective Services was in charge of Resident #147. They did not express an understanding that our facility could not accommodate him due to safety and fear of elopement. When he was being discharged from the hospital, the nurse took report from the hospital, our center nurse told the hospital we are not accepting him back due to safety reasons.
During an interview on 02/27/23 at 12:53 PM, the Director of Nursing (DON) stated Resident #14 was wanting to leave, unable to redirected. He was having behaviors and at a risk for elopement. We were calling to find an alternative place on the day they sent him, no beds were available anywhere. We did not have any beds in our secure unit for a room change. We feared for his safety,of him getting out of the building. We knew when we sent Resident #147 out to the hospital we would not be taking him back due to the safety concerns. We were sending Resident #147 back to a local hospital that he was discharged from but they were unable to take him. The ambulance took him to another local area hospital for a psych evaluation. We told the local hospital we could not take him back, for safety issues.
During an interview on 02/28/23 at 9:55 AM the Administrator acknowledged Resident #147's MDS was coded incorrectly, due to the facility not anticipating his return.
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CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical records and staff interview the facility failed to follow Standard Practice of Care recommendations for weigh...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical records and staff interview the facility failed to follow Standard Practice of Care recommendations for weight monitoring for a resident with Congestive Heart Failure (CHF). This was true for one (1) of eight (8) residents reviewed during the survey. Resident Identifier: #148 Facility Census: 146.
Findings included:
a) Resident #148
On 2/27/23 at 1:15 PM, review of the medical records show Resident #148 admitted to the facility on [DATE] at a weight of 197.6 pounds. She had a diagnosis of Congested Heart Failure (CHF). She received an intravenous fluid (IVF) bolus on 12/13/21-12/14/21. Documentation shows she had a 7.6 pound weight gain from 12/7/21 through 12/13/21.
Due to her diagnosis of CHF she should have been re-weighed and the weight reported to the Physician if this was a true weight gain. The facility failed to re-weigh her as standard practice of care which indicates to report a weight gain of five (5) pounds or more to the Physician for a CHF diagnosis. This was confirmed with the Director of Nursing and Administrator on 3/01/23 at 8:35 AM.
12/20/2021 09:50
201.8 Lbs
Standing
12/13/2021 09:07
205.2 Lbs
Standing
12/13/2021 09:05
205.2 Lbs
Standing
12/7/2021 09:57
197.6 Lbs
Mechanical lift scale
12/7/2021 09:55
197.6 Lbs
Mechanical lift scale
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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
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Based on observation and staff interview the facility failed to ensure a safe environment for residents. The treatment cart for the Transitional Care Unit was found unlocked. This was a random oppor...
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Based on observation and staff interview the facility failed to ensure a safe environment for residents. The treatment cart for the Transitional Care Unit was found unlocked. This was a random opportunity for discovery during a complaint investigation in the area accidents during the Long Term Care Survey Process. Facility census: 146.
Findings included:
a) Unlocked treatment cart
During a random opportunity for discovery on 02/27/23 at 12:39 PM, observation found the treatment cart for the Transitional Care Unit was unlocked.
On 02/27/23 at 12:42 PM, the Unit Charge Nurse #26 verified the treatment cart was unlocked.
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Nov 2022
14 deficiencies
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
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Based on resident interview, record review, and staff interview, the facility failed to ensure one (1) of one (1) resident reviewed for the care area of notification of changes was informed in advan...
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Based on resident interview, record review, and staff interview, the facility failed to ensure one (1) of one (1) resident reviewed for the care area of notification of changes was informed in advance of outpatient appointments. Resident identifier: #5. Facility census: 144.
Findings included:
a) Resident #5
On 11/14/22 at 9:50 AM, the resident said, I never know when my appointments are. One day not too long ago they came in, woke me up from a sleep, and said you are going to the doctor now. I said what Doctor am I going to? I wish they would tell me these things before it's time to go. If they would tell me, I would keep track of the appointments. The resident said this has happened before.
Review of the medical record found the physician determined the resident has capacity to make decisions on 04/06/20 and again on 05/04/22.
The residents most recent minimum data set (MDS) with an assessment reference date (ARD) of 08/17/22 indicated the resident was cognitively intact with a brief interview for mental status (BIMS) of 15.
Review of the electronic medical record found the following:
04/20/2022 08:19
Appointments Note
Appointment : Note new order for appt (appointment) at (Name of Hospital) imaging for 2D echo 4/21/2022 at 2:30 pm. MPOA (medical power of attorney) aware.
On 05/04/22 an order was written for (Name of physician) (neurologist) appointment on 10/28/2022 at 1:00 pm.
On 11/15/22 at 9:42 AM, the Registered Nurse (RN) unit manager, #101 said she told the resident about the echo appointment on 04/21/22, but she didn't document anything. RN #101 confirmed she could find no documentation the resident was aware of the neurologist appointment scheduled on 10/28/22.
During an interview that began at 11:59 AM, on 11/16/22, the above issues were discussed with the administrator. No further information was provided before the close of the survey.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to ensure appropriate information was communicated to the rece...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to ensure appropriate information was communicated to the receiving hospital to ensure a safe and effective transition of care. This was true for one (1) of three (3) residents reviewed for the care area of hospitalizations during the long-term care survey process. Resident Identifier: Resident #493. Facility census: 144.
Findings included:
A facility policy titled Transfer and discharge (including AMA) with a revision date of 05/03/21 found the following.
.7. Emergency Transfers/Discharges
.d. Completed and send with the patient a Transfer Form which documents:
i.Patients status, including baseline current mental behavioral and functional status and recent vital signs
ii. Current diagnosis, allergies and reason for transfer/discharge.
iii. Contact information of the practioner responsible for the care of the patient
iv. Patient representative information including contact information
v. Current medication medication (including when last received), treatments, most recent relevant lab and/or radiological findings and recent immunizations
vi. Special instructions or precautions for ongoing care to include precautions such as isolation or contact
vii. Special risks such as risk for falls, elopement, bleeding or pressure injury and or aspiration precautions
viii. Comprehensive care plans goals and
ix. Any other documents, as applicable to ensure a safe and effective transition of care.
e. A copy of any Advance Directive, Durable Power of Attorney, DNR or Withholding or Withdrawing of Life-Sustaining Treatment forms should be sent with the patient.
a) Resident #493
A medical record review on 11/15/22 at 12:07 PM, revealed a nurse note dated 07/08/22 typed as written resident sent out to the ER.
Review of the medical record on 11/15/22 revealed a discharge Minimum Data Set, dated [DATE].
A further review of the medical record on 11/15/22 07/07/22, revealed A nurses note written by Registered Nurse #73 dated 07/07/22 typed as written called to room .pt (patient) sitting on side of her bed and pt yelling that her left hip popped,. with 2 therapists at bedside,.spontaneously the hip popped as she was trying to bear a little weight .not even full weight was achieved, pt sitting on side of bed and the NP (nurse practioner) was called and updated and stat ray of the left hip ordered.
The record did not reflect that a transfer form was completed by nursing staff and sent with the patient to the receiving facility. There was no evidence the facility had communicated contact information of the physician responsible for the care of the resident, resident representative information including contact information, advance directive information, any special instructions or precautions for ongoing care.
During an interview on 11/16/22 at 10:45 AM the Director Of Nursing acknowledged there was no evidence the facility provided any documentation to the receiving hospital when Resident #493 was transferred to a local emergency room
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to provide evidence a copy of the Notice of Transfer w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to provide evidence a copy of the Notice of Transfer was sent to the Office of the State Long-Term Care Ombudsman. This was true for one (1) of three (3) reviewed for the care area of hospitalization during the long-term care process. Resident Identifier: Resident #493. Facility Census: 144.
Findings Included:
A facility policy titled Transfer and Discharge (including AMA) with a revision date 05/03/21 found the following.
.7. Emergency Transfers/Discharges
.k. Social Services Director, or designee, shall provide notice of transfer to a representative of the State Long-Term Care Ombudsman via monthly list.
a) Resident #493
During a review of Resident #493's medical record on 11/15/22 at 12:07 PM, revealed she was transferred to a local hospital on the following dates:
-07/29/22
-07/07/22
-06/21/22
A further review of the medical record revealed Resident #493 was provided Bed hold policy on the following dates:
-07/29/22
-07/07/22
-06/21/22
During an interview on 11/15/22 at 1:21 PM the Administrator stated the Social Worker sends them every Friday. She does not keep the fax confirmation where they are faxed every Friday. I will look through the fax confirmations to see if I can find the information.
On 11/16/22 at 9:33 AM, the Administrator acknowledged the facility was unable to provide evidence the facility had sent a copy of the Notice of Transfer to the Office of the State Long-Term Care Ombudsman for her transfers to the hospital on [DATE], 07/07/22 and/or 06/21/22.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to ensure two (2) of twenty-nine (29) minimum data sets (MDS) ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to ensure two (2) of twenty-nine (29) minimum data sets (MDS) reviewed during the Long-term Care Survey Process (LTCSP) were accurately coded. For Resident #75, the MDS were inaccurate in area of medication. For Resident # 104 the MDS inaccurately coded her siderails as a physical restraint. Resident identifiers: #75 and #104. Facility census: 144.
Findings include:
a) Resident #75
Review of Resident #75's medical records revealed Resident #75 was re-admitted to the facility on [DATE].
Review of Resident #75's 5 day-admission MDS with assessment reference date (ARD) of 10/09/22, found under section N -Medications; the MDS was coded the resident's use of an anticoagulant.
Resident #75's physicians orders reviewed found an order for, Plavix-(Clopidogrel) 75 milligrams (mg) daily
Review of the Center for Medicare and Medication Services (CMS), Resident Assessment Instrument (RAI) Version 3.0 Manual CH 3: MDS Items [P] Page N-7.
N0410E, Anticoagulant (e.g., warfarin, heparin, or low- molecular weight heparin): Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Do not code antiplatelet medications such as aspirin/extended release, dipyridamole, or clopidogrel here.
During an interview on 11/16/22 at 2:00 PM with the MDS Coordinator, Employee #146, confirmed Resident #75's MDS with ARD of 10/09/22 was inaccurate related to the use of anticoagulant. He agreed Plavix is an antiplatelet medication, not an anticoagulant medication.
b) Resident #104
During a medical record review on 11/15/22 the MDS assessment with an annual reference date (ARD) of 08/05/22 had Resident #104 coded as having a restraint in Section P. Resident #104 used quarter bed rails for turning and repositioning and were not used as a restraint.
In an interview with the MDS Coordinator on 11/15/22 at 1:12 PM, the MDS coordinator reported the MDS (Section P) incorrectly coded bed rails as a restraint.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
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Based on resident interview, observation and record review the facility failed to develop and implement a care plan for two (2) of 27 records reviewed during the long term care survey. Resident iden...
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Based on resident interview, observation and record review the facility failed to develop and implement a care plan for two (2) of 27 records reviewed during the long term care survey. Resident identifiers: #5 and #19. Facility census: 144.
Findings included:
a) Resident #5
On 11/14/22 at 8:36 AM, the resident said her hearing aids were broken. She said I am afraid I will have an appointment with the neurologist and I won't be able to understand what he is saying. It is very important that I hear him because I need to know what's happening to me. The surveyor had to adjust the voice tone and stand at the resident's left side for the resident to hear. The resident said one hearing aid is broken and the other one isn't working. They told me those need cleaned but I can't clean them myself. The resident said she was unsure of the exact time frame when each hearing aid quit working. She said it was less than a month. One broke probably 3 weeks ago. Then the other one quit, working about a week ago.
Review of the medical record found the physician determined the resident has capacity to make decisions on 04/06/20 and again on 05/04/22.
The residents' most recent minimum data set (MDS) with an assessment reference date (ARD) of 08/17/22 indicated the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15. The MDS also coded the resident as having hearing aids.
Review of the residents' current care plan found a focus, dated 09/08/20:
(Name of Resident) is hard of hearing
The goal associated with the focus:
(Name of Resident) will be able to make basic needs known daily through next review period.
Interventions included:
Eliminate background noise as able to facilitate effective communication.
Monitor physical and non-verbal indicators of distress/frustration related to communication deficit and follow up.
Speak directly to resident in a slow, clear, concise voice. Look directly at resident when speaking or speak into ear if needed. Increase tone of voice if needed for resident to hear.
On 11/15/22 at 1:35 PM, the MDS coordinator #146 reviewed the care plan. E #146 said, normally I would include wearing the hearing aids as an intervention to improve the residents hearing, but I didn't write that care plan. E #146 could not find any information on the care plan indicating the resident had hearing aids and the hearing aids should be checked to confirm they were in good working order.
b) Resident #19
Observation of the resident on 11/14/22 at 8:56 AM, found the resident was wearing bilateral hand palm guards for contractures.
Record review found an order dated 06/22/22:
Apply bilateral hand palm guards by CNA in AM after skin care. Remove in PM by CNA
No directions specified for order.
Review of the residents' current care plan found a focus:
(Name of resident) requires assistance for ADL (activities of daily living) care as evidenced by need for total staff assistance d/t TBI (traumatic brain injury) with quadriplegic, cognitive impairment, bilateral contractures to bilateral upper and lower extremities. He has excessive secretions, constipation, muscle spasms, GERD.
The need for bilateral hand palm guards was not addressed on the residents' care plan.
On 11/16/22 at 10:25 AM, the assistant administrator (AA) #62 reviewed the care plan and confirmed the physicians' order to wear the bilateral hand palm guards was not care planned.
During an interview that began at 11:59 AM, on 11/16/22, the above issues were discussed with the administrator. No further information was provided before the close of the survey.
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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
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Based on record review, observation and staff interview, the facility failed to follow a physician's order for the application of hipsters for a resident with a history of multiple falls. This was t...
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Based on record review, observation and staff interview, the facility failed to follow a physician's order for the application of hipsters for a resident with a history of multiple falls. This was true for one (1) of four (4) residents reviewed under the care area of falls. Resident Identifier: #33. Facility Census: 144.
Findings Included:
a) Resident #33
On 11/15/22 at 11:30 AM, a record review was completed for Resident #33. A physician's order dated 08/02/22 stated the following:
hipsters at all times may remove for bathing, hygiene, and skin checks every day and every night shift.
The care plan also listed hipsters at all times as an intervention under the focus area of actual falls with potential injuries .
On 11/15/22 at 1:35 PM, the resident was found with no hipsters in place. Nurse Aid (NA) #88 verified the resident was not wearing the hipsters per the physician's order.
On 11/15/22 at 2:17 PM, the Administrator was notified and confirmed the resident should be wearing hipsters per the physician's order and care plan intervention.
No further information was obtained during the long-term survey process.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
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Based on resident interview, observation, and record review, the facility failed to ensure one (1) of one (1) resident reviewed for the care area of communication/sensory during the long-term care s...
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Based on resident interview, observation, and record review, the facility failed to ensure one (1) of one (1) resident reviewed for the care area of communication/sensory during the long-term care survey had hearing aids in good repair. Resident identifier: 5. Facility census: 144.
Findings included:
a) Resident #5
On 11/14/22 at 8:36 AM, the resident said her hearing aids were broken. She said, I am afraid I will have an appointment with the neurologist and I won't be able to understand what he is saying. It is very important that I hear him because I need to know what's happening to me. The surveyor had to adjust the voice tone and stand at the resident's left side for the resident to hear. The resident said one hearing aid is broken and the other one isn't working. They told me those need cleaned but I can't clean them myself. The resident said she was unsure of the exact time frame when each hearing aid quit working. She said it was less than a month. One broke probably 3 weeks ago. Then the other one quit working about a week ago.
Review of the medical record found the physician determined the resident has capacity to make decisions on 04/06/20 and again on 05/04/22.
The residents' most recent minimum data set (MDS) with an assessment reference date (ARD) of 08/17/22 indicated the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15.
On 11/15/22 at 8:20 AM, the resident said, I don't know what you said to those people out there, but they are getting my hearing aids fixed.
On 11/15/22 at 8:27 AM, the residents' nurse aide (NA) #88 said the resident had a broken hearing aid. She said she thought last week a part was ordered, but it just hasn't came in yet.
On 11/15/22 at approximately 9:00 AM, the Registered Nurse (RN) unit manager #101 said, I told the resident about 6:00 this morning I would get her hearing aids repaired.
Review of the medication administration record (MAR) found an order dated 05/20/21:
Place bilateral hearing aids every morning and remove at bedtime two times a day. Review of the MAR with RN #101 found the day shift nurse initialed the hearing aids were put in at 10:00 AM on 11/14/22 and the evening shift nurse initialed the hearing aids were removed at 10:00 PM on 11/14/22. The MAR was initialed daily from 11/01/22 to present indicating the hearing aids were worn by the resident.
On 11/15/22 at 9:25 AM, RN #101 and the surveyor interviewed the resident in her room. The resident was asked if she wore her hearing aids yesterday (11/14/22?) The resident said, they were broke, how could I wear them? The resident had RN #101 get the hearing aids out of a cup on the over the bed table. RN #101 found the left hearing aid had the battery encasement broken, the broken piece was in the cup. The resident said the right one doesn't work either. RN #101 gathered the residents hearing aids and said I am taking them to the audiologist today for repair.
RN #101 was asked how the nurse could have documented on the MAR the resident wore the hearing aids yesterday when they were not working yesterday? RN #101 said she did not know.
On 11/15/22 at 9:57 AM, the licensed practical nurse (LPN) #120 who initialed the MAR saying the hearing aids were placed in the residents ears on 11/14/22 was asked about the residents hearing aids and if the resident wore them yesterday. LPN #120 said, I am so new that I don't know if I did put them in or not. RN #101 was present during the interview.
During an interview that began at 11:59 AM, on 11/16/22, the above issues were discussed with the administrator. No further information was provided before the close of the survey.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on resident interview, observation, medical record review and staff interview, the facility failed to provide foot care ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on resident interview, observation, medical record review and staff interview, the facility failed to provide foot care to a diabetic resident consistent with professional standards of practice. Arrangements were not made for routine podiatry services to prevent foot complications and maintain comfort in a resident with diabetes. This was a random opportunity for discovery. Resident identifier: 10. Facility census: 144.
Findings include:
a) Resident (R) #10
During an interview on 11/14/22 at 8:58 AM, R#10 reported foot discomfort and stated she needed her toe nails trimmed. An observation during this interview found her toe nails to be long with overlapping toes.
Review of the medical record on 11/15/22 revealed R#10 was admitted to the facility on [DATE] with multiple diagnoses including diabetes. The physician orders include an order for a podiatrist consult written 03/22/22. The care plan states see podiatrist as needed for diabetic foot care. The record lacks any information regarding podiatry services or visits since R#10's admission.
During an interview on 11/16/22 at 8:45 AM, Registered Nurse (RN) #145 reviewed the medical record and confirmed R#10 has not seen a podiatrist. RN #145 acknowledged R#10 is a diabetic and podiatry visits should have been scheduled.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
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b) Resident #47
On 11/14/2022 at 10:57 AM, the resident said she is supposed to have palm guards for her hands, and staff are not putting them on. Observation found no palm guards were in place. Res...
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b) Resident #47
On 11/14/2022 at 10:57 AM, the resident said she is supposed to have palm guards for her hands, and staff are not putting them on. Observation found no palm guards were in place. Resident #47 states that she believes they must have thrown it away as she said she has not seen it in a long time.
On 11/14/2022 at 1:55 PM, staff observed that resident #47 did not have palm guards in place as directed by the care plan which says, CNA (certified nursing assistant) to apply left palm guard in the AM after skin care. CNA to remove in the PM, dated 06/20/2022.
On 06/22/22, the physician wrote an order for: CNA to apply left palm guard in the AM after skin care. CNA to remove in the PM, order dated 06/22/2022.
On 11/14/2022 at 2:00 PM, Registered Nurse (RN) #14 stated that applying the palm guard was a task assigned to the nursing assistants and she was unsure if they are currently applying the palm guard to resident.
On 11/15/2022 at 9:00 AM, Resident #47 was again observed by staff without palm guard.
On 11/15/2022 at 9:10 AM, the Assistant Director of Nursing (ADON) #5 reported the palm guard was currently in the laundry and must have been sent down there on 11/14/2022, and the CNA's are the ones who log this into point of care (POC.) ADON #5 provided the POC print out of last 30 days of entries from point of care by the CNA's. POC documentation indicates that staff applied the palm guard on 11/14/2022 at 11:29 AM, with no indication of it being removed that same day, and the POC also indicates that it was applied on 11/15/2022 at 6:59 AM.
On 11/15/2022 at 9:15 AM, RN Unit Manager #101, stated that resident says she does not like the current splint and they will be working with the physical therapy department to attempt to find another suitable guard for the resident.
On 11/15/2022 at 10:00 AM, upon record review, CNA staff documented that palm guard splint was applied to resident on 11/14/2022 at 11:29AM despite staff having observed resident without split and on 11/15/2022 at 6:59 AM while the splint was in the laundry.
On 11/16/22 at 8:15 AM, record review indicated that RN Unit Manager #101 documented on 11/15/2022 at 10:02 AM, Attempted to apply left palm guard, resident stated I don't like wearing that. Note to d/c current splint, will refer back to therapy for appropriate interventions. Unable to reach MPOA message left.
Based on observation, record interview, and staff interview, the facility failed to ensure interventions to maintain range of motion were in place for two (2) of four (4) residents reviewed for positioning/ mobility. Resident identifiers: #117 and #47. Facility census: 144.
Findings included:
a) Resident #117
Observations of the resident on 11/14/22 at 9:00 AM, and 11:52 AM found the resident had contractures of both hands. No splinting devices or any palm protectors were in place.
Review of the medical record found the resident had a physicians order for bilateral hand palm guards by CNA in the AM after skin care. Remove in PM by CNA. Notify nurse with any concerns.
On 11/14/22 at 11:52 Licensed Practical Nurse (LPN) #120 confirmed the resident did not have any bilateral hand palm guards in place. She said, I am new here but I will look for them. At 12:07 PM LPN #120 confirmed she was unable to have any palm guards in the residents room.
On 11/14/22 at 12:49 PM, LPN #120 said, They found a carrot and it's in his right hand. Observation of the resident at 12:55 PM confirmed the statement.
Observations of the resident on 11/15/22 at 8:11 AM and 11:22 AM found no palm guards were in the residents hands.
Observation of the resident at 8:30 AM on 11/16/22 found no palm guards were in place.
On 11/16/22 at 8:45 AM, Registered Nurse Unit Manager (RN) #101 said, typically around 9:00 AM when the resident gets up he would have skin care and the bilateral palm protectors would be applied. The palm protectors would be removed around bed time.
The documentation survey report completed by nurse aides was reviewed with RN #101. On 11/14/22 a nurse aide initialed the palm protectors were placed on the resident at 12:11 PM. There was no documentation to indicate the palm protectors were ever removed on 11/14/22. On 11/15/22 documentation revealed the palm protectors were placed on the resident at 12:34 PM. There was no documentation the palm protectors were ever removed. RN #101 confirmed the order indicates the palm protectors should be on the resident every day in the AM which would be before noon. The documentation on 11/14/22 and 11/15/22 does not support the physician's order was followed as written.
On 11/16/22 at 9:07 AM, observation of the resident with the Director of Nursing (DON) found only one (1) carrot could be found in the residents' room in the dresser drawer.
During an interview that began at 11:59 AM, on 11/16/22, the above issues were discussed with the administrator. No further information was provided before the close of the survey.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
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Based on medical record review, observation and staff interview the facility failed to provide hemodialysis services consistent with professional standards of practice. This was discovered for one (...
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Based on medical record review, observation and staff interview the facility failed to provide hemodialysis services consistent with professional standards of practice. This was discovered for one (1) of one (1) resident reviewed for dialysis services during the Long Term Care Service Process. Resident identifier: #96. Facility census: 144.
Findings included:
a) Resident #96
During a medical record review for Resident #96 on 11/15/22 a physician's order indicated hemostats were to be readily available for Resident #96's perma catheter.
On 11/16/22 at 8:42 AM, the Unit Charge Nurse #145 was unable to locate any hemostats in Resident #96's room. The UCN #145 reported the hemostats were not readily accessible at bedside for the perma catheter for Resident #96.
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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
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Based on record review and staff interview the facility failed to ensure the physician provided a rationale for disagreeing to discontinue an unnecessary medication, recommended by the facility phar...
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Based on record review and staff interview the facility failed to ensure the physician provided a rationale for disagreeing to discontinue an unnecessary medication, recommended by the facility pharmacist. This was true for one (1) out of five (5) residents reviewed for unnecessary medications. Resident identifiers: # 114. Facility census 144.
Findings included:
a) Resident #114
Medical record review found on 10/21/22, the facility pharmacist recommended the medication, Methenamine Hippurate 1 gram to be discontinued. Methenamine Hippurate is used to prevent urinary tract infections (UTI).
The facility attending physician did not provide a rationale for disagreeing with the pharmacist. The physician marked the disagree box, signed, and dated the recommendation.
During an interview on 11/15/22 at 2:00 PM, the Administrator agreed there was no rationale provided for not accepting the Gradual Drug Reduction (GDR) recommended by the pharmacist.
On 11/15/22 at 2:12 PM, the Director of Nursing (DON) verified the physician provided no rationale for disagreeing with the pharmacist.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it ...
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Based on observation and staff interview, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it was discovered food had not been dated after opening and the ice machine needed to be cleaned. These practices had the potential to affect a limited number of residents receiving nourishment from the kitchen.
Facility census: 144.
Findings included:
a) Kitchen tour
During the kitchen tour on 11/14/22 at 10:56 AM, it was discovered a package of parmesan cheese was not dated after opening and the ice machine was dirty with corrosion build up around the lid area.
On 11/14/22 at 11:05 AM, the Dietary Manager verified the parmesan cheese had not been dated after opening and the ice machine needed to be cleaned.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
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Based on record review, observation and staff interview, the facility failed to ensure the residents medical record was complete and accurate for two (2) of four (4) residents reviewed for position ...
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Based on record review, observation and staff interview, the facility failed to ensure the residents medical record was complete and accurate for two (2) of four (4) residents reviewed for position and mobility. Resident identifier: #117 and #19. Facility census: 144.
Findings included:
a) Resident #117
Review of the physician's orders found the following order on the medication administration record (MAR):
Seat belt placement checks and repositioning while up in wheelchair Q (every) 2 hours
-Start Date: 08/04/22.
Review of the MAR for November 2022 with Registered Nurse (RN) unit manager #101 on 11/15/22 at 10:49 AM, found the MAR was initialed by the residents nurse every 2 hours on the following days:
11/03/22
11/06/22
11/08/22
11/09/22
11/10/22
11/11/22
11/12/22
11/13/22
RN #101 confirmed initialing the MAR every 2 hours for 24 hours would indicate the resident was up in his wheelchair all day for 24 hours a day on the above dates, which RN #101 said was not true. RN #101 said the order needed to be rewritten because it is confusing.
b) Resident #19
Observation of the resident on 11/14/22 at 8:56 AM, 11/15/22 at 8:20 AM, and 11/16/22 at 8:07 AM, found the resident was wearing bilateral hand palm guards for contractures of both hands.
Record review found a physician's order dated 06/22/22:
Apply bilateral hand palm guards by CNA in AM after skin care. Remove in PM by CNA
On 11/16/22 at 10:48 AM, Registered Nurse Unit Manager (RN) #101 reviewed the documentation survey report for November 2022, used by the nursing assistants to document the placement and removal of the bilateral hand palm guards. RN #101 confirmed the NA's are not documenting the placement and removal of the hand splints anywhere because, the order didn't carry over.
During an interview that began at 11:59 AM, on 11/16/22, the above issues were discussed with the administrator. No further information was provided before the close of the survey.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
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b) Facility: Administration of medication
A facility policy titled Medication Administration with a date of 06/21/17 found the following.
.Never touch any of the medication with fingers.
An observ...
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b) Facility: Administration of medication
A facility policy titled Medication Administration with a date of 06/21/17 found the following.
.Never touch any of the medication with fingers.
An observation on EB-1 Hall on 11/15/22 at 9:45 AM, found Licensed Practical Nurse (LPN) #64 dropped a pill on the floor.
LPN #64 stated, does this apply to the five (5) second rule and laughed.
LPN #64 picked up the pill with her bare fingers off the floor, placed it in the medication cup with other medication that was already in the cup. LPN #64 continued to get another medication out of a package, thinking she dropped it on the floor. Several staff members and this surveyor looked for the medication on the floor. LPN #64 stated, Oh look it's in my pocket. LPN #64 reached in her pocket, and placed the medication in the medication cup with other pills. LPN #64 acknowledged one pill was in the floor and the other pill was in her pocket, and continued to place other medication in the cup.
Registered Nurse (RN) #145 acknowledged LPN #64 putting the pill from her pocket in the medication cup with all the other medications. RN #145 stated, you need to destroy all the medication and get new ones. Then call the pharmacy letting them know what happened, so we can get another dose of medication.
On 11/15/22 at 1:13 PM, the above information was discussed with the Director of Nursing.
Based on observation and staff interview, the facility failed to maintain appropriate infection control standards during medication administration and nebulizer storage. These were random opportunities for discovery. Resident Identifier: #77. Facility Census: 144.
Findings Included:
a) Resident #77
On 11/14/22 at 9:08 AM, a nebulizer mask was observed on the night stand without being stored in a respiratory bag. Licensed Practical Nurse (LPN) #120 confirmed the nebulizer mask was not stored correctly.
On 11/15/22 at 10:29 AM, the Administrator was notified and confirmed the nebulizer mask should be stored in a respiratory bag.
No further information was obtained during the long-term survey process.
Aug 2021
17 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 record review and staff interview the facility failed to put interventions in place to prevent avoidable pressure ulc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview the facility failed to put interventions in place to prevent avoidable pressure ulcers. In addition, the facility failed to identify and treat pressure ulcers once developed. This resulted in actual harm for Resident #338. Resident Identifier: #338. Facility Census 142.
Findings included:
a) Resident #338
Record review revealed Resident #338 was transported from the facility to the dialysis center on [DATE]. The dialysis center sent the resident to the hospital.
Medical record review found a form titled, Weekly Licensed Nurse Skin Evaluation dated, [DATE] which read as follows:
A. Skin/Check Evaluation
1. If any of the following questions are checked 'yes' indicate on the body outline.
1a. Any reddened areas that remain after 30 minutes of pressure reduction?
1) Yes
2) No
1aa. If yes indicate location/description:
---This was blank---
2a. Any rashes?
1) Yes
2) No
2aa. If yes indicate location/description
---This was blank---
3a. Any bruises?
1) Yes
2) No
3aa. If yes indicate location/description
---This was blank---
4a. Any opened lesions, cuts, lacerations. or skin tears?
1) Yes
2) No
4aa. If yes indicate location/description.
---This was blank---
5a. Any blisters?
1) Yes
2) No
5aa. If yes indicate location/description.
---This was blank---
6a. Any existing ulcers (previously identified)?
1) Yes
2) No
6aa. Any new ulcers?
1) Yes
2) No
6aaa. If yes indicate location/description.
---This was blank---
7a. Excessively dry or flaky skin?
1) Yes
2) No
7aa. If yes indicate location/description.
---This was blank---
8a. Nursing Note:
Weekly skin assessment completed. No new skin issues noted. Noted lesion to right heel and noted redness to buttocks is not new. Treatments already in place.
Signed by Registered Nurse # 122. Dated [DATE].
A review of the medical record found treatment orders as follows:
*Cleanse bilateral buttock with skin cleansing lotion. pat dry, Apply Chamosyn every shift and night.
*Cleanse groin with skin cleansing lotion, pat dry, apply antifungal powder every shift and night.
*Apply Topicort Cream to lesion on right heel every shift.
A nursing note written by Licensed Practical Nurse # 270 (former employee) on [DATE] at 3:47 AM:
Resident has BIL (bilateral) laceration type wounds to inner thigh resulting from resident digging herself with her fingernails. ABD pads placed for protective measures, but resident refuses any creams to be applied. Resident has been digging places on her buttock with her fingernails as well. Resident refuses to let staff cut her fingernails.
Review of the medical record found no evidence indicating the attending physician was notified of the resident's behaviors and noncompliance with treatment. There was no further evidence found in the medical record regarding Resident # 338's skin condition.
A review of the admission assessment forms completed by the hospital at the time time of arrival on [DATE] found the following pressure ulcers:
Wound #1 Thigh left, right circumferential
Type of wound: Pressure Ulcer
Present on admission: [DATE]
Pressure ulcer stage: Deep Tissue Injury (DTI)
Wound length: 24 cm (centimeters)
Wound width: 8 cm
Color Purple
Wound #2 Thigh Left Anterior
Type of wound: Pressure ulcer
Present on admission: [DATE]
Pressure Ulcer stage: III
Wound length: 4cm
Wound width: 0.5 cm
Wound #3 Buttock left
Type of wound: Pressure ulcer
Present on admission: [DATE]
Pressure ulcer stage: II
Wound length: 6 cm
Wound width: 5cm
Wound #4 Coccyx
Type of wound: Pressure Ulcer
Present on admission: [DATE]
Pressure Ulcer stage: II
Wound length: 2,5 cm
Wound width: 1 cm
Wound #5 Buttock Right
Type of wound: Pressure Ulcer
Present on admission: [DATE]
Pressure ulcer stage: II
Wound length: 7.8
Wound width: 5 cm
Wound #6 Thigh right posterior upper
Type of wound: Pressure Ulcer
Present on admission: [DATE]
Pressure ulcer stage: Deep Tissue Injury
Wound length: 4 cm
Wound width: 8cm
Color: purple
Wound #7 Thigh right middle posterior
Type of wound: Blister, Pressure Ulcer
Present on admission: [DATE]
Pressure ulcer stage: Deep Tissue Injury
Wound length: 4 cm
Wound width: 9 cm
Wound #8 Right ankle posterior
Type of wound: Pressure ulcer
Present on admission: [DATE]
Pressure ulcer stage: Deep Tissue Injury
Wound length: 1.5 cm
Wound width: 0.5
Wound #9 Right ankle lateral
Type of wound: Pressure Ulcer
Present on admission: [DATE]
Pressure ulcer stage: Deep Tissue Injury
Wound length: 2 cm
Wound width: 0.5 cm
Wound #10 Right heel
Type of wound: Pressure ulcer
Present on admission: [DATE]
Pressure ulcer stage: Deep Tissue Injury
Wound Length: 3 cm
Wound width: 3 cm
Wound #11 Left heel
Type of wound: Pressure ulcer
Present on admission: [DATE]
Pressure ulcer stage: Deep Tissue Injury
Wound length: 3 cm
Wound width: 3 cm
During an interview on [DATE] at 11:00 AM, Registered Nurse (RN) # 75 stated this happened before the facility developed a wound care team. She went on to say that the facility knew they had a problem at that time with inaccurate documentation on the weekly skin assessments. RN #75 and the Administrator had no further comments.
Resident # 338 was admitted to the local hospital on [DATE] with the diagnosis of Sepsis (is a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to malfunctioning of various organs, shock and death). Resident # 338 expired on [DATE] from Sepsis.
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SERIOUS
(G)
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** .
Based on record review, staff and resident interview, and observation, the facility failed to consistently provide pain manage...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, staff and resident interview, and observation, the facility failed to consistently provide pain management, attempt non-pharmacological interventions, document the location of the pain, and the severity of pain in accordance with the physicians' orders for Resident #3. This failure resulted in actual harm for Resident #3. For Resident #99, the facility failed to rate the resident's pain before administering an as needed (PRN) pain medication. In addition, the facility administered pain medication when the resident indicated there was no pain. For Resident #340 the facility failed to document non-pharmacological interventions attempted, failed to document the location of pain, and failed to document the administration of narcotics signed out on two (2) occasions. These findings were a random opportunity for discovery. Resident identifiers: #3, #99, #340. Facility census: 142.
Findings included:
a) Resident #3
Observation
During initial tour of the long-term care facility on 08/02/21 at 11:28 AM, Resident #3 stated she is always in pain and said, I got one (pain medication) coming now should be time for it. At that time the Resident rated her pain level at a seven (7) on a one (1) to ten (10) pain scale with 10 being the most severe. The Resident was noted to be rubbing her left leg during interview, grimacing with slightly reddened face, and crying. Resident stated she had an old leg fracture on the left side and that caused her leg and hip pain constantly, sometimes keeping her awake at night. Resident stated she gets pain medication every 6 hours and she used to get them every 4 hours, but they changed it and she can't get anyone to talk to her about why. The Resident stated again, I am always in pain. Resident stated, Sorry to be 'weepy, but that's what I do when I hurt. The Resident rubbed her lower stomach and stated, I also have a terrible problem with my bowels and being constipated, it's a constant battle and so uncomfortable.
At 11:30 AM on 08/02/21, the surveyor informed Licensed Practical Nurse (LPN) #239, in the B hallway outside the residents room, the resident was having pain. LPN #239 stated That resident (Resident #3) is on Hall A med cart, I don't have her I have Hall B Med Cart. Her meds are given from Hall A med cart. Surveyor located medication cart for hall A occupied by LPN #44, and informed LPN #44 Resident #3 was crying in pain and requested a pain pill. LPN #44 stated, Yea she does that, I will be giving it soon, she is scheduled to have it at noon.
Record Review
Record review of Resident's active orders revealed an order for Norco Tablet 7.5-325 mg (hydrocodone-acetaminophen) give one tablet by mouth every six hours.
Review of Residents Medication Administration Record (MAR) for May of 2021 indicated the scheduled pain medication, (Norco Tablet 7.5-325 mg (hydrocodone-acetaminophen) to be given every six hours), doses were omitted on the following dates:
May 2021 -
5/05/21 - 6:00 PM dose omitted.
5/13/21 - 6:00 AM dose omitted.
5/14/21 - 6:00 AM dose omitted.
5/24/21 - 6:00 PM dose omitted.
Review of Residents Medication Administration Record (MAR) for May 2021 indicated the scheduled pain assessment was not adequately performed for the entire month of May. The pain assessment was to be completed every day and every evening shift, with question of Is Resident currently experiencing pain? 1 = yes, 2 = no. A check mark and staff initials were entered in the box for each shift (7a-7p, 7p-7a) daily, with only an X in the box where the numeric indication if Resident reported pain (1 yes, 2 no pain) should be noted.
Review of Residents Medication Administration Record (MAR) for June of 2021 indicated the scheduled pain medication, (Norco Tablet 7.5-325 mg (hydrocodone-acetaminophen) to be given every six hours), sixteen (16) doses were omitted on the following dates:
June 2021 -
6/05/21 - 6:00 PM dose omitted.
6/07/21 - 6:00 PM dose omitted.
6/09/21 - 6:00 PM dose omitted.
6/10/21 - 6:00 AM dose omitted.
6/13/21 - 12:00 PM and 6:00 PM doses omitted.
6/23/21 - 6:00 PM dose omitted.
6/24/21 - 12:00 AM, 6:00 AM, 12:00 PM and 6:00 PM doses omitted.
6/25/21 - 12:00 PM, and 6:00 PM doses omitted.
6/27/21 - 6:00 PM dose omitted.
6/29/21 - 12:00 AM and 6:00 AM doses omitted.
Review of Residents Medication Administration Record (MAR) for June 2021 indicated the scheduled pain assessment was not adequately performed for the entire of June. The pain assessment was to be completed every day and every evening shift, with question of Is Resident currently experiencing pain? 1 = yes, 2 = no. answered. A check mark and staff initials were entered in the box for each shift (7a-7p, 7p-7a) on June 1st - June 6th with only an X in the box where the numeric indication if Resident reported pain (1)/no pain (2) was to be noted. No Pain assessment was completed on June 23rd, 2021, for either shift. On June 24th and 25th, 2021 no pain assessment was completed for dayshift (7a - 7p shift).
Review of Residents Medication Administration Record (MAR) for July of 2021 indicated the scheduled pain medication, Norco Tablet 7.5-325 mg (hydrocodone-acetaminophen) that was scheduled to be given every six (6) hours for pain was omitted from administration for a total of fourteen (14) occurrences on the following dates:
July 2021 -
7/02/21 - 12:00 PM, and 6:00 PM doses omitted.
7/04/21 - 6:00 AM dose omitted.
7/05/21 - 12:00 PM and 6:00 PM dose omitted.
7/08/21 - 12:00 PM and 6:00 PM dose omitted.
7/10/21 - 12:00 PM and 6:00 PM doses omitted.
7/11/21 - 6:00 PM dose omitted.
7/25/21 - 12:00 PM and 6:00 PM doses omitted.
7/29/21 - 12:00 PM and 6:00 PM doses omitted.
Review of Residents Medication Administration Record (MAR) for July 2021 indicated the scheduled pain assessment was not adequately performed for six (6) occurrences in July. The pain assessment was to be completed every day and every evening shift, with question of Is Resident currently experiencing pain? 1 = yes, 2 = no. answered.
No Pain assessment was completed during dayshift (7a - 7p shift) for the following dates: 7/02/21, 7/05/21, 7/08/21, 7/10/21, 7/25/21, 7/29/21.
The facility's policy Pain Management, implemented 11/27/17, Revised 5/3/21, listed the following behavioral signs and symptoms for recognition that may suggest the presence of pain: bracing, guarding, or rubbing, facial expressions such as grimacing, frowning, fear, and sleeping poorly, and crying. The policy stated non-pharmacological interventions include adjusting room temperature, smoothing linens, turning, and repositioning patient, cognitive behavioral interventions, of which none were documented within the resident's medical record as attempted or provided on 08/02/21 before or after staff were notified by of Resident's pain by Surveyor.
Review of Residents Medication Administration Record (MAR) for August 1st through August 3rd, 2021, indicated the scheduled pain medication, Norco Tablet 7.5-325 mg (hydrocodone-acetaminophen was to be given every six hours and was omitted from administration on the following date: 08/02/21 - 6:00 PM dose omitted.
Review of the facility's policy, Mediation Administration, effective 06/21/17, stated, Return to the mediation cart and document medication administration with initials on the Medication Administration Record (MAR) immediately after administering mediation to each resident.
Review of most current Physician Determination of Capacity dated 9/25/20 indicated Resident #3 demonstrated capacity to make decisions.
Record review revealed Resident's last reported BIMS score of 12 on quarterly MDS in progress dated July 24th, 2021.
Review of radiology report dated 11/9/2020 concluded a S/P (status post) internal fixation of fracture of left distal femur with modest displacement without significant callus formation. The findings were unchanged from 9/18/2020. Record Review indicated a Diagnosis of Encounter of closed fracture with routine healing on with onset date 9/20/20.
Review of physician progress note dated 08/04/21 revealed documentation of Resident stating to the physician, I have never asked anyone for anything in my life, but please make my pain pill Q4H (every four (4) hours) again.
Review of the Emergency Department Physician's note provided by the facility to indicate Resident may be drug seeking (as evidenced by the Resident's sisters' information given to ED at that time) dated 01/08/2018 contained the following statement from the Emergency Department Physician: The patient presented to the ER with complaints of worsening back pain. The patient does have a history of low back pain and follows with her pain management specialist, (Doctor Last Name). The patient is currently on Norco 7.5 and has been taking as prescribed. The patient presented here via EMS and the patient's sister called to the ER multiple times stating that the patient has been taking her Norco for more frequently than prescribed. I however, looked at the patient's mediation that she brought with her, and she had the appropriate amount of Norco left in her prescription. I do not believe that the patient is overmedicating. The patient is awake and alert. She is talking to me appropriately.
Review of the Emergency Department Physician note, provided by the facility to indicate Resident may be drug seeking (as evidenced by information given to ED by the Resident's family at that time) dated 03/27/2018 contained the following:
Increase in discharged pain medication home from the Emergency Department Physician: Discharge Medications Home: Norco 10mg-325mg oral tablet, one tab every six (6) hours as needed. Resident was initially taking 7.5/325 mg dose of Norco on previous visit to ED on 01/08/20. This note does not represent the resident is, drug seeking, as the Residents pain medication was increased.
During the Pain MDS 3.0 rev 4-16 assessment conducted on 08/04/21, J0500 Pain effect on function was answered by Resident as follows:
-A. Ask the Resident, Over the past few days, has pain made it hard for you to sleep at night?
Resident Response: Yes
-B. Ask Resident, Over the past 5 days, have you limited your day-to-day activities because of pain?
Resident Response: Yes
During the Pain MDS 3.0 rev 4-16 assessment conducted on 7/23/21, J0500 Pain effect on function was answered by Resident as follows:
-A. Ask the Resident, Over the past few days, has pain made it hard for you to sleep at night?
Resident Response: Yes
-B. Ask Resident, Over the past 5 days, have you limited your day-to-day activities because of pain?
Resident Response: Yes
Record reviewed indicated the following diagnosis for he resident:
Pain in the Right Leg - onset date 5/18/18
Presence of Bilateral Artificial Knee Joint - onset 5/18/18
Other chronic pain - onset 5/18/18
Periprosthetic fracture around internal Prosthetic left knee joint subsequent encounter - onset 2/01/21. Unspecified Fracture of the left Femur subsequent encounter for closed Fracture with routine healing onset - 9/24/20.
Staff Interview
On 8/04/21 at 2:55 PM, Licensed Practical Nurse (LPN) #12 was asked to clarify the process of giving medications to Resident #3 since the Resident was located on Hall B and she had Hall A med cart. LPN #12 replied, I just remember, to flip the screen to Hall B and go check. I usually save that Resident to last. It could be easy to forget her (Resident #3) I guess since the rest of med pass is on hall A.
During an interview at 3:00 PM on 08/04/21, the Licensed Practice Nurse (LPN) #239 was asked if she ever administers mediations from Hall A med Cart to Resident #3 on Hall B, and if so how did she remember to verify all medications had been given? LPN #239 stated, Yes, sometimes I have Med Cart for Hall A, and we have a report sheet (LPN #239 pointed to clip board laying on Med Cart) that tells us our assignments so we should never forget her (Resident #3) or forgot to give her meds and should sign them off as soon as they are given.
On 8/4/21 at 11:30 AM the Administrator stated, The unit managers run an audit every morning before stand up meeting to check for any discrepancies or missed does on the MAR (Medication Administration Record) they should be catching this. We are doing an enteral audit; I notified the pharmacist sometime last week I thought we had some issues. The Administrator provided the Pharmacist phone number for use by Surveyor. Please note, the Administrator was not able to provide an exact date and time the pharmacist was notified.
During an Interview on 8/5/21 at 08:30 AM, the Director of Nursing (DON) stated, If anything I feel like these holes in the MAR are just med errors, I am sure it's a documentation issue and they (staff) forgot to sign off the meds given. We know having that one Resident from a different hall on the A Hall cart is a problem, we are working on it.
The failure to provide pain medication and assess pain level as prescribed resulted in actual harm to Resident #3.
b) Resident #99.
Medical record review revealed Resident #99's Physician order:
Norco Tablet 5-325 MG (Hydrocodone-Acetaminophen) *Controlled Drug*
Give 1 tablet by mouth every four (4) hours as needed (PRN) for pain.
A continued review of the Medication Administration Record (MAR) revealed, Resident #99 was administered as needed controlled pain medication without being assessed for pain. On five (5) occasions the resident received PRN pain medication when the pain was rated as (0), indicating no pain:
--05/31/21 at 3:00 AM pain level X- Norco given with the Code E= Effective.
--05/31/21 at 8:19 AM pain level X- Norco given with the Code E= Effective.
--06/01/21 at 1:35 AM pain level X- Norco given with the Code E= Effective.
--06/03/21 at 7:00 PM pain level X- Norco given with the Code E= Effective.
--06/04/21 at 1:18 AM pain level X- Norco given with the Code E= Effective.
--06/04/21 at 8:35 AM pain level X- Norco given with the Code E= Effective.
--07/10/21 at 9:00 AM pain level 0 - Norco given with the Code E= Effective.
--07/14/21 at 8:00 AM pain level 0 - Norco given with the Code E= Effective.
--07/22/21 at 2:22 PM pain level 0 - Norco given with the Code E= Effective.
--08/04/21 at 12:31 AM pain level 0 - Norco given with the Code E= Effective.
--08/04/21 at 5:26 AM pain level 0 - Norco given with the Code E= Effective.
On 08/04/21 at 12:45 PM, the DON stated the expectation to administer a PRN Controlled Norco, should have been evaluated for pain and not have been given if the pain level is 0.
On 08/05/21 at 08:52 AM during an Interview with DON, she stated, I feel these are medication errors and they should have been investigated.
c) Resident #340
Medical record review for Resident #340 found she was admitted to the facility on [DATE] at 10:20 pm. Diagnosis included: severe aortic stenosis, chronic respiratory failure, pseudoaneurysm, chronic obstructive pulmonary disease, diabetes mellitus, atrial fibrillation, and heart failure with preserved ejection fraction. Review of the admission minimum data set (MDS) with assessment reference date of 12/20/20 reveals a Brief Mini-Mental Interview Status (BIMS) of 15, which indicates she is cognitively intact.
Resident #340's physician orders included an order for, Percocet (oxycodone/acetaminophen) 5/325 milligrams (mgs)- give one tablet by mouth every six (6) hours for pain as needed (PRN) order date of 12/15/20.
Review of Medication Administration Record (MAR) and nurse's progress notes found: no non-pharmaceutical interventions, location and type of pain was not documented and on four (4) occasions the pain medication was ineffective with no indication the physician was notified and/or no other interventions attempted.
The following dates and times the Percocet was ineffective:
--12/15/20 at 3:37 pm
--12/16/20 at 12:23 am
--12/21/20 at 1:09 am
--12/25/20 at 8:36 am
The following dates and times the location of the pain and non-pharmaceutical interventions were not documented:
--12/15/20 at 3:37 pm
--12/16/20 at 12:23 am, 7:47 pm.
--12/17/20 at 8:30 pm
--12/18/20 at 3:10 am and 8:21 pm
--12/19/20 at 7:20 pm
--12/20/20 at 8:19 am and 8:30 pm
--12/21/20 at 1:09 am, 6:48 am and 7:36 pm
--12/23/20 at 5:32 am and 9:16 am
--12/24/20 at 5:55 am and 8:11 pm
--12/25/20 at 8:36 am and 4:39 pm
--12/26/20 at 2:41 am and 8:58 pm
--12/27/20 at 8:27 pm
--12/29/20 at 5:05 am and 8:32 pm
--12/30/20 at 5:20 am
--12/31/20 at 3:02 am, 12:23 pm and 7:30 pm
Further review of the Controlled Drug Receipt/Record/Disposition Form and the MAR found the following doses of Percocet were signed out on the Controlled Drug Receipt/Record/Disposition Form but was not documented as administered on the MAR:
--12/22/20 at 4:19 am and 11:00 pm.
During a review of the Narcotic sheets and the MAR with the Director of Nursing (DON) on 08/05/2021 at 11:30 am., she confirmed the nursing staff failed to document non-pharmacological interventions attempted and failed to document the location of pain and additionally on the two (2) above episodes the medication was signed out on the narcotic record but was not documented on the MAR as administered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
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Based on observation, record review, resident interview, and staff interview, the facility failed to ensure residents had the right to receive services in the facility with reasonable accommodations...
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Based on observation, record review, resident interview, and staff interview, the facility failed to ensure residents had the right to receive services in the facility with reasonable accommodations of the residents needs and preferences for one (1) of twenty- eight (28) residents reviewed. Resident Identifier; Resident # 63. Census: 142
Findings included:
a) Resident #63
During a resident interview on 08/03/21 at 9:00 AM, Resident #63 stated she did not want to get up in that chair (referencing the regular wheelchair in her room) because it hurt too much, and her feet could not touch the floor when seated in the chair. It was further stated, she experienced pain if she sat up too long in the regular wheelchair because of sitting there too long. An observation at this time, revealed a regular wheelchair with no footrests in place in the resident's room.
A record review noted a Physical Therapy encounter note, dated 03/02/21, showing Resident #63 was in a high back chair with an adjustable high back for comfort and could tolerate sitting up.
An Interview with the facility's Rehabilitation Director, on 08/03/21 at 11:45 AM, verified Resident #63 was supposed to have a high back chair that was assessed in March 2021 because the resident has back pain. During the interview, the Rehabilitation Director verified the wheelchair in the resident's room was not the appropriate chair for Resident #63 to use.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
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Based on interviews and record review during a recertification survey, the facility failed to ensure the right to make choices about aspects of life that is important to one (1) of two (2) residents...
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Based on interviews and record review during a recertification survey, the facility failed to ensure the right to make choices about aspects of life that is important to one (1) of two (2) residents reviewed for choices. Specifically, Resident #37 was not given showers when requested or the choice between bed baths or showers. Resident identifier: #37. Facility census: 142.
Findings included:
a) Resident #37
During an interview with Resident #37 on 08/02/21 at 12:35 PM, She stated she never receives her shower when she prefers them on the nights prior to dialysis. Resident #37 continued, sometime the staff will say they will be back to get me for a shower, but they never return.
Medical record review revealed, Resident #37's shower schedule is on Monday, Wednesday and Friday on night shift.
A review of the 05/19/21 admission Minimum Data Set (MDS), found the resident's brief interview for mental status was fourteen (14). MDS Section E (Behaviors) also indicated Resident #37 does not reject care such as ADL Care, medications, or treatments.
A review of Resident #37's Care Plan revealed,
Focus:
--Resident needs assistants with Activities of Daily Living (ADLs) due to decreased functional mobility.
Goal:
--(Named) will receive necessary assistance to meet ADL needs (being clean, dry, well groomed daily through next review.
Interventions:
--Assist Resident with showers with one (1) assist.
A continued review of Resident #37s ADL documentation found the following bathing documentation for Resident #37:
--07/02/21 at 10:04 PM- 4,3 BB = bed bath on evening shift, documented.
--07/06/21 at 8:57 PM- 8,8 NA= activity itself did not occur, documented.
--07/09/21 at 7:21 PM-8,8 RR= activity itself did not occur, documented.
--07/13/21 at 10:59 PM-8,8 RR= activity itself did not occur, documented.
--07/20/21 at 10:22 PM -8,8 N/A= activity itself did not occur, documented.
--07/26/21 at 10:59 PM - 4,3 BB= bed bath on evening shift, documented.
--07/31/21 at 4:16 PM -4,8 N/A= activity itself did not occur, documented.
--08/03/21 at 4:29 PM - 4.3 BB- bed bath on evening shift, documented.
On 08/03/21 at 09:08 AM during an Interview with Social Worker (SW) #66, She stated there has been issues with Resident #37 receiving her showers as scheduled since she was moved to the long-term care hall. SW #66 stated that they have been working with staff and trying to get Resident #37 showers when she prefers.
No further information was provided prior to the end of survey on 08/05/21 at 4:30 PM.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to ensure one (1) of 28 residents reviewed during the long-term care survey process had a Physician Orders for Scope of Treatment (POS...
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Based on record review and staff interview, the facility failed to ensure one (1) of 28 residents reviewed during the long-term care survey process had a Physician Orders for Scope of Treatment (POST) form completed correctly per directions specified by the [NAME] Virginia Center for End-of-Life Care. Resident identifier: #12. Facility census: 142.
Findings included:
a) Resident #12
An electronic medical record review was completed on 08/02/21 at 12:26 PM. There was a scanned Physician's Determination of Capacity form, dated 05/12/21, noting Resident #12 lacks capacity to make medical decisions. There was also a scanned Medical Power of Attorney (MPOA) form which listed Resident's choice of MPOA.
Additionally, a 2021 Edition of the POST form was also found in Resident #12's medical record. The Patient or Patient Representative signature line on the POST form was dated 05/26/21. Verbal consent had been accepted via phone by Social Worker #66 and witnessed by Social Worker #266. However, the name of the person giving the verbal consent was not listed on signature line.
Review of all progress notes in the electronic medical record did not reveal Social Services documentation related to the completion of the POST form, identification of the MPOA who gave consent or that the MPOA had been asked to sign form at their earliest convenience.
Review of the Using the POST Form Guidance for Health Care Professionals, 2021 Edition, revealed the following guidance for completing Section E: Signature: The signature section provides a declaration on behalf of the patient (or incapacitated patient's Medical Power of Attorney (MPOA) representative or health care surrogate) related to their voluntary participation in the completion of the POST form and agreement with the orders on the form. The patient (or incapacitated patient's MPOA representative or health care surrogate) must sign and date this section for the form to be legally valid. If the incapacitated patient's MPOA representative or health care surrogate is unavailable at the time of form completion, this section can be signed by two witnesses for verbal confirmation of agreement from the patient's MPOA representative or health care surrogate. The form should be signed at the earliest available opportunity.
During an interview on 08/03/21 at 8:35 AM, Social Worker #66 reported she did not understand the name of the person giving the consent should be written on the signature line or that the POST form needed to be signed at the earliest available opportunity. Social Worker #66 acknowledged 71 days had passed since the verbal consent had been accepted and it had been an oversight that a signature had not been requested from Resident #12's MPOA.
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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
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Based on family interview, staff interview, and record review the facility failed to immediately notify the Medical Power Of Attorney of a significant change. This was a random opportunity for disco...
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Based on family interview, staff interview, and record review the facility failed to immediately notify the Medical Power Of Attorney of a significant change. This was a random opportunity for discovery. Resident identifier: Resident #116. Facility census 142.
Findings included:
a) Resident # 116
During a phone interview on 08/02/21 at 2:26 PM, the Medical Power Of Attorney (MPOA) the wife of Resident # 116 reported he had a choking incident on 07/14/21 on a plastic piece of a flower. The MPOA said no one called her to let her know about the incident. She stated that when she found out about the incident five days later, she called and talked to the Director of Nursing (DON) about it. The DON told her she would look into it, but has not responded.
Review of the medical record revealed this incident did occur on 07/14/21.
The nursing note by the Licensed Practical Nurse (LPN) # 236 dated 07/14/21 at 12:23 PM, while in the dining room on EB2 consuming lunch this resident was noted to have coughing visualized by the activities director. The resident's skin began turning cyanotic, the activities director immediately initiated the Heimlich Maneuver. The resident immediately coughed expelling a green object that appeared to resemble the green peas that was on the food tray. The resident then was able to speak with a raspy tone of voice when questioned. The resident continued to chew for several minutes. This nurse nor other staff was able to do a finger sweep for the resident began to bite down with each attempt. Nurse Practitioner in house called to the dining area at this time, after several attempts to get the resident to spit the objects the resident did spit out 2 hard plastic pieces that resembled the plastic centerpieces that where on the tables. Awaiting new orders at this time. V/S (vital signs) obtained of BP (blood pressure) 164/70,
P (Pulse) 84, T (temperature) 97.6, R (respirations) 16, O2 SAT (oxygen saturation) 100% on R/A (room air). The resident delivered back to the day lounge on the 2nd floor via staff at this time. NP (Nurse Practioner) ordered an AP (anterior and posterior) and lateral x-ray. An incident report was completed.
The following is a statement provided by the Activities Director dated 07/19/21 which read as follows:
I looked out my door when he coughed and seen something was wrong and went to him and he was choking so I got him up and performed the Heimlich Maneuver, and a piece of green object ejected I thought it was one of the peas he was eating.
There were no evidence the wife (MPOA) was notified about this incident.
On 08/04/21 at 9:00 AM, the Administrator confirmed the Resident's wife (MPOA) was not notified of the incident. The administrator provided a typed note written by the Director of Nursing (DON). The note read as follows:
On July 19, 2021, this nurse, NAME of DON, spoke with Name of Resident # 116's MPOA, (name of MPOA) regarding a choking incident that occurred on July 14, 2021. She was informed by (name of Registered Nurse (RN) #3 that this occurred when she came for a visit the following day. She went on to say that she was fine with the situation just wished she would have been notified. We discussed the process of MPOA notification, and she was satisfied with conversation. She did not want this discussed with staff, although DON did follow-up with staff to determine reason notification did not occur. Each person that observed the incident thought the other person completed notification. She was happy with the response from the team.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on record reviews, staff interviews, and policy review, the facility failed to ensure allegations of neglect were reported immediately, to the State Survey Agency and Adult Protective Services. ...
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Based on record reviews, staff interviews, and policy review, the facility failed to ensure allegations of neglect were reported immediately, to the State Survey Agency and Adult Protective Services. The facility did not report falls with serious bodily injury for Resident #51 and # 99. This practice affected two (2) of four (4) residents reviewed for accidents during the Long Term Care Survey Process (LTCSP). Resident identifiers: Resident #51 and #99. Facility census: 142.
Findings included:
a) Resident #51
Record review for Resident #51 on 08/04/21, revealed a progress note on 05/19/21 at 6:35 PM. Resident found on floor beside the bedside commode. Observation revealed resident had a laceration measuring 1/4 inch on tip of nose, with swelling and bruising to bridge of nose, neurological checks started. Physician was notified with an order to send resident to the emergency room (ER). Medical Power of Attorney (MPOA) aware. Resident returned to the facility, neurological checks resumed and within normal limits (WNL). A review of the Discharge Instructions from the ER visit had a final diagnosis: Head injury due to trauma with nasal bone fracture and a laceration of nose.
Further review indicated the serious bodily injury resulting from the fall on 05/19/21 for Resident #51 was not reported to the State Survey Agency or Adult Protective Services.
In an interview on 08/04/21 at 10:00 AM with the Director of Nursing, verified there were no reports sent to any state entities regarding the major fall with serious bodily injury for Resident #51.
b) Resident #99
An interview with Resident #99 on 08/02/21 at 12:19 PM revealed, she has had multiple falls. She stated that she has even been hurt during several falls and had to be sent to the hospital.
A progress note review revealed an unwitnessed fall on 04/08/21 at 08:30 AM.
Resident was observed lying beside her bed. Resident was assessed by the Physician and Nurse Practioner that was in the building. The Resident was noted to have a large hematoma to right forehead, and BP 184/89. After evaluation, it was decided to send the Resident to the ER for c-spine clearance.
A review of current medication list found, Resident #99's to be on Eliquis and Xarelto anti-platelet therapy.
A review of the emergency room (ER) documentation revealed, Resident #99 was sent to the ER from the nursing home.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to ensure two (2) of twenty-eight (28) sampled residents had m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to ensure two (2) of twenty-eight (28) sampled residents had minimum data sets (MDS) which were accurately coded. For Resident #339, her MDS failed to show the diagnosis for Hospice services. The MDS for Resident # 34, failed to accurately reflect her falls. Resident identifiers: #339 and #34. Facility census:142.
Findings include:
a) Resident #339
Review of Resident #339's medical records, revealed Resident #339 was admitted to Hospice services for a diagnosis of Alzheimer's disease on 10/09/2020.
Review of Resident #339's significant change MDS with assessment reference date (ARD) of 10/29/20, found under section I -active diagnosis of Alzheimer's disease was not checked.
An interview on 08/03/21 at 2:00 PM with the Director of Nursing (DON) confirmed Resident #339 had been admitted to hospice service on 10/09/20 for the diagnosis of Alzheimer's disease and the significant change MDS with the ARD of 10/29/20 failed to check Alzheimer's disease as an active diagnosis.
b) Resident #34
A review of the current Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had not had any falls since the time of her admission. The document was listed as 0 for none.
At 1:12 pm on 08/03/21 the MDS coordinator was asked about this MDS. They later presented a correction for the MDS with an ARD of 05/18/21 which was now coded to reflect Resident #34 had one fall since her admission.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
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Based on observation and interview, the facility failed to provide ADL care to dependent residents for One (1) of five (5) residents reviewed. Resident #37 was not provided services for good persona...
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Based on observation and interview, the facility failed to provide ADL care to dependent residents for One (1) of five (5) residents reviewed. Resident #37 was not provided services for good personal hygiene. Resident #37 was not assisted with showers as scheduled. Resident Identifier: #37. Facility census: 142.
Findings included:
a) Resident #37
During an interview with Resident #37 on 08/02/21 at 12:35 PM, She stated that she never receives her shower when she prefers them on the nights prior to dialysis. Resident #37 continued, sometime the staff will say they will be back to get me for a shower, but they never return.
Medical record review revealed, Resident #37's shower schedule is on Monday, Wednesday and Friday on night shift.
A review of the 05/19/21 admission Minimum Data Set (MDS), found the resident's brief interview for mental status was fourteen (14). MDS Section E (Behaviors) also indicated Resident #37 does not reject care such as ADL Care, medications, or treatments.
A review of Resident #37's Care Plan revealed,
Focus:
--Resident needs assistants with Activities of Daily Living (ADLs) due to decreased functional mobility.
Goal:
--(Named) will receive necessary assistance to meet ADL needs (being clean, dry, well groomed daily through next review.
Interventions:
--Assist Resident with showers with one (1) assist.
A continued review of Resident #37s ADL documentation found the following documentation related to bathing:
--07/02/21 at 10:04 PM- 4,3 BB = bed bath on evening shift, documented.
--07/06/21 at 8:57 PM- 8,8 NA= activity itself did not occur, documented.
--07/09/21 at 7:21 PM-8,8 RR= activity itself did not occur, documented.
--07/13/21 at 10:59 PM-8,8 RR= activity itself did not occur, documented.
--07/20/21 at 10:22 PM -8,8 N/A= activity itself did not occur, documented.
--07/26/21 at 10:59 PM - 4,3 BB= bed bath on evening shift, documented.
--07/31/21 at 4:16 PM -4,8 N/A= activity itself did not occur, documented.
--08/03/21 at 4:29 PM - 4.3 BB- bed bath on evening shift, documented.
A review of tasks information in the electronic medical revealed resident #37 preference for three showers/bed baths a week on Monday, Wednesday, and Friday. For the month of July 2021 there were thirteen (13) opportunities, Resident #37 received three (3) offered showers/bed baths and two (2) documented incidents of refusals without documentation of altered opportunity time to reschedule and three (3) documented not applicable with no clarification or reason.
On 08/03/21 at 09:08 AM during an Interview with Social Worker (SW) #66, She stated that there has been issues with Resident #37 receiving her showers as scheduled since she was moved to the long-term care hall. SW #66 stated that they have been working with staff and trying to get Resident #37 showers when she prefers and scheduled.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
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Based on observation, record review and staff interview the facility failed to administer supplemental oxygen as prescribed. Residents #3 was receiving Oxygen at an incorrect liter flow rate. This w...
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Based on observation, record review and staff interview the facility failed to administer supplemental oxygen as prescribed. Residents #3 was receiving Oxygen at an incorrect liter flow rate. This was a random opportunity for discovery. Resident identifiers: #3. Facility census: 142.
Findings included:
a) Observation
During observation of care on 08/03/21 at 2:36 PM, Resident #3 was observed utilizing supplemental Oxygen (O2) via Nasal Cannula (NC) at 3 liters/minute (l/m). Resident stated she used oxygen all the time, even at night at 2 l/m.
b) Record Review
Record review indicated an active order with effective date 06/13/21 for Oxygen to be administered every day and every evening shirt at 2 l/m via nasal canula related to Chronic Diastolic Congestive Heart Failure.
c) Staff Interview
On 06/28/21 01:02 PM, Licensed Practical Nurse (LPN) #12 and Nurse Aid #151 verified the O2 concentrator was on 3 l/m and should be administered at 2 l/m via nasal canula. LPN #12 immediately adjusted the liter flow to the correct setting of 2 l/m.
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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** .
b) Resident # 116
A review of records revealed there are missing information. missing the Monthly Record Review (MRR) for Nov....
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
b) Resident # 116
A review of records revealed there are missing information. missing the Monthly Record Review (MRR) for Nov. 2020 and July 2021 also the Gradual Drug Reduction (GDR) in September 2020, was not addressed by the physician. The medications were Ativan 0.5 mg in the morning and Ativan 1.5 mg night, plus Seroquel 25 mg twice a day.
During a brief interview on 08/04/21 at 11:25 AM, Director of Nursing (DON) was shown that there are two (2) missing Medical Record Reviews (MRR) on the months of 11/20 and July 21. In addition, the Gradual Drug Reduction (GDR) in Sept. 20 not being addressed by the attending physician. She agreed there was two months of the MRR's missing and the GDR was not answered by the physician.
Based on staff interview and record review, the facility failed to consistently ensure non-pharmacological interventions were implement before administering an antianxiety (Ativan) medication, as needed (PRN) and failed to provide a rational for giving the medication for Resident #340 and for Resident #116 a gradual dose reduction (GDR) approved by the physician was not implemented. This was true for one (1) of five (5) residents reviewed for unnecessary medication and a random opportunity for discovery. Resident identifiers: #340 and #116. Facility census: 142.
Findings included:
a) Resident #340
Medical record review for Resident #340 found she was admitted to the facility on [DATE] at 10:20 pm. Diagnosis include: severe aortic stenosis, chronic respiratory failure, pseudoaneurysm, chronic obstructive pulmonary disease, diabetes mellitus, atrial fibrillation, and heart failure with preserved ejection fraction. Review of the admission minimum data set (MDS) with assessment reference date of 12/20/20 reveals a Brief Mini-Mental Interview Status (BIMS) of 15, which indicates she is cognitive intact.
Resident #340's physician orders included an order for, Ativan 0.5 milligrams (MG) give one-half tablet to equal 0.25mg by mouth every eight (8) hours for anxiety as needed (PRN) order date of 12/15/20.
Review of Resident #340's medication administration records (MAR) for December 2020, were reviewed and on the following dates and times the staff failed indicate the increased anxiety (crying, wring hands, and or pacing, etc.) as well as failed to attempt non-pharmaceutical interventions:
--12/15/20 at 3:37 pm
--12/16/20 at 12:22 am and 7:51 pm
--12/17/20 at 8:31 pm
--12/18/20 at 8:20 pm
--12/19/20 at 6:00 am and 7:21 pm
--12/20/20 at 8:18 am and 5:37 pm
--12/21/20 at 1:08 am and 7:36 pm
On 12/23/20 a new physician order read: Ativan 0.5 mg by mouth every eight hours for anxiety.
Review of the Controlled Drug Receipt/Records/Disposition Form found the wrong dosage of Ativan was administered as prescribed:
12/23/20 at 6:00 am and 10:00 pm- wrong dose administered
12/24/20 at 6:00 am and 2:00 pm and 10:00 pm was not administered.
12/25/20 at 6:00 am and 2:00 pm and 10:00 pm - wrong dose administered
12/26/20 at 6:00 am and 2:00 pm and 10:00 pm - wrong dose administered
12/27/20 at 6:00 am - wrong dose administered
12/28/20 at 2:00 pm - wrong dose administered
12/29/20 at 6:00 am and 2:00 pm and 10:00 pm - wrong dose administered
12/30/20 at 6:00 am and 2:00 pm and 10:00 pm - wrong dose administered
12/31/20 at 6:00 am and 2:00 pm and 10:00 pm - wrong dose administered
Review of the December MAR and the controlled drug record with the director of nursing (DON) on 08/05/21 at 11am. The DON confirmed Ativan was administered on the above-mentioned dates and. on all the licensed nursing staff failed to clarify increased anxiety (crying, wring hands, and or pacing, etc.) and failed to document non-pharmalogical interventions prior to administering the Ativan.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview, the facility failed to labeled medications in accordance with currently accepted professional principles. This failed practice was true for three (3) of eig...
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Based on observation and staff interview, the facility failed to labeled medications in accordance with currently accepted professional principles. This failed practice was true for three (3) of eight (8) insulin and one (1) of one (1) lidocaine which were not dated when intitally opened, and the Lidocaine did not have any resident identifying information to indicate which resident it belonged to. Resident Identifiers: Resident # 130, # 353, # 351, and # 135.
Findings included:
a) Medication cart on B-Hall on first floor
On 08/03/21 at 8:48 AM, Licensed Practical Nurse (LPN) # 237 was present while inspecting the medication cart on the B-hall and was witness to the following findings:
There were three (3) insulin pens that were used and did not have a date on the pens to indicate when the insulin pens were first accessed. These three (3) insulins pens belonged to Resident # 130 Levemir, Resident # 353 Lantus, and Resident # 351 Levemir.
There was one (1) multi-use lidocaine vial with approximately 25% of the remaining medication in the vial, no identifying name or open date was on the vial or bag. LPN #237 stated, the lidocaine belonged to Resident # 135.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
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Based on record review, observation and interview, the facility failed to ensure food items prepared and served met resident's needs and choices including their nutritional, religious, cultural, and...
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Based on record review, observation and interview, the facility failed to ensure food items prepared and served met resident's needs and choices including their nutritional, religious, cultural, and ethnic needs while using established national guidelines for one (1) random observation. This was true to Resident #63. Census: 142
Findings included:
During an interview on 08/02/21 at 11:10 AM, Resident #63 stated she was allergic to pork and received pork on her tray.
A record review noted Resident #63's hard copy of the medical record was flagged for a Pork Allergy with a red and white allergy sticker on the inside cover the chart.
An observation of the tray card during the noon meal on 08/02/21 noted the resident was not to receive pork.
An observation on 08/03/21 at 09:00 AM, Resident #63 received two (2) meat patties on the breakfast tray.
On 08/03/21 at 10:34 AM, the administrator verified Resident #63 did receive pork on the tray and it was noted on the tray card not to receive it
A record review showed a progress note, dated 8/3/21 at 09:53, written by the Assistant Director of Nursing (ADON) which read patient has an allergy to pork noted on allergy tab in chart, patient was served pork sausage for breakfast. Dr notified. continue to monitor patient for any adverse reactions. Staff will talk with patient to confirm if this is a true allergy or a preference. The progress note was written after surveyor discussion with facility staff.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to ensure each resident's medical record was complete and accurate. This was true for one (1) of twenty-eight (28) residents reviewed ...
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Based on record review and staff interview, the facility failed to ensure each resident's medical record was complete and accurate. This was true for one (1) of twenty-eight (28) residents reviewed during the Long-Term Care Survey Process (LTCSP). For Resident #339, her medical record failed to show the diagnosis of Alzheimer's disease. Resident identifier: #339. Facility census:142.
Findings include:
a) Resident #339
Review of Resident #339's medical records revealed Resident #339 was admitted to Hospice services for diagnosis of Alzheimer's disease on 10/09/2020.
Review of Resident #339's diagnosis sheet found no diagnosis for Alzheimer's disease.
During an interview on 08/03/21 at 2:00 PM with the Director of Nursing (DON) she confirmed Resident #339 had been admitted to hospice service on 10/09/20 for the diagnosis of Alzheimer's disease and the diagnosis sheet should have Alzheimer's disease as an active diagnosis.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, staff interview and observation, the facility failed to provide resident-centered care and services, i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, staff interview and observation, the facility failed to provide resident-centered care and services, in accordance with preferences, goals for care and professional standards of practice to meet each resident's physical, mental, and psychosocial needs. This was true for five (5) of twenty-eight (28) residents reviewed during the Long-Term Survey Process (LTSP). For Resident #340, the facility failed to complete an admission assessment on 12/14/20 and follow physician orders to notify the physician when blood sugars were above 400. For Resident #99, the facility failed to complete neuro-checks after a fall. For Resident #57, the facility failed provide alternatives when meals were not consumed. For Resident #341, the facility failed to follow physician orders for weights and a doctors appointment. Finally for, Resident #51, the facility failed to complete neuro-checks per the facility's policy. Resident identifiers: #340, #99, #57, #341 and #51. Facility census: 142.
Findings include:
a) Resident #340
A review of Resident #340's medical record found the resident was admitted to the facility on [DATE] at 10:20 pm. No nursing assessment was completed.
Additional review of the medical records found a physician's order dated 12/15/20 for accu-checks four times a day and if accu-checks were over 400 to administer 10 units of Novolog insulin and then notify the physician for treatment of diabetes mellitus.
A record review of accu-checks from 12/15/20 through 12/31/2020 found the following occasions when Resident #340's accu-check was over 400 and 10 units of insulin was not administered and/or the physician was not notified as ordered.
--12/16/20- no Accucheck done.
--12/21/20 at 4:30 pm Accucheck 405- insulin administer/physician not notified.
--12/23/20 at 7:00 am- Accucheck 583- no insulin administered, and physician not notified
--12/25/20- no Accucheck done.
--12/26/20 at 11:30 am Accucheck 437 -insulin administer/physician not notified
--12/26/20 at 4:30 pm Accucheck 518 - insulin administer/physician not notified
--12/31/20 at 4:30 pm Accucheck 487 -no insulin administer/physician not notified
An interview with the Director of Nursing (DON) at 1:05 p.m. on 08/04/21 confirmed Resident #340s attending physician was not notified when she had an Accucheck greater than 400 as directed by the physician's order. Additionally, on two (2) occasions there was no indication the resident received 10 units of Novolog as directed by the physician order.
b) Resident #99
An interview with Resident #99 on 08/02/21 at 12:19 PM revealed, she has had multiple falls. She stated that she has even been hurt during several falls and had to be sent to the hospital.
A progress notes review revealed an unwitnessed fall on 03/09/21 at 11:59 PM. Resident was heard saying HELP. Resident #99 was noted to be sitting on the floor beside her bed, leaning toward the left. Resident was assessed for injury and a small red area to left forehead noted. Neurological checks (Neuro's) initiated due to unwitnessed fall and red area to left forehead.
A fall note completed on 03/10/21 revealed, Neurological checks should be initiated if indicated (i.e., unwitnessed fall OR resident hit head with fall)
A continued review of Resident #99's medical record revealed, no Neuros found in the medical record for the 03/09/21 fall.
During an interview with the Director of Nursing (DON) on 08/03/21 at 03:00 PM, she stated they would try to find the neuro checks for the fall on 03/09/21.
On 08/04/21 at 08:19 AM an interview with DON revealed, they were unable to find Neuro Checks for the fall on 3/10/21.
c.) Resident #57
Resident #57 was admitted to the facility on [DATE], with diagnoses of Type II Diabetes, Pressure ulcers, symptoms and signs involving cognitive functions and awareness, congestive heart failure, anemia, major depressive disorder, hyperlipidemia, age- related osteoporosis, muscle weakness, repeated falls, and history of urinary tract infections.
A review of the medical record revealed Resident #57 weighed 226.0 pounds on 03/27/21 and weighed 164.4 lbs on 07/28/21. On 06/07/21 a significant change MDS was completed related to weight loss.
An interview, with the Director of Nursing (DON), on 08/03/21 at 9:10 AM, verified Resident #57 was not receiving hospice services.
On 08/02/21 at 01:25 PM, Resident #57 was observed lying flat, on her side with the noon meal on the bedside tray. Resident #57 was not consuming the meal but demonstrated she could lift her fork when asked. Resident #57 was not offered an alternate when the meal was not eaten.
On 08/03/21 at 08:15 AM, Resident #57 was observed in bed with the breakfast meal. A half piece of sausage was observed on her chest and remained there through the observation. Pancakes were cut up but not eaten. The resident's coffee was not opened. Resident #57 was observed to pick up the dry cornflakes, looked at them and laid them back on the tray several times. The resident did not consume the meal and nursing assistant# 106 (NA #106), instructed the resident she was leaving the cereal and coffee when the tray was picked up, but no alternative was offered.
A review of the policy, Serving a Meal, revision date, 05/03/21, under Section 10, noted Patients are encouraged to feed themselves to the extent possible, and to consume all foods. Alternate foods should be offered, when a patient consumes less than half of the meal, or upon patient request.
A review of the meal consumption records documented by staff for 07/01/21 through 08/04/21, noted the following dates when Resident #57 consumed 0-25 percent of the meal and was not offered an alternative:
07/02/21 08:32 documented the resident consumed 0-25 % with no alternative provided
07/03/21 09:00 documented the resident consumed 0-25% with no alternative provided
07/03/21 13:00 documented the resident consumed 0-25% with no alternative provided
07/07/21 09:05 documented the resident consumed 0-25% with no alternative provided
07/07/21 13:31 documented the resident consumed 0-25% with no alternative provided
07/07/21 19:09 documented the resident consumed 0-25% with no alternative provided
07/10/21 14:16 documented the resident consumed 0-25% with no alternative provided
07/11/21 14:31 documented the resident consumed 0-25 % with no alternative provided
07/12/21 13:22 documented the resident consumed 0-25% with no alternative provided
07/14/21 10:35 documented the resident consumed 0-25% with no alternative provided
07/14/21 13:43 documented the resident consumed 0-25% with no alternative provided
07/16/21 08:05 documented the resident consumed 0-25% with no alternative provided
07/16/21 13:32 documented the resident consumed 0-25% with no alternative provided
07/19/21 08:35 documented the resident consumed 0-25% with no alternative provided
07/19/21 13:00 documented the resident consumed 0-25% with no alternative provided
07/19/21 18:29 documented the resident consumed 0-25% with no alternative provided
07/21/21 18:43 documented the resident consumed 0-25% with no alternative provided
07/26/21 09:30 documented the resident consumed 0-25% with no alternative provided
07/26/21 14:21 documented the resident consumed 0-25% with no alternative provided
07/27/21 10:38 documented the resident consumed 0-25% with no alternative provided
07/28/21 13:00 documented the resident consumed 0-25% with no alternative provided
07/29/21 08:44 documented the resident consumed 0-25% with no alternative provided
07/29/21 13:47 documented the resident consumed 0-25% with no alternative provided
07/31/21 15:01 documented the resident consumed 0-25% with no alternative provided
08/01/21 11:58 documented the resident consumed 0-25% with no alternative provided
08/01/21 15:08 documented the resident consumed 0-25% with no alternative provided
08/02/21 15:12 documented the resident consumed 0-25% with no alternative provided
08/03/21 16:20 documented the resident consumed 0-25% with no alternative provided
An interview with the DON, on 08/04/21 at 11:09 AM, verified Resident #57 was identified as being independent but agreed the resident should be assisted when not eating her meal. It was also verified the documentation provided by the facility , confirmed the resident was not always offered an alternative to the meal served when 0-25 % of the meal was consumed.
D) Resident #341
An electronic medical record review was completed on 08/03/21 at 5:15 PM. An appointment note, dated 03/02/21 at 10:47 AM, reflected that Resident #341 had a follow-up appointment with a specialty doctor on 03/17/21 at 8:30 AM. Review of Resident #341's paper chart found a Transfer / Discharge Notice as well as a Bed Hold Notice, both dated for 03/18/21 at 7:45 AM. Assistant Director of Nursing (ADON) #21 was interviewed on 08/04/21 at 11:15 AM, regarding the discrepancy between the appointment note in Resident #341's electronic medical record (which reflected the appointment was for 03/17/21) and the Transfer / Discharge Notice and Bed Hold Notice (which were dated for 03/18/21). ADON #21 replied the notices, dated for 03/18/21, was an indication Resident #21 was taken to the appointment on 03/18/21 because all residents are sent with the above-mentioned paperwork when going out to appointments. ADON #21 further reported the resident transport staff member, Employee #73 would have documented in the electronic medical record if the appointment had changed from the original 03/17/21 date. Following a short review in the electronic medical record, ADON #21 concluded there was no evidence that the facility had taken the resident to the appointment on the correct date.
Resident #341's electronic medical record also revealed resident was admitted to the facility on [DATE] and had a physician order for Weekly weights x 4 on admission and then monthly. Resident #341's care plan identified Resident #341 for being at risk of altered nutrition/hydration status and one of the listed interventions was to monitor weights as ordered. Review of Resident #341's recorded weights reflected:
-Resident #341 weighed 136.8 lbs. on Saturday, 02/27/21
-Resident #341 weighed 135.8 lbs. on Saturday, 03/06/21
-Resident #341 weighed 132.8 lbs. on Saturday, 03/13/21
-There was no weight recorded for Saturday, 03/20/21
During an interview with Director of Nursing (DON), on 08/04/21 at 11:00 AM, the DON stated she would check into the missing weight.
On 08/04/21 at 3:10 PM, Corporate Nurse #265 reported there was no weight for Resident #341 on 03/20/2021, It was missed that week, and the resident was discharged on 03/21/21.
e) Resident #51
A record review for Resident #51 on 08/04/21, revealed a progress note on 05/19/21 at 6:35 PM. Which read as follows: Resident found on floor beside the bedside commode. Observation revealed resident had a laceration measuring 1/4 inch on tip of nose, with swelling and bruising to bridge of nose, neurological checks started. Physician was notified with an order to send resident to the emergency room (ER). Medical Power of Attorney (MPOA) was made aware. Resident returned to the facility, neurological checks resumed and within normal limits (WNL). A review of the Discharge Instructions from the ER visit had a final diagnosis: Head injury due to trauma with nasal bone fracture and a laceration of nose.
A review of the Neurological Assessment Flow Sheet for 05/19/21 to 05/21/21, verified Resident #51 had not received neurological (neuro) checks as directed by the standing orders for any fall involving a head injury. The last sequence of the neuro check assessment order was neuro checks every eight (8) hours times six (6). There last eight (8) hour neuro check was missing. The last neuro check was completed on 05/21/21 at 4:55 PM.
In an interview with the Director of Nursing on 08/04/21 at 11:00 AM, she provided the Neurological Assessment Flow Sheet and verified the missing neuro check.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, and staff interview the facility failed to ensure a system was in place for accurate reconciliation an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, and staff interview the facility failed to ensure a system was in place for accurate reconciliation and accounting for all controlled medications which would enabled prompt identification of loss or potential diversion. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents residing at the facility. Resident identifiers: #391, #3, #99, #340. Facility census: 142.
Findings included:
a) Resident #391
Record review revealed an active order effective 7/20/21 for Percocet Tablet 7.5-325 MG (oxycodone-acetaminophen), Give one (1) tablet by mouth every four (4) hours as needed for pain hold for sedation.
Review of Controlled Drug Receipt Disposition Form (used for inventory purposed on medication cart to track sign out of controlled medications) for Controlled Medication, Oxycodone/Apap Tab 7.5/325MG, indicated the following doses of PRN (as needed) pain medication were signed out and removed from medication cart and not administered as evidenced by the Resident's Medication Administration Record (MAR) for the following dates:
July 2021
7/21/21 - One (1) tablet signed out at 11:48 AM, no documentation of administration on MAR.
August 2021
8/3/21 - One (1) tablet signed out at 7:32 PM, no documentation of administration on MAR
8/3/21 - One (1) tablet signed out at 8:15 PM, no documentation of administration on MAR
8/3/21 - One (1) tablet signed out at 11:45PM, no documentation of administration on MAR
Review of the Pharmacy Inventory Delivery Sheet, provided by the Director of Nursing on 8/5/21, indicated Controlled Drug Receipt Disposition Forms (used for inventory purpose on medication cart to track and sign out controlled medications) for Oxycodone/Apap Tab 7.5/325MG (that had been completed and removed from the inventory logbook on the medication cart) were missing for the following Prescription (Rx) numbers and delivery dates:
RX #25448168
Quantity: 30
Delivery Date: 7/20/21
RX #25448168
Quantity: 30
Delivery Date: 7/20/21
The surveyor was unable to conduct any further investigation for Resident #391 for July 2021 due to the missing Controlled Drug Receipt Disposition Forms from the medication cart.
During an Interview on 08/05/21 at 12:36 PM, the DON was asked if they located the missing Controlled Drug Receipt Disposition Forms for Resident #391's Oxycodone? She stated, No we can't find them, and we don't have a system in place to monitor this.
On 8/4/21 at 11:30 AM the Administrator stated, The unit managers run an audit every morning before stand up meeting to check for any discrepancies or missed dose on the MAR (Medication Administration Record) they should be catching this. We are doing an internal audit; I notified the pharmacist sometime last week I thought we had some issues. The Administrator provided the Pharmacist phone number for use by Surveyor. Please note, the Administrator was not able to provide an exact date and time the pharmacist was notified.
During a phone interview on 8/5/21 at 1:42 PM Pharmacist #301 stated (regarding being contacted by administrator for controlled medication issues), I am actually at the beach. I just took over that building in July. You may want to call (Pharmacist #300 name), she is covering for me. I really can't help you much, sorry.
On 8/4/21 at 2:47 PM, Pharmacist #300 was asked if she aware of any medication issues at the facility. Pharmacist #300 stated, That's not my normal building, I am covering for (Pharmacist #301 name). I have not talked to anyone at the center thus far. (Pharmacist #301's name) called me yesterday morning and said they had some holes in Mars (Medication Administration Records). Pharmacist #300 was asked if she was currently conducting an investigation into the holes in Mars situation and she stated, No I am not, I have a call out the Director of Nursing (DON) but she has not returned my call yet. Pharmacist #300 suggested that Surveyor contact (Pharmacy Services Specialist #302's name) that she does monthly audits and see if she knew anything.
During a phone interview on 08/04/21 at 3:22 PM Pharmacy Services Specialist #302 was asked if she was aware on any eternal investigation being conducted or issues with controlled medications at the facility? Pharmacy Services Specialist #302 stated, It was mentioned, not in detail, just said they had it, they (Pharmacist #300) called yesterday (8/3/21). The Pharmacy Services Specialist further stated, When I do my audits in the facility, I don't do anything with controlled medications, I only check the PRN (as needed) medications and look at declining inventory sheets for them. I do not audit any controlled medications. As for myself, I am not doing any kind of investigation for controlled medications currently.
B) Resident #3
During initial tour of the long-term care facility on 08/02/21 at 11:28 AM, Resident #3 stated she is always in pain and said, I got one (pain medication) coming now should be time for it. At that time the Resident rated her pain level at a seven (7) on a one (1) to ten (10) pain scale with 10 being the most severe. The Resident was noted to be rubbing her left leg during interview, grimacing with slightly reddened face, and crying. Resident stated she had an old leg fracture on the left side and that caused her leg and hip pain constantly, sometimes keeping her awake at night. Resident stated she gets pain medication every 6 hours and she used to get them every 4 hours, but they changed it and she can't get anyone to talk to her about why. The Resident stated again, I am always in pain. Resident stated, Sorry to be 'weepy, but that's what I do when I hurt. The Resident rubbed her lower stomach and state, I also have a terrible with my bowels and being constipated, it's a constant battle and so uncomfortable.
Record review revealed an active order effective 3/30/21 for [NAME] Tablet 7.5-325 MG (hydrocarbon-acetaminophen), Give one (1) tablet by mouth every six (6) hours for pain.
Review of Residents Medication Administration Record (MAR) for June of 2021 indicated scheduled pain medication ([NAME] Tablet 7.5-325 mg to be given every six (6) hours at the schedules times of 12:00 AM, 6:00 AM, 12:00 PM and 6:00 PM) was signed out and removed from the medication cart and not administered for a total thirteen (13) occurrences for the following dates:
June 2021 -
6/05/21 - One (1) tablet signed out at 6:00 PM, not administered.
6/07/21 - One (1) tablet signed out at 6:00 PM, not administered.
6/09/21 - One (1) tablet signed out at 6:00 PM, not administered.
6/13/21 - One (1) tablet signed out at 12:00 PM, not administered.
6/13/21 - One (1) tablet signed out at 6:00 PM, not administered.
6/23/21 - One (1) tablet signed out at 6:00 PM, not administered.
6/24/21 - One (1) tablet signed out at 12:00 PM not administered.
6/24/21 - One (1) tablet signed out at 6:00 PM, not administered.
6/24/21 - One (1) tablet signed out at 9:00 PM, not administered.
6/25/21 - One (1) tablet signed out at 12:00 PM, not administered.
6/25/21 - One (1) tablet signed out at 6:00 PM, not administered.
6/27/21 - One (1) tablet signed out at 6:00 PM, not administered.
6/29/21 - One (1) tablet signed out at 11:00 PM, not administered.
Review of Residents Medication Administration Record (MAR) for July of 2021 indicated scheduled pain medication ([NAME] Tablet 7.5-325 mg to be given every six hours at 12:00 AM, 6:00 AM, 12:00 PM and 6:00 PM) was signed out and removed from the medication cart and not administered for a total fourteen (14) occurrences for the dates:
July 2021 -
7/02/21 - One (1) tablet signed out 12:00 PM, not administered.
7/02/21 - One (1) tablet signed out 6:00 PM, not administered.
7/04/21 - One (1) tablet signed out 6:00 AM, not administered.
7/05/21 - One (1) tablet signed out 12:00 PM, not administered.
7/05/21 - One (1) tablet signed out 6:00 PM, not administered.
7/08/21 - One (1) tablet signed out 12:00 PM, not administered.
7/08/21 - One (1) tablet signed out 6:00 PM, not administered.
7/10/21 - One (1) tablet signed out 12:00 PM, not administered.
7/10/21 - One (1) tablet signed out 6:00 PM, not administered.
7/11/21 - One (1) tablet signed out 6:00 PM, not administered.
7/25/21 - One (1) tablet signed out 12:00 PM, not administered.
7/25/21 - One (1) tablet signed out 6:00 PM, not administered.
7/29/21 - One (1) tablet signed out 12:00 PM, not administered.
7/29/21 - One (1) tablet signed out 6:00 PM, not administered.
Review of Residents Medication Administration Record (MAR) for August 1st through August 3rd, 2021, indicated the scheduled pain medication ([NAME] Tablet 7.5-325 mg to be given every six hours) was signed out and removed from the medication cart and not administered for the following date:
8/2/21 - - One (1) tablet signed out 6:00 PM, not administered.
During an Interview on 8/5/21 at 08:30 AM, the Director of Nursing (DON) stated, If anything I feel like these holes in the MAR are just med errors, I am sure it's a documentation issue and they (staff) forgot to sign off the med's given. We know having that one Resident from a different hall on the A Hall med cart is a problem, we are working on it.
During an Interview on 08/05/21 at 12:36 PM, the DON was asked if they located the missing Controlled Drug Receipt Disposition Forms for Resident #391's Oxycodone, and she stated, No we can't find them, and we don't have a system in place to monitor this.
On 8/4/21 at 11:30 AM the Administrator stated, The unit managers run an audit every morning before stand up meeting to check for any discrepancies or missed dose on the MAR (Medication Administration Record) they should be catching this. We are doing an internal audit; I notified the pharmacist sometime last week I thought we had some issues. The Administrator provided the Pharmacist phone number for use by Surveyor. Please note, the Administrator was not able to provide an exact date and time the pharmacist was notified.
During a phone interview on 8/5/21 at 1:42 PM Pharmacist #301 stated (regarding being contacted by administrator for controlled medication issues), I am actually at the beach. I just took over that building in July. You may want to call (Pharmacist #300 name), she is covering for me. I really can't help you much, sorry.
On 8/4/21 at 2:47 PM, Pharmacist #300 was asked if she aware of any medication issues at the facility. Pharmacist #300 stated, That's not my normal building, I am covering for (Pharmacist #301 name). I have not talked to anyone at the center thus far. (Pharmacist #301's name) called me yesterday morning and said they had some holes in Mars (Medication Administration Records). Pharmacist #300 was asked if she was currently conducting an investigation into the holes in MARs situation and she stated, No I am not, I have a call out the Director of Nursing (DON) but she has not returned my call yet. Pharmacist #300 suggested that Surveyor contact (Pharmacy Services Specialist #302's name) that she does monthly audits and see if she knew anything.
During a phone interview on 08/04/21 at 3:22 PM Pharmacy Services Specialist #302 was asked if she was aware on any eternal investigation being conducted or issues with controlled medications at the facility? Pharmacy Services Specialist #302 stated, It was mentioned, not in detail, just said they had it, they (Pharmacist #300) called yesterday (8/3/21). The Pharmacy Services Specialist further stated, When I do my audits in the facility, I don't do anything with controlled medications, I only check the PRN (as needed) medications and look at declining inventory sheets for them. I do not audit any controlled medications. As for myself, I am not doing any kind of investigation for controlled medications currently.
c) Resident #99
A medical record review for Resident #99 revealed, a Physician Order for:
Norco Tablet 5-325 MG (hydrocodone-Acetaminophen) *Controlled Drug*
Give 1 tablet by mouth every four (4) hours as needed for pain.
A continued review of Resident #99's Medication Administration Record and Narcotic Disposition Log revealed discrepancies as noted below.
--05/01/21, one (1) Norco was signed out on the Narcotic Disposition log at 12:00 AM. There is no corresponding documentation on the MAR.
--05/01/21, one (1) Norco was signed out on the Narcotic Disposition log at 8:00 AM. There is no corresponding documentation on the MAR.
--05/01/21, one (1) Norco was signed out on the Narcotic Disposition log at 4:00 PM. There is no corresponding documentation on the MAR.
--05/02/21, one (1) Norco was signed out on the Narcotic Disposition log at 2:00 AM. There is no corresponding documentation on the MAR.
--05/02/21, one (1) Norco was signed out on the Narcotic Disposition log at 3:00 PM. There is no corresponding documentation on the MAR.
--05/02/21, one (1) Norco was signed out on the Narcotic Disposition log at 12:00 AM. There is no corresponding documentation on the MAR.
--05/04/21, one (1) Norco was signed out on the Narcotic Disposition log at 2:00 AM. There is no corresponding documentation on the MAR.
--05/04/21, A check mark and initials was signed in the box for PRN Norco with a pain level 6 and the chart code E = Effective, 03:41 AM was in the time box. The medication was not signed out on the Narcotic Disposition log.
--05/05/21, one (1) Norco was signed out on the Narcotic Disposition log at 12:30 AM. There is no corresponding documentation on the MAR.
--05/06/21, one (1) Norco was signed out on the Narcotic Disposition log at 9:00 AM. There is no corresponding documentation on the MAR.
--05/07/21, one (1) Norco was signed out on the Narcotic Disposition log at 2:30 AM. There is no corresponding documentation on the MAR.
--05/09/21, one (1) Norco was signed out on the Narcotic Disposition log at 3:04 AM. There is no corresponding documentation on the MAR.
--05/10/21, one (1) Norco was signed out on the Narcotic Disposition log at 9:00 AM. There is no corresponding documentation on the MAR.
--05/10/21, one (1) Norco was signed out on the Narcotic Disposition log at 4:00 PM. There is no corresponding documentation on the MAR.
--05/11/21, one (1) Norco was signed out on the Narcotic Disposition log at 4:00 AM. There is no corresponding documentation on the MAR.
--05/11/21, one (1) Norco was signed out on the Narcotic Disposition log at 9:00 AM. There is no corresponding documentation on the MAR.
--05/11/21, one (1) Norco was signed out on the Narcotic Disposition log at 5:00 PM. There is no corresponding documentation on the MAR.
--05/15/21, one (1) Norco was signed out on the Narcotic Disposition log at 12:41 AM. There is no corresponding documentation on the MAR.
--05/15/21, one (1) Norco was signed out on the Narcotic Disposition log at 8:00 AM. There is no corresponding documentation on the MAR.
--05/15/21, one (1) Norco was signed out on the Narcotic Disposition log at 4:00 PM. There is no corresponding documentation on the MAR.
--05/16/21, one (1) Norco was signed out on the Narcotic Disposition log at 9:00 AM. There is no corresponding documentation on the MAR.
--05/16/21, one (1) Norco was signed out on the Narcotic Disposition log at 3:00 PM. There is no corresponding documentation on the MAR.
--05/18/21, one (1) Norco was signed out on the Narcotic Disposition log at 11:00 PM. There is no corresponding documentation on the MAR.
--05/19/21, one (1) Norco was signed out on the Narcotic Disposition log at 8:00 AM. There is no corresponding documentation on the MAR.
--05/19/21, one (1) Norco was signed out on the Narcotic Disposition log at 4:00 PM. There is no corresponding documentation on the MAR.
--05/20/21, one (1) Norco was signed out on the Narcotic Disposition log at 8:00 AM. There is no corresponding documentation on the MAR.
--05/20/21, one (1) Norco was signed out on the Narcotic Disposition log at 4:00 AM. There is no corresponding documentation on the MAR.
--05/24/21, one (1) Norco was signed out on the Narcotic Disposition log at 7:00 AM. There is no corresponding documentation on the MAR.
--05/24/21, one (1) Norco was signed out on the Narcotic Disposition log at 1:00 PM. There is no corresponding documentation on the MAR.
--05/24/21, one (1) Norco was signed out on the Narcotic Disposition log at 7:00 PM. There is no corresponding documentation on the MAR.
--05/25/21, one (1) Norco was signed out on the Narcotic Disposition log at 1:00 AM. There is no corresponding documentation on the MAR.
--05/27/21, one (1) Norco was signed out on the Narcotic Disposition log at 12:30 AM. There is no corresponding documentation on the MAR.
--05/28/21, one (1) Norco was signed out on the Narcotic Disposition log at 3:00 AM. There is no corresponding documentation on the MAR.
--05/29/21, one (1) Norco was signed out on the Narcotic Disposition log at 8:00 AM. There is no corresponding documentation on the MAR.
--05/29/21, one (1) Norco was signed out on the Narcotic Disposition log at 4:00 PM. There is no corresponding documentation on the MAR.
--05/30/21, one (1) Norco was signed out on the Narcotic Disposition log at 12:00 AM. There is no corresponding documentation on the MAR.
--05/30/21, one (1) Norco was signed out on the Narcotic Disposition log at 8:00 AM. There is no corresponding documentation on the MAR.
--05/30/21, one (1) Norco was signed out on the Narcotic Disposition log at 3:00 PM. There is no corresponding documentation on the MAR.
--06/02/21, one (1) Norco was signed out on the Narcotic Disposition log at 1:30 AM. There is no corresponding documentation on the MAR.
--06/02/21, one (1) Norco was signed out on the Narcotic Disposition log at 8:00 AM. There is no corresponding documentation on the MAR.
--06/02/21, one (1) Norco was signed out on the Narcotic Disposition log at 4:00 PM. There is no corresponding documentation on the MAR.
--06/02/21, one (1) Norco was signed out on the Narcotic Disposition log at 12:30 AM. There is no corresponding documentation on the MAR.
--06/03/21, one (1) Norco was signed out on the Narcotic Disposition log at 7:00 AM. There is no corresponding documentation on the MAR.
--06/03/21, one (1) Norco was signed out on the Narcotic Disposition log at 1:00 PM. There is no corresponding documentation on the MAR.
--06/03/21, one (1) Norco was signed out on the Narcotic Disposition log at 7:00 PM. There is no corresponding documentation on the MAR.
--06/03/21, A check mark and initials was signed in the box for PRN Norco with a pain level X and the chart code E = Effective, 07:00 PM was in the time box. The medication was not signed out on the Narcotic Disposition log.
--06/07/21, one (1) Norco was signed out on the Narcotic Disposition log at 1:00 AM. There is no corresponding documentation on the MAR.
--06/08/21, one (1) Norco was signed out on the Narcotic Disposition log at 8:00 AM. There is no corresponding documentation on the MAR.
--06/08/21, one (1) Norco was signed out on the Narcotic Disposition log at 4:00 PM. There is no corresponding documentation on the MAR.
--06/08/21, one (1) Norco was signed out on the Narcotic Disposition log at 12:00 PM. There is no corresponding documentation on the MAR.
--06/11/21, one (1) Norco was signed out on the Narcotic Disposition log at 11:00 AM. There is no corresponding documentation on the MAR.
--06/11/21, one (1) Norco was signed out on the Narcotic Disposition log at 3:00 PM. There is no corresponding documentation on the MAR.
--06/12/21, one (1) Norco was signed out on the Narcotic Disposition log at 8:00 AM. There is no corresponding documentation on the MAR.
--06/13/21, one (1) Norco was signed out on the Narcotic Disposition log at 8:00 AM. There is no corresponding documentation on the MAR.
--06/13/21, one (1) Norco was signed out on the Narcotic Disposition log at 4:00 PM. There is no corresponding documentation on the MAR.
--06/14/21, one (1) Norco was signed out on the Narcotic Disposition log at 1:00 AM. There is no corresponding documentation on the MAR.
--06/15/21, A check mark and initials was signed in the box for PRN Norco with a pain level 6 and the chart code E = Effective, 2:05 AM was in the time box. The medication was not signed out on the Narcotic Disposition log.
--06/16/21, one (1) Norco was signed out on the Narcotic Disposition log at 9:00 AM. There is no corresponding documentation on the MAR.
--06/16/21, one (1) Norco was signed out on the Narcotic Disposition log at 5:00 PM. There is no corresponding documentation on the MAR.
--06/17/21, one (1) Norco was signed out on the Narcotic Disposition log at 8:00 AM. There is no corresponding documentation on the MAR.
--06/17/21, one (1) Norco was signed out on the Narcotic Disposition log at 4:00 PM. There is no corresponding documentation on the MAR.
--06/19/21, one (1) Norco was signed out on the Narcotic Disposition log at 10:21 PM. There is no corresponding documentation on the MAR.
--06/21/21, one (1) Norco was signed out on the Narcotic Disposition log at 2:00 AM. There is no corresponding documentation on the MAR.
--06/21/21, one (1) Norco was signed out on the Narcotic Disposition log at 8:00 AM. There is no corresponding documentation on the MAR.
--06/21/21, one (1) Norco was signed out on the Narcotic Disposition log at 3:00 PM. There is no corresponding documentation on the MAR.
--06/22/21, one (1) Norco was signed out on the Narcotic Disposition log at 3:00 AM. There is no corresponding documentation on the MAR.
--06/22/21, one (1) Norco was signed out on the Narcotic Disposition log at 8:00 AM. There is no corresponding documentation on the MAR.
--06/22/21, one (1) Norco was signed out on the Narcotic Disposition log at 1:00 PM. There is no corresponding documentation on the MAR.
--06/25/21, one (1) Norco was signed out on the Narcotic Disposition log at 8:00 AM. There is no corresponding documentation on the MAR.
--06/25/21, one (1) Norco was signed out on the Narcotic Disposition log at 2:00 PM. There is no corresponding documentation on the MAR.
--06/26/21, one (1) Norco was signed out on the Narcotic Disposition log at 8:00 AM. There is no corresponding documentation on the MAR.
--06/26/21, one (1) Norco was signed out on the Narcotic Disposition log at 4:00 PM. There is no corresponding documentation on the MAR.
--06/27/21, one (1) Norco was signed out on the Narcotic Disposition log at 8:00 AM. There is no corresponding documentation on the MAR.
--06/27/21, one (1) Norco was signed out on the Narcotic Disposition log at 3:00 PM. There is no corresponding documentation on the MAR.
--06/30/21, one (1) Norco was signed out on the Narcotic Disposition log at 9:00 AM. There is no corresponding documentation on the MAR.
--07/01/21, A check mark and initials was signed in the box for PRN Norco with a pain level 5 and the chart code E = Effective, 09:00 AM was in the time box. The medication was not signed out on the Narcotic Disposition log.
--07/01/21, one (1) Norco was signed out on the Narcotic Disposition log at 11:50 AM/PM (not verified). There is no corresponding documentation on the MAR.
--07/02/21, A check mark and initials was signed in the box for PRN Norco with a pain level 8 and the chart code E = Effective, 12:09 AM was in the time box. The medication was not signed out on the Narcotic Disposition log.
--07/07/21, A check mark and initials was signed in the box for PRN Norco and the chart code E = Effective, 09:06 PM was in the time box. The medication was not signed out on the Narcotic Disposition log.
--07/07/21, one (1) Norco was signed out on the Narcotic Disposition log at 8:00 PM.
There is no corresponding documentation on the MAR.
--07/07/21, one (1) Norco was signed out on the Narcotic Disposition log at 10:00 PM.
There is no corresponding documentation on the MAR.
--07/09/21, A check mark and initials was signed in the box for PRN Norco with a pain level 3 and the chart code E = Effective, 11:53 PM was in the time box. The medication was not signed out on the Narcotic Disposition log.
--07/10/21, A check mark and initials was signed in the box for PRN Norco with a pain level 10 and the chart code E = Effective, 04:53 AM was in the time box. The medication was not signed out on the Narcotic Disposition log.
--07/10/21, A check mark and initials was signed in the box for PRN Norco with a pain level 0 and the chart code E = Effective, 09:00 AM was in the time box. The medication was not signed out on the Narcotic Disposition log.
--07/10/21, one (1) Norco was signed out on the Narcotic Disposition log at 11:00 AM. There is no corresponding documentation on the MAR.
--07/14/21, one (1) Norco was signed out on the Narcotic Disposition log at 4:00 PM. There is no corresponding documentation on the MAR.
--07/14/21, one (1) Norco was signed out on the Narcotic Disposition log at 8:00 PM. There is no corresponding documentation on the MAR.
--07/19/21, one (1) Norco was signed out on the Narcotic Disposition log at 8:00 AM. There is no corresponding documentation on the MAR.
--07/19/21, one (1) Norco was signed out on the Narcotic Disposition log at 12:00 PM. There is no corresponding documentation on the MAR.
--07/20/21, one (1) Norco was signed out on the Narcotic Disposition log at 8:00 AM. There is no corresponding documentation on the MAR.
--07/21/21, one (1) Norco was signed out on the Narcotic Disposition log at 3:00 PM. There is no corresponding documentation on the MAR.
--07/23/21, one (1) Norco was signed out on the Narcotic Disposition log at 9:00 AM. There is no corresponding documentation on the MAR.
--07/23/21, one (1) Norco was signed out on the Narcotic Disposition log at 4:00 PM. There is no corresponding documentation on the MAR.
--07/24/21, one (1) Norco was signed out on the Narcotic Disposition log at 8:00 AM. There is no corresponding documentation on the MAR.
--07/24/21, one (1) Norco was signed out on the Narcotic Disposition log at 4:00 PM. There is no corresponding documentation on the MAR.
--07/25/21, one (1) Norco was signed out on the Narcotic Disposition log at 8:00 AM. There is no corresponding documentation on the MAR.
--07/25/21, one (1) Norco was signed out on the Narcotic Disposition log at 4:00 PM. There is no corresponding documentation on the MAR.
--07/26/21, one (1) Norco was signed out on the Narcotic Disposition log at 12:08
PM. There is no corresponding documentation on the MAR.
--07/27/21, one (1) Norco was signed out on the Narcotic Disposition log at 11:30 PM. There is no corresponding documentation on the MAR.
--07/28/21, one (1) Norco was signed out on the Narcotic Disposition log at 8:00 AM. There is no corresponding documentation on the MAR.
--07/28/21, one (1) Norco was signed out on the Narcotic Disposition log at 4:00 PM. There is no corresponding documentation on the MAR.
--07/28/21, one (1) Norco was signed out on the Narcotic Disposition log at 8:00 PM. There is no corresponding documentation on the MAR.
--07/31/21, one (1) Norco was signed out on the Narcotic Disposition log at 4:40 PM. There is no corresponding documentation on the MAR.
--08/01/21, one (1) Norco was signed out on the Narcotic Disposition log at 10:00 PM. There is no corresponding documentation on the MAR.
--08/02/21, one (1) Norco was signed out on the Narcotic Disposition log at 6:00 AM. There is no corresponding documentation on the MAR.
During an interview on 08/05/21 at 8:52 AM with DON, she stated, I feel these are medication errors and documentation errors, they should have been investigated.
No further information was provided prior to the end of the survey on 08/05/21 at 4:30 PM.
d) Resident #340
Medical record review for Resident #340 found she was admitted to the facility on [DATE] at 10:20 pm. Diagnosis included: severe aortic stenosis, chronic respiratory failure, pseudoaneurysm, chronic obstructive pulmonary disease, diabetes mellitus, atrial fibrillation, and heart failure with preserved ejection fraction. Review of the admission minimum data set (MDS) with assessment reference date of 12/20/20 reveals a Brief Mini-Mental Interview Status (BIMS) of 15, which indicates she is cognitive intact.
Resident #340's physician orders included an order for, Percocet (oxycodone/acetaminophen) 5/325 milligrams (mgs)- give one tablet by mouth every six (6) hours for pain as needed (PRN) order date of 12/15/20.
Further review of the Controlled Drug Receipt/Record/Disposition Form and the MAR the following doses of Percocet was signed out on the Controlled Drug Receipt/Record/Disposition Form but was not documented as administered on the MAR:
--12/22/20 at 4:19 am and 11:00 pm.
During a review of the Narcotic sheets and the MAR with the Director of Nursing (DON) on 08/05/2021 at 11:30 am., she confirmed on two (2) above episodes the medication was signed out on the narcotic record but was not documented on the MAR as administered.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected multiple residents
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Based on record review and staff interview, the facility failed to ensure a monthly medication review was completed on each resident by a licensed pharmacist. Additionally, the attending physician f...
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Based on record review and staff interview, the facility failed to ensure a monthly medication review was completed on each resident by a licensed pharmacist. Additionally, the attending physician failed to review and act on any identified irregularities. Resident Identifiers: #81, #116, #123, and #34. Facility Census: 142.
Findings included:
a) Resident #81
On 08/03/21 at 10:13 AM, an electronic medical record review was completed.
A monthly medication review was completed by the consulting pharmacist on 04/23/21 with the following irregularity noted: Per the CMS guidelines for psychoactive medications, the following medication(s) are due for an evaluation for continued use: Lexapro 10 mg qd [once a day] started on 11/02/2020.
There was no documented physician response in the electronic medical record indicating that the written monthly medication review had been reviewed by the attending physician.
Review of the April 2021, May 2021, June 2021, July 2021, and August 2021 Medication Administration Records indicated Resident #81 continued to receive the Lexapro 10 mg once a day.
During an interview on 08/04/21 at 3:00 PM, Corporate Nurse #265 reported the facility was unable to produce evidence the physician had reviewed the 04/23/21 medication review and there was no rationale documented to note the physician did not wish to change the medication.
b) Resident # 116
Record review found the pharmacist failed to review the drug regimen for Resident #116 for the months of November 2020 and July 2021. In addition, the pharmacist recommended a Gradual Drug Reduction (GDR) in September, 2020, for the medications: Ativan 0.5 mg in the morning and Ativan 1.5 mg night, plus Seroquel 25 mg twice a day. There was no evidence the physician reviewed and addressed the recommendations.
During an interview on 08/04/21 at 11:25 AM, the Director of Nursing (DON) confirmed the pharmacist did not review the drug regimens for November 2020 and July 2021. In addition, the DON conformed the physician failed to address the pharmacists recommendations for a GDR.
c) Resident #123
On 08/04/21 at 11:15 AM, a review of resident #123's medical record found a monthly drug regimen review by the consultant pharmacist on 04/22/21. The recommendations are as follows:
Per manufactures recommendation, 15 mg and 20 mg daily doses of Xarelto are to be taken with the evening meal to reduce the potential risk of decreased efficacy. The recommendation was for Xarelto administration time to be with dinner.
On 03/19/21, the consultant pharmacist reviewed the antipsychotic medication due to recent fall and documented the following recommendation:
Anitpsychotic medications can increase fall risk due to syncope, sedation, slowed reflexes, loss of balance and impaired psychomotor functions. Recommendation for a trial decrease for Seroquel 25 mg daily for two (2) weeks then discontinue. Resident #123 is currently receiving 25 mg of Seroquel two (2) times a day.
On 8/4/21 at 11:57 AM, the assistant director of nursing (ADON) #21 confirmed the recommendations were not addressed by the physician.
d) Resident #34
The resident was noted to have a recommendation from the registered pharmacist regarding changes to the following medications: Claritin, Saline nasal spray and refresh tears. A document was presented to the surveyor by the Director of Nursing on 8/20/21 that showed the physician had been given these recommendations but he had not signed or dated the form. He additionally had not acknowledged if he agreed to the recommendation or refused.
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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
- "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: 3 harm violation(s). Review inspection reports carefully.
- • 95 deficiencies on record, including 3 serious (caused harm) violations. Ask about corrective actions taken.
- • $12,831 in fines. Above average for West Virginia. Some compliance problems on record.
- • Grade D (43/100). Below average facility with significant concerns.
Bottom line: Trust Score of 43/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Charleston Healthcare Center's CMS Rating?
CMS assigns CHARLESTON HEALTHCARE CENTER an overall rating of 3 out of 5 stars, which is considered average nationally. Within West Virginia, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Charleston Healthcare Center Staffed?
CMS rates CHARLESTON HEALTHCARE CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 46%, compared to the West Virginia average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Charleston Healthcare Center?
State health inspectors documented 95 deficiencies at CHARLESTON HEALTHCARE CENTER during 2021 to 2024. These included: 3 that caused actual resident harm and 92 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Charleston Healthcare Center?
CHARLESTON HEALTHCARE 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 COMMUNICARE HEALTH, a chain that manages multiple nursing homes. With 150 certified beds and approximately 146 residents (about 97% occupancy), it is a mid-sized facility located in CHARLESTON, West Virginia.
How Does Charleston Healthcare Center Compare to Other West Virginia Nursing Homes?
Compared to the 100 nursing homes in West Virginia, CHARLESTON HEALTHCARE CENTER's overall rating (3 stars) is above the state average of 2.7, staff turnover (46%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Charleston Healthcare Center?
Based on this facility's data, families visiting should ask: "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?" "Can I speak with family members of current residents about their experience?"
Is Charleston Healthcare Center Safe?
Based on CMS inspection data, CHARLESTON HEALTHCARE 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 3-star overall rating and ranks #1 of 100 nursing homes in West 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 Charleston Healthcare Center Stick Around?
CHARLESTON HEALTHCARE CENTER has a staff turnover rate of 46%, which is about average for West Virginia nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Charleston Healthcare Center Ever Fined?
CHARLESTON HEALTHCARE CENTER has been fined $12,831 across 1 penalty action. This is below the West Virginia average of $33,207. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Charleston Healthcare Center on Any Federal Watch List?
CHARLESTON HEALTHCARE 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.