AUTUMN LAKE HEALTHCARE AT CRYSTAL SPRINGS
For profit - Corporation
84 Beds
AUTUMN LAKE HEALTHCARE
Data: November 2025
Trust Grade
35/100
#91 of 122 in WV
Photo by Autumn Lake Healthcare at Crystal Springs
Photo by Autumn Lake Healthcare at Crystal Springs
Photo by Autumn Lake Healthcare at Crystal Springs
1 / 5 photos
Last Inspection: March 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Autumn Lake Healthcare at Crystal Springs has received a Trust Grade of F, indicating significant concerns about the quality of care provided. Ranking #91 out of 122 facilities in West Virginia places it in the bottom half of nursing homes in the state, while being #2 of 3 in Randolph County suggests limited local options with only one facility performing better. The trend here is improving, with the number of issues decreasing from 29 in 2024 to 15 in 2025, but the facility still faces serious challenges. Staffing is a major concern, with a poor rating of 1 out of 5 stars and a high turnover rate of 69%, which is significantly above the state average of 44%. While the facility has not incurred any fines, which is a positive aspect, it faces critical issues like inadequate infection control practices and failure to establish a proper grievance policy. For instance, there were instances where staff members lacked the necessary competencies to care for residents, and infection surveillance was poorly maintained, leading to potential risks of communicable diseases. Overall, families should weigh these strengths and weaknesses carefully when considering this facility for their loved ones.
- Trust Score
- F
- In West Virginia
- #91/122
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 69% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most West Virginia facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 16 minutes of Registered Nurse (RN) attention daily — below average for West Virginia. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 78 deficiencies on record. Higher than average. Multiple issues found across inspections.
35/100
Bottom 26%
No red flags
29 → 15 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 29 issues
2025: 15 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below West Virginia average (2.7)
Significant quality concerns identified by CMS
Staff Turnover: 69%
22pts above West Virginia avg (46%)
Frequent staff changes - ask about care continuity
Chain: AUTUMN LAKE HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (69%)
21 points above West Virginia average of 48%
The Ugly 78 deficiencies on record
Mar 2025
15 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation and staff interview, the facility failed to allow residents to have a dignified existence related to having an uncovered catheter bag. This failed practice was a random opportunit...
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Based on observation and staff interview, the facility failed to allow residents to have a dignified existence related to having an uncovered catheter bag. This failed practice was a random opportunity of discovery. Resident identifier: #23. Facility census: 77
Findings included:
a) Resident #23
On 03/03/2025 at 2:46 PM, during a resident interview, it was observed that Resident # 23's catheter bag did not have a bag cover.
On 03/03/25 at 2:44 PM the LPN acknowledged the catheter bag was not covered.
During an interview, on 03/05/2025, at approximately 3:45 PM, the facility administrator stated the facility had purchased enough catheter bag covers for all needed residents but did not know why Resident # 23 did not have one
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0577
(Tag F0577)
Could have caused harm · This affected 1 resident
Based on observation and interviews, the facility failed to display notices regarding the availability of survey results, and the related plans of correction, in areas that are prominent and easily ac...
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Based on observation and interviews, the facility failed to display notices regarding the availability of survey results, and the related plans of correction, in areas that are prominent and easily accessible to residents and their representatives. Facility census: 77.
Findings include:
a) Observation on 03/04/25 at approximately 10:55 AM, revealed there was no signage posted indicating the availability of the survey results for residents to review.
After being notified of this lapse, on 03/04/25 at approximately 11:30 AM, the Administrator indicated that the survey results were available for review in a binder located on the table near the entrance of the facility.
During a resident council meeting on 03/05/25, at approximately 2:05 PM, when resident council members were asked, Do you know where the facility survey results are? Resident #5 stated, That's not our business; that's for the staff!
The Assistant Director of Nursing (ADON) confirmed on 03/05/25 at approximately 2:30 PM that there was no posted notice identifying where residents or their representatives could review the survey results.
During a meeting with the Administrator, on 03/05/5 at 3:18 PM, the Administrator addressed Resident #5's response to a question about the survey results. The Administrator noted that they had a meeting last year and explained to the residents what survey tags were and what they were doing to correct each of them following the last annual survey. The Administrator said the current resident council president was not a resident at that time. The Administrator also said they had discussions in resident council with residents about being involved in the healthcare information of others.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) letter to one (1) of three (3) residents reviewed during the annual surv...
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Based on record review and staff interview, the facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) letter to one (1) of three (3) residents reviewed during the annual survey process. This failure placed residents at risk of not being informed of their rights prior to the end of Medicare Part A covered services. Resident identifiers: #333, #334, and #335.
Facility census: 77.
Findings Included:
a) Resident #333
On 02/19/25 at 2:15 PM, a review was completed regarding the beneficiary protection notification liability notices given for the following resident:
Resident #333 began Medicare Part A skilled services on 01/07/25. The last covered day of Part A service was 02/08/25. There was no evidence that a NOMNC form was provided.
Review of the social worker's social service notes to Resident # 333's daughter, dated 02/06/25, verified a planned discharge. The note stated, This worker updated (Resident #333) on upcoming discharge that PT/OTwill be put in the home and Lincare is dropping resident off an oxygen tank to have on Saturday after discharge.
In an interview on 02/20/25 at approximately 1:10 PM, the Administrator stated the facility was unable to provide verification the NOMNC form was given to Resident # 333.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment. Resident #34's bathroom wall was not in good repair. This was a random op...
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Based on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment. Resident #34's bathroom wall was not in good repair. This was a random opportunity for discovery. Resident identifier: #34. Facility census: 77.
Findings included:
a) Resident #34
Upon entering Resident #34's bathroom on 03/06/25 at approximately 9:20 AM, an immediate observation found one (1) rectangle shaped tear approximately 11 inches wide by 8 inches long in the dry wall on the left wall area, to the left side above the sink.
On 03/06/25 at 9:25 AM, during an interview with Registered Nurse (RN) #5 she acknowledged there was a tear in the drywall on the bathroom wall left of the sink. She said she would notify maintenance for repair schedule.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
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 the resident's Pre-admission Screening (PAS) was updat...
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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 the resident's Pre-admission Screening (PAS) was updated after a new diagnosis. This was true for two (2) out of three (3) residents reviewed for the category of PASARR (Pre-admission Screening and Record Review, during the Long-Term Care Survey Process. Resident identifiers: #23, #28 and #27. Facility census: 77.
Findings included:
a) Resident #28
- A PAS, completed on 01/04/18, marked Mental Retardation under Section III Question 30 entitled, Current Diagnosis . Additionally, Section IV Question 37 entitled, Diagnosis included the following:
Spontaneous rupture of flexor tendons, right lower leg.
Fracture of unspecified part of scapula, left shoulder, initial encounter for closed fracture.
essential (primary) hypertension.
Mild intellectual disabilities
Anxiety disorder, unspecified.
A medical record review, completed on 03/04/25 at 9:18 AM, revealed Resident #28 had a diagnosis of: Unspecified Psychosis Not due to due to a substance or physiological condition with onset date of 06/08/21 and Major Depressive Disorder, Single Episode with an onset of 06/02/21.
During an interview, on 03/05/25 at 11:23 AM, the Director of Social Services reported that no new PASARR had been completed after the new diagnosis.
b) Resident #27
A medical record review, completed on 03/04/25 at 9:45 PM, revealed Resident #27 had a diagnosis of: Unspecified Psychosis not due to due to a substance or known physiological condition with onset date of 06/22/21.
A PAS, completed on 03/21/24, marked NONE under Section III Question 30 entitled, Current Diagnosis . Additionally, Section V Question 40 entitled, Major Mental Illness or Suspected MI was marked NONE,
During an interview on 03/05/25 at 11:23 AM, the Director of Social Services reported that new PASARR had been completed after the new diagnosis but failed to capture the diagnosis.
c) Resident #23
A medical record review, completed on 03/04/25 at 9:07 AM, revealed Resident #23 had been admitted to the facility on [DATE] with the following diagnoses:
-Major Depression Disorder
-Schizoaffective Disorder
A PAS, completed on 11/27/24, marked NONE under Section III Question 30 entitled, Current Diagnosis (Check all that apply). Additionally, Section V Question 40 entitled, Major Mental Illness (MI) or Suspected MI - Major Depression Disorder was not marked.
During an interview on 03/05/25 at 11:23 AM, the Director of Social Services reported that resident's Major Depression Disorder diagnoses had not been captured on the 11/27/24 PAS and a new one had not been completed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview and record review the facility failed to provide evidence that residents were invit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview and record review the facility failed to provide evidence that residents were invited to care plan meetings in order to participate in planning for her their own care. This was true for Resident #15. Facility census: 77.
Findings included:
a) On 03/03/25 at 3:41 PM during an interview with Resident #15, she reported that she had never been asked to attend her care planning meetings. She reported that she did not feel she was a part of the decision making process for her care.
On 03/05/25 at 3:14 PM an interview was conducted with Facility Administrator who reported that they do not have documentation to support that Resident #15 had been invited to care plan meetings. She stated that the facility, was cited for this last time and they were doing what they were supposed to but do not have current documentation that they have been doing this.
A review of Minimum Data Set MDS assessment dated [DATE] Section Q, Participation in Assessment and Goal Setting, question A. Resident #15 responded Yes indicating that she would like to be included in this process.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record review, The facility failed to ensure two (2) of two (2) resident environmen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record review, The facility failed to ensure two (2) of two (2) resident environments were free from accident hazards for which it had control. Resident identifiers: #23 and #34. Facility census: 77.
Findings included:
a) Resident #23
On 03/03/25 at 02:46 PM It was observed there were no fall mats at Resident #23 bedside per physician orders.
03/03/25 at 2:48 Nurse Aide (NA) #85 acknowledged there were no fall mats on the floor at resident #23's bedside.
Physician Order dated 11/27/25 indicated:
Fall Mats were to be located at bedside while Resident #23 was in bed.
A Care Plan review revealed:
Risk for fall R/T (related to) S/P (status post) CVA. Contractures right knee and left hip. Unable to ambulate on own or transfer self in/out of bed.
·
b) Resident #34
During an observation in Resident # 34's room, on 03/06/2025 at 9:20 AM, a 6 fluid ounce bottle of Derma-[NAME] containing Hydro-Cortisone Cream was found in Resident 34's bathroom.
A subsequent record review revealed there was no physician order stating that Resident #34 could administer her own medication. In addition, there was no physician order for the bottle of Derma-[NAME], which had been found in the resident's possession.
c) Material Safety Data Sheet (MSDS):
Review of the MSDS revealed the following information:
-This product is not meant for oral consumption or for ophthalmic use.
-Inhalation: May cause irritation of nose and throat
-Ingestion: May be harmful if swallowed
-Skin Contact: May cause slight irritation.
-Eye Contact: Will cause irritation to the eyes
During an interview on 03/06/25 at 9:25 AM, Registered Nurse (RN) #5 verified the Derma-[NAME] with Hydrocortisone was in resident's room and stated it should be removed from the resident's room.
CONCERN
(D)
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 ensure the updated staffing information was posted. Facility census: 77.
Findings included:
a)The facility failed to post an updated s...
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Based on observation and staff interview the facility failed to ensure the updated staffing information was posted. Facility census: 77.
Findings included:
a)The facility failed to post an updated staffing report sheet for 03/03/2025.
On 03/03/25 at 11:35 AM, Upon entrance to the facility the posted daily staffing report sheet had not been updated for 5 days. The daily staffing report sheet was dated 02/26/2025 actual date of entry was 03/03/2025.
03/05/25 at10:54 AM In an interview with the DON, she acknowledged that on Monday 03/03/25, the Daily Staffing report sheet was dated 02/26/25.
The Facility failed to post the census on the nurse staffing data at the beginning of each shift for eight (8) of eight (8) sampled days.
Not listed for the 7:00 PM - 7:00 AM shift:
-Sunday, 07/07/24
-Sunday, 07/21/24
-Sunday, 08/04/24
-Sunday, 08/18/24
-Saturday, 09/14/54
-Sunday, 09/15/24
-Saturday, 09/28/24
-Sunday 09/29/24
In an interview 03/05/2025 at 10:45AM, the DON confirmed census was not listed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected 1 resident
Based on observation and staff interview it was determined that the facility failed to ensure they disposed of garbage and refuge properly. The facility failed to ensure garbage and refuse containers ...
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Based on observation and staff interview it was determined that the facility failed to ensure they disposed of garbage and refuge properly. The facility failed to ensure garbage and refuse containers were in good condition and waste was properly contained in dumpsters or compactors with lids or otherwise covered. This practice had the potential to affect more than an isolated number of residents. Facility census: 77.
Findings included:
a) On 03/03/25 at 1:35PM during the tour of the facility, the dumpster was observed with one lid open and one lid that was broken and did not fit properly.
On 03/03/25 at 1:40PM during an interview with Kitchen Account Manager #44 who acknowledged the dumpster lids should be closed and properly fitting.
On 03/06/25 at 1:05 AM, a review of document title HCSG Policy 030, Policy Statement All garbage and refuse will be collected and disposed of in a safe and efficient manner. Procedures # two (2), The Dining Services Director will ensure that appropriate lids are provided for all containers.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
Based on observation and interviews, the facility failed to established a grievance policy that meets essential requirements. Specifically, it failed to: Notify residents individually or provide clear...
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Based on observation and interviews, the facility failed to established a grievance policy that meets essential requirements. Specifically, it failed to: Notify residents individually or provide clear postings throughout the facility about their right to file a grievance. The facility did not provide easy access to grievance forms. They facility did not notify residents of the right to file a grievance anonymously.
Additionally, the facility did not provide easily accessible and clearly presented contact information for independent entities where grievances can be filed, such as the appropriate state agency, Quality Improvement Organization, State Survey Agency, and State Long-Term Care Ombudsman programs. Facility Census: 77
Findings include:
a) On 03/03/25, at around 2:00 PM, it was observed that there were no posted notices informing residents about their right to file a grievance, including the option to do so anonymously. Further investigation indicated that residents had been directed to submit any complaints or grievances directly to the administrator.
During an interview with Resident #14 on 03/03/25 at approximately 2:08 PM, when asked how she would file a complaint, she responded, I'll talk to the nurse, I guess!
During another interview with Resident #26 on 03/03/25 at 2:45 PM, the resident stated that he would have to request a grievance form.
On 0303/25, at approximately 3:00 PM, the administrator stated during an interview that the contact information for submitting a grievance was prominently displayed on the facility's TV screens in large text, making it visible to everyone.
Further investigation revealed that the TV screens displayed various messages in a continuous loop. Observation showed that the following message appeared approximately every two and a half minutes:
Questions, comments, or concerns
Call our compliance hotline
1-888-983-7080
Compliance is everyone's responsibility
Help us improve our care
See something, Say something
The administrator insisted the message was visible to all residents and they could call in their complaints or grievances.
During an interview, with the Assistant Director of Nursing (ADON) on 03/04/25, at approximately 10:45 AM, the ADON confirmed that the sign stating Resident Rights was posted too high for a person using a wheelchair to read.
During a Resident Council Meeting on 03/05/25 at approximately 2:05 PM, when asked how residents would file a grievance, the Resident Council President (RCP) stated that you write a letter.
During an observation on 03/03/25 at approximately 2:00 PM, it was noted that there were no postings indicating where grievance forms were located. Additionally, there were no grievance forms readily accessible for residents to file concerns anonymously.
Further investigation revealed that residents had been instructed to submit complaints or grievances to the Administrator.
During an interview with the administrator on 03/03/25, at approximately 3:00 PM, the administrator stated that the contact information for submitting a grievance was displayed in large text on the TV screens throughout the facility, making it visible to everyone. When asked how a resident could file a grievance in writing, the administrator explained that grievance forms were available at the nurses' station and that residents could request one whenever needed.
A follow-up interview with the administrator revealed that completed grievance forms could be submitted at the nurses' station or dropped off at the administrator's office. When asked how a resident could submit a grievance anonymously, the administrator explained that residents could call the compliance number displayed on the TV screens throughout the facility.
During a Resident Council Meeting on 03/05/25 at approximately 2:05 PM, when asked how residents could file a grievance, the Resident Council President (RCP) stated, You write a letter.
During a resident council meeting on 03/05/25, at approximately 2:05 PM, the Resident Council President (RCP) was asked how residents could file a grievance. The RCP responded, You write a letter. When inquired about how someone could file a grievance anonymously, she replied, I don't care; I tell them what I want!
Upon being asked again how someone who wished to remain unidentified could file a complaint, the RCP stated, You just write a letter and slide it under the Administrator's door! You don't sign it!
On 03/05/25, at around 3:00 PM, the Administrator confirmed during an interview that grievance letters could be submitted anonymously by sliding them under her door. However, she noted that the facility is small and that everyone can be easily observed, which limits true anonymity.
d) No easily accessible location to submit a grievance.
On 03/05/25, it was observed that there was no lockbox or designated location for residents to drop off grievance forms. During an interview on the same day at approximately 11:25 AM, the ADON mentioned that there was a box located in the lobby. However, upon inspecting the box, it was found to be a small container labeled Suggestions that was fixed to the wall. The ADON confirmed that it was not possible to insert any documents into this box.
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 medical record review, observation, and staff interview, the facility failed to ensure Resident's received treatment an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to ensure Resident's received treatment and care in accordance with professional standards of practice. Resident #68's nebulizer treatment was left running for 20 minutes longer than it should have been. A resident was receiving oxygen at a rate that was not prescribed. Resident #22 did not receive blood sugar monitoring as required by physician order. Resident #28 was identified as a fall risk and had an order for their bed to be in the lowest posiotion did not have their bed in that position. Resident #85 had a seizure disorder and an intervention for padded side rails did not have padded side rails in place. Resident #8, #68, #22, #28, and #28. Facility census: 77.
Findings included:
a) Resident #68
An observation of Resident #68, on 03/04/25 at 8:55 AM, revealed the Resident was lying in bed receiving a nebulizer treatment (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs.) The nebulizer medication cup was empty at this time.
During an Interview on 03/04/25 at 9:29 AM, The Director of Nursing (DON) verified the nebulizer treatment was still running after 40 minutes. She stated that the Treatment should have only been on for about 20 minutes.
b) Resident #8
An observation, on 03/04/25 at 10:23 AM, found Resident #8 was receiving oxygen at three (3) Liters via nasal cannula (LPM) from an oxygen concentrator (an oxygen delivery device).
A review of Resident #8's medical record revealed a Physicians order for:
-Oxygen at 1-2 LPM via Nasal Cannula as needed Post Treatment Evaluate heart rate, respiratory rate, pulse oximetry, skin color, and breath sounds with an order date 7/11/2024.
An observation on 03/06/25 at 9:53 AM found the Resident #8 was receiving oxygen at two (2) Liters via nasal cannula (LPM).
During an Interview, on 03/06/25 at 10:00 AM, the Director of Nursing verified an Oxygen order was incorrect with the flow liter. She stated that she would notify the physician for a accurate order.
c) Resident #22
Record review and interview on 03/04/25 at 11:18 AM revealed that Resident #22 had been admitted to the hospital on [DATE] at approximately 6:15 PM, and returned back to the facility at approximately 9:15 PM on 03/03/25.
Record review revealed a physician's order dated 02/12/25, which stated the following:
Accu-Chek before meals and at bedtime for diabetes.
Insulin Lispro 100 UNIT/ML Solution Inject subcutaneously before meals and at bedtime
insulin Lispro 100 UNIT/ML Solution
Inject as per sliding scale:
if 150 - 200 = 2 units;
201 - 250 = 4 units;
251 - 300 = 6 units;
301 - 350 = 8 units;
351 - 400 = 10 units;
401 - 450 = 12 units;
451 - 600 = 14 units,
subcutaneously before meals and at bedtime
Further record review revealed the following historical Accu-Chek results at bedtime:
03/03/25 at 8:04 PM
268.0 mg/dL
- Struck out - Clerical correction
03/03/25 at 8:04 PM
268.0 mg/dL - Struck out - Clerical correction
03/02/25 at 9:15 PM
233.0 mg/dL
03/01/25 at 8:42 PM
234.0 mg/dL
02/28/25 at 8:00 PM
195.0 mg/dL
02/27/25 at 8:55 PM
256.0 mg/dL
02/26/25 at 9:49 PM
320.0 mg/dL
During an interview with the Director of Nursing (DON) on 03/04/25, at approximately 11:25 AM, the DON stated the records would indicate the resident was not in the facility at 8:00 PM for the regular bedtime Accu-Chek. She further mentioned that the resident's blood glucose was not checked after arriving at the facility because it had already been checked at the hospital prior to discharge.
A review of the hospital's discharge summary revealed that the resident's blood glucose level was checked in the hospital on [DATE] at 6:34 PM, and it was recorded as 138 mg/dL. The resident returned to the facility at 9:15 PM on 03/03/25.
Upon return, records show that the resident was allowed to go to bed without her blood glucose being checked.
d) 28
The facility failed to ensure padding was installed on bed rails due to Seizure precautions, as ordered by his physician.
On 03/03/25 at 2:49 PM, during an interview with Nurse Aide (NA) #85, he acknowledged the padding had not ben installed on the resident's bed rails.
A physician's order dated 11/27/24 indicated the resident was to have seizure precautions at all times. Padded rails for safety every shift.
d) Resident #28
Review of care plan on 03/05/25 at 10:11 AM revealed the following:
Focus- Risk for falls related to history of falls, receives antidepressant medications daily. Fracture to right hand on 10/02/24. Date initiated 01/07/25.
Interventions included Keep bed at lowest level at all times. initiated on 01/07/25.
On 03/05/25 at 01:20 PM observation of Resident #28 lying in bed with non-skid socks, 1/4 assist rails up and his bed in a high position.
On 03/05/25 at 01:28 PM during an interview with Nursing Assistant (NA) #83 to inquire about resident's bed position the resident was lying in bed with non-skid slippers. NA #83 stated that she did not know if his bed was in the lowest position. She used the bed control and moved the bed down to lowest position. She acknowledged that the bed had not been in lowest position.
During an interview with Licensed Practical Nurse #89 on 03/06/25 at 10:48 AM LPN #89 said that Resident #28 should have his bed in lowest position at all times.
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 F0727
(Tag F0727)
Could have caused harm · This affected multiple residents
Based on record review and staff interviews, the facility failed to have Sufficient and Competent staffing due to the lack of RN coverage for eight (8) consecutive hours a day for eight (8) of eight (...
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Based on record review and staff interviews, the facility failed to have Sufficient and Competent staffing due to the lack of RN coverage for eight (8) consecutive hours a day for eight (8) of eight (8) sampled days.
Findings included:
a) On 03/04/25 at approximately 2:25 PM the administrator reported the facility did not have the eight (8) consecutive hours a day Registered Nurse (RN) coverage for the following sampled days:
-Sunday, 07/07/24
-Sunday, 07/21/24
-Sunday, 08/04/24
-Sunday, 08/18/24
-Saturday, 09/14/254
-Sunday, 09/15/24
-Saturday, 09/28/24
-Sunday 09/29/24
The payroll based journal (PBJ) report review revealed there was no RN coverage on the days listed above.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on observation, staff interview, and food tray temperatures the facility failed to serve food to residents that was at an appetizing temperature. This failed practice was true for one (1) of one...
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Based on observation, staff interview, and food tray temperatures the facility failed to serve food to residents that was at an appetizing temperature. This failed practice was true for one (1) of one (1) hallways tested for food tray temperatures throughout the Long-Term Care Survey Process. Facility census: 77.
Findings included:
a) South Side Front Hall Lunch Time Meal Observation
During an observation on 03/03/25 at 12:15 PM, it was noted that food carts were brought out of the south side nurses' station. One staff member began to feel cups with the appropriate beverages according to residents' dietary slips. Another staff member began delivering meals. At 12:37 PM, meal service / delivery began on the south side front hall.
At 12:43 PM, when four (4) trays were left on the food truck, the Surveyor requested that Nurse Aide (NA) #85 select one tray that would be served last. NA #85 selected Resident #39's tray.
On 03/03/25 at 12:49 PM, the Dietary Manager tested the temperature of Resident #39's lunch tray with the following results:
-Hotdog: 104.9 degrees Fahrenheit (F)
-Fries: 108.1 degrees F
-Pineapple Cake: 62.6 degrees F
-Yogurt: 59.3 degrees F
The Dietary Manager agreed the food temperatures obtained were not considered to be the appropriate desired temperature for the point of delivery to the residents. It was discussed that hot foods would typically be served at 120 degrees F or above and cold foods would be served at 40 degrees F or below. The Dietary Manager stated the food is always 135 degrees or above when it leaves the kitchen and that she was not sure what it ended up being when it was delivered to the residents.
CONCERN
(E)
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, interview and policy review, the facility failed to properly store food in accordance with professional st...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, the facility failed to properly store food in accordance with professional standards. This is true for the facility kitchen and nourishment pantry. This had the potential to affect all residents in the facility. Facility census 77.
Findings included:
a) On 03/03/25 at 11:27 AM, during Initial Brief Tour of Kitchen, with Kitchen Account Manager #44 who acknowledged the following in Freezer #1 with no dates:
Bag of unopened frozen chicken breasts.
Bag of opened fish filets.
Bag of opened fish patties.
Bag of opened french fries.
On 03/06/25 at 1:00 PM a review facility policy labeled HCSG Policy 019, Food Storage: Cold Foods. Procedures, number 5 stated All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.
b)Freezer #1 also contained frozen foods that KAM #44 reported had belonged to a resident who was no longer in the facility, there were no names written on the food boxes and the best by dates were as follows:
Gardein Ultimate Plant based chicken filet with a best by date of 2/25/25.
Gardein Ultimate Turkey and gravy with best by date of 2/26/25.
On 03/06/25 at 1:00 PM a review facility policy labeled HCSG Policy 019, Food Storage: Cold Foods. Procedures, number 5 stated All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.
c)03/4/25 11:30AM Observation of North Hall Pantry:
-Oreos and packaging in a ziplock bag in cabinet- not sealed, no date or name
-Freezer ziplock bag full of prepackaged cookies and cakes with no date that included
*2 fudge rounds- undated
*2 gram crackers - undated
*6 [NAME] Soft Baked Sugar free lemon cookies with best by date of 1/25/25, 5 dated 1/13/25,
and 7 with no date.
*2 undated small baggies of animal crackers- undated and not labeled
-24 Bowls of dry cereal with lids with no expiration dates
On 03/4/25 at 11:40AM, during an interview with the Kitchen Manager it was reported the kitchen brings new food from the kitchen and it was housekeeping responsibility to dispose of expired food.
On 3/4/25 at 11:50AM, during an interview with the DON, it was acknowledged that the cookies had expiration dates, and the cereal had no dates. She acknowledged that the staff drinks and food should not have been in the pantry.
On 03/06/25 a review of facility policy marked HCSG Policy 018 Food Storage: Dry Goods, listed under procedures number six (6) stated: 'Storage areas will be neat, arranged for easy identification, and date marked as appropriate.
d)On 03/04/25 at 11:33 AM observed Resident nourishment room cabinet contained staff keys, two (2) [NAME] drink cups, three (3) opened canned drinks, an open bottle of soda, a to-go cup with drink, and an open bag of BBQ snacks.
On 03/05/25 at 9:00 AM observed a sign on the outside of the nourishment room that stated: Do not put personal food and drink in the kitchenette. Room is only to be used for food/drink for residents.
On 3/4/25 at 11:50AM, Interview with DON who acknowledged the cookies with expiration dates, as well as cereal with no dates. She acknowledged that the staff drinks and food should not have been in the pantry.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to establish and maintain an infection prevention and control pr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, 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 with regards to the water management, PPE, resident hand washing, resident's personal products and unsanitary practices. This practice had the potential to affect all residents that reside in the facility. Resident identifiers: #26, #24, #30, #40, #46, #53, #70, #74, and #285. Facility census: 72.
Findings included:
a) Hand Hygiene Prior to Meals
An observation on 03/03/25 at 12:15 PM revealed that the resident's on north hall did not receive hand hygiene prior to or during the lunch meal tray pass.
During an interview, on 03/03/25 at 12:26 PM, Nursing Assistant (NA) #16 was asked if the residents on the north hall had their hands washed or sanitized prior to the lunch meal on this day. NA #16 stated she was not sure if they had hand hygiene before lunch. NA #16 stated some residents get their hands washed in the resident rooms during AM care, and some residents wash their own hands.
During lunch service on 03/03/25 at approximately 12:45 PM, It was noted that Nursing Assistant (NA) #71 did not offer hand sanitizer to Residents # 30, #40, #46, #53, #70, and #74.
Upon being asked why the residents had not been offered hand hygiene prior to eating their meal, NA #71 stated Well if I could find sanitizer, I would have used it!
During an interview with Licensed Practical Nurse (LPN) #39, at approximately 1:11 PM she stated We have plenty of sanitizer!, and produced two containers of hand sanitizer.
LPN #39 confirmed that the residents had not been offered hand hygiene.
On 03/03/2025, at 12:48 PM, it was observed, On the south wing of the facility, while delivering the residents lunch trays, CNA # 85 did not wash or sanitize any of the resident's hands.
In and interview with CNA # 85, on 03/03/2025 at 12:52 PM, he acknowledged he did not offer to wash or sanitze the residents hands before he served them
On 03/05/2025 at approximately 3:30 PM, the DON acknowledged the CNA's should have been offering to sanitize or wash the resident's hands before serving them.
b) Water Management Plan
During facility record review of the water management revealed, the documentation was not maintained to prevent growth of water borne pathogens including description of the building water system. The flow diagram did not Identify the buildings water systems for which Legionella control measures are needed.
No documentation was provided for weekly water flushes for dead legs, unused showers, water fountains and bathtubs.
On 03/05/25 at 1:07 PM the Maintenance Director verified the facility did not maintain the water management program. He stated that it would be corrected.
c) Resident #24
During an observation of wound care on 03/04/25, at approximately 3:30 PM, Wound care was administered to Resident #24 by Nurse Practitioner (NP) #104 and Registered Nurse (RN) #5. During this procedure, RN #5 and NP #104 assessed, turned, and repositioned the resident to be able visualize his wounds. However, neither NP #104 nor RN #5 donned personal protective equipment (PPE) during the process.
Resident is a bilateral amputee. The resident's right lower thigh has a ligature scar that is in the process of healing, and his suture line showed an area of dehiscence about 2 inches long, with light drainage. NP #104 stated that she would notify the surgeon that the resident has to be seen immediately.
NP #104 and RN #5 continued turning resident in his bed to better visualize and document his wounds. They then continued would care, still without donning any PPE
d) Resident #26
On 03/04/25, at approximately 3:25 PM, NP #104 and RN #5 were providing wound care to Resident #26. However, neither NP #104 nor RN #5 were wearing personal protective equipment (PPE) during the procedure. They then proceeded to turn and reposition the resident in order to address the wounds on the resident's back.
NP #104 wore an instrument pouch around her waist. She used a pair of scissors to cut the resident's dressing and then returned the scissors to her pouch without cleaning or disinfecting them.
During an interview with the Assistant Director of Nursing (ADON) on 03/04/25, at approximately 3:45 PM, it was reported that both Nurse Practitioner #104 and Registered Nurse #5 were not wearing personal protective equipment (PPE). The ADON stated that she would investigate the situation and follow up regarding why the staff were not wearing PPE.
At approximately 3:55 PM, the ADON returned and confirmed that NP #104 and RN #5 were performing wound care without following barrier precautions. The ADON noted that NP #104 and RN #5 had not put on personal protective equipment (PPE) because there was no sign indicating that Enhanced Barrier Precautions (EBP) were required outside the doors of Resident #24 and Resident #26. The ADON verified that both residents were under Enhanced Barrier Precautions and stated that she had posted a new EBP notice on the door. She further stated that education on infection control would be implemented immediately.
A note by NP #104 on 03/05/25 at approximately 3:55 PM stated:
Recommended to ADON to contact surgeon regarding small wound dehiscence with purulent drainage. Dark area to the left of dehiscence is concerning but is covered by eschar. The resident's wound is healing. Continue the current treatment plan. Wound care to follow.
e) Resident #285
During an inspection of Resident #285's room on 03/04/25, at approximately 1:20 PM, the bathroom was observed to have a toilet seat in the bathtub, with a brown substance splattered on it.
Licensed Practical Nurse (LPN) #107 confirmed that the toilet seat should not have been left in the bathtub. She stated that she would contact the housekeeping department to have it removed.
On 03/05/25 at approximately 1:34 PM an inspection of Resident #285's bathroom revealed the toilet seat with the brown substance still in the bathtub.
LPN #89 confirmed that it should be removed and housekeeping should be directed to remove the toilet seat. Housekeeping staff removed the toilet seat a few minutes later.
f) room [ROOM NUMBER]
An observation of room [ROOM NUMBER], which had no occupant, on 03/05/25 at approximately 1:30 PM revealed an IV pump with a tube feed still connected. The tube feed still had residual solution in the bag and tube. The bag was dated 02/23/25. A container one third (1/3) full of tube feed solution was observed on the side table.
Further investigation revealed that the resident had been admitted to the hospital on [DATE]. LPN #89 confirmed that the room should have been cleaned ,and the tube feed discarded. She further stated the tube feed solution could have grown all kinds of organisms.
During an interview with the ADON on 03/05/25, at approximately 2:00 PM, the ADON stated the resident was transferred to the hospital, and the bed was being held because he was expected to come back to the facility soon. ADON further stated that the room should have been cleaned after the resident had left for the hospital on [DATE]. ADON notified the housekeeping department to clean the room immediately.
g) Shower Room
On 03/05/25 at 09:11 AM, during facility water temperature tests with the Maintenance director, it was observed that several bottles ot hygiene products were left in the shower rooms without labels with names or dates.
In an interview with the Administrator and DON present on 03/05/2025, at approximately 4:15 PM, they both acknowledged the bottles of hygiene products should not have been in the shower rooms without labels/dates.
Nov 2024
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
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 honor code status for one (1) of 23 residents reviewed...
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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 honor code status for one (1) of 23 residents reviewed. This is cited as past non compliance due to the facility's correction of the problem prior to the surveyors arrival at the facility. Resident identifier: #83. Facility census: 82.
Findings included:
a) Resident #83
At approximately 11:00 AM on [DATE], a review of a facility reported incident was conducted. During the review it was noted Resident #83 had passed away at the facility on [DATE] and the facility failed to administer CPR, despite the resident being a full code status.
According to a summary report provided by the Administrator and Director of Nursing (DON), Resident #83 had an order to Do Not Resuscitate (DNR) until [DATE], when the code status was changed on [DATE] at a hospital for a surgical procedure.
The resident was admitted to the facility on [DATE] with orders from the hospital as a full code, meaning CPR was to be initiated if needed. However, the hospital sent a POST form stating the resident was a DNR ,even though the status had been changed. It was determined Unit Manager (UM) #94 queued orders in the computer system and told the admitting nurse to activate those orders and she would verify the accuracy of said orders upon arrival to the facility the morning of [DATE].
The admitting nurse activated the orders, including the order entered for DNR by UM #94. However, UM #94 did not verify the status of the orders when she arrived to the facility on [DATE] and stated she assumed the order from the hospital for a full code was wrong and did not verify it for that reason. The DNR order was signed by the facility physician.
On [DATE], Resident #83 was found to have no pulse or respirations and CPR was not attempted and Emergency Services were called and the resident was pronounced dead.
As a result of the investigation by the facility, UM #94 was suspended and later terminated due to failing to verify the orders.
At approximately 12:30 PM on [DATE], an interview was conducted with the Administrator and DON. During the interview, both stated CPR should have been performed on Resident #83. The Administrator stated the admitting nurse had it in writing from a group nurse chat stating UM #94 told her to activate the orders she had queued and she would verify the accuracy the following morning. Regarding the conflicting orders on the discharge summary from the hospital and the POST form for Resident #83, both stated orders should have been pulled from the discharge summary, however, they should have been verified due to them being conflicting. Neither the hospital or wife was contacted to verify. The Administrator stated the facility was unaware Resident #83 should have received CPR until a nurse contacted his wife on [DATE] to inform her of his passing at the facility. The Administrator stated UM #94 inserted her opinion for what the doctors and wife wanted regarding Resident #83's code status.
The facility plan of correction is as follows:
Facility performed a facility wide audit of resident code statuses, POST forms, and CPR certification for all residents.
All nurses were educated on verifying code statuses, accuracy of orders if orders are conflicting.
Audits completed by the DON to ensure all admissions were completed and code status was verified. DON performed random audits of ten (10) percent of resident population to ensure code status and POST forms.
CPR drills were conducted twice per month, and will continue for six (6) months.
DON will conduct monthly audits, and upon hire, to ensure all nursing CPR certifications are up to date. Audits will last six (6) months.
All audit results will be reported to QAPI for review.
The correction occurred on [DATE].
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
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
.
Based on a complaint investigation conducted from 11/25/24 through 11/26/24. Record review, and interview, revealed that the facility failed to ensure that the physician reviewed and documented a re...
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.
Based on a complaint investigation conducted from 11/25/24 through 11/26/24. Record review, and interview, revealed that the facility failed to ensure that the physician reviewed and documented a response, to the irregularities noted by the consultant pharmacist. This was true for one (1) of six (6) resident records surveyed. Resident Identifier: #35. Facility census:82
Findings included:
a) Resident #35
Record review on 11/25/24 at approximately 12:30 PM revealed that Resident #35 was currently on the following medications:
Seroquel Oral Tablet 50 MG (Quetiapine Fumarate) Give 1 tablet by mouth every morning and at bedtime for psychosis Order dated 07/18/24
Depakote Sprinkles Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium)
Give 125 mg by mouth three times a day for psychosis may mix in food such as pudding or ice cream.
Order dated 07/16/24.
Record review of the consultant pharmacist's recommendations for the period 02/09/24 to 11/11/24 revealed the following:
Consultant pharmacist review on 04/09/24:
The Consulting pharmacist suggested discontinuing PRN use of Seroquel for agitation/wound changes. Suggested considering the use of a medication from a different therapeutic class such as a short acting Benzodiazepine for PRN use with a 14 day stop.
Per State and Federal guidelines:
PRN orders for antipsychotic drugs are limited to 14 days and cannot be renewed, unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Record review revealed that the physician had been notified on 05/06/24, and no response to the recommendation had been received.
During an interview with the Director of Nursing (DON) on 11/26/24 at approximately 2:00 PM, the DON confirmed that there were no records indicating that the physician had responded to the consulting pharmacist's recommendation.
Consultant pharmacist review on 06/12/24:
The Consulting Pharmacist noted this resident has been taking Depakote DR 125 MG TID since 06/23 without a Gradual Dose Reduction (GDR). Could we attempt a dose reduction at this time to perhaps 125 MG BID to verify the resident is on the lowest possible dose? If not, please indicate response.
Federal guidelines state that psychopharmacological drugs should have an attempt at a GDR twice per year for the first year in two (2) different quarters with one (1) month between attempts, then annually thereafter, when used to manage behavior, stabilize mood, or treat psych disorder.
The recommendation was faxed to the physician on 06/18/24. The physician had not responded to the pharmacist's recommendation.
During the interview with the DON on 11/26/24 at approximately 2:00 PM, the DON stated that though the physician had not responded to the recommendation, the physician had come into the facility and performed a complete history and physical, and medication review of Resident #35, on 06/24/24 at approximately 7:00 AM.
A review of the physician's documentation revealed no notes referring to the pharmacist's recommendation, and the Depakote prescription remained unchanged.
This citation refers to the following Federal guidelines related to pharmacist, and physician's obligations:
§483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
§483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of a
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, the facility failed to implement the care plan intervention of weekly skin evaluations for Resident #30, #76, #18 and #75. This was true for four (4) of fiv...
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Based on record review and staff interview, the facility failed to implement the care plan intervention of weekly skin evaluations for Resident #30, #76, #18 and #75. This was true for four (4) of five (5) residents reviewed during the survey process. Resident Identifiers: #30, #76, #18 and #75. Facility Census: 82.
Findings Include:
a) Resident #30
On 11/26/24 at 10:00 AM, a record review was completed for Resident #30. The review found the care plan had not been implemented regarding weekly skin evaluations. The following dates of the completed skin evaluations have greater than seven (7) days in between weekly skin evaluations:
--02/19/24-02/27/24 8 days
--03/04/24-03/19/24 15 days
--04/15/24-04/23/24 8 days
--05/14/24-05/28/24 14 days
--06/04/24-06/18/24 14 days
--07/16/24-08/01/24 16 days
--08/06/24-08/20/24 14 days
--08/20/24-09/02/24 13 days
--09/02/24-09/17/24 15 days
--09/30/24-10/14/24 15 days
On 11/26/24 at 1:15 PM, the Assistant Director of Nursing (ADON) #53 confirmed the skin evaluations were not being completed weekly.
b) Resident #76
On 11/26/24 at 10:30 AM, a record review was completed for Resident #76. The review found the care plan had not been implemented regarding weekly skin evaluations. The following dates of the completed skin evaluations have greater than seven (7) days in between weekly skin evaluations:
--02/05/24-02/13/24 8 days
--02/20/24-03/12/24 21 days
--04/01/24-04/09/24 8 days
--04/16/24-05/21/24 35 days
--05/21/24-06/04/24 14 days
--06/11/24-06/21/24 10 days
--07/19/24-07/29/24 10 days
--08/01/24-08/09/24 8 days
--08/30/24-09/13/24 14 days
--09/13/24-09/27/24 14 days
--09/27/24-10/10/24 13 days
--11/15/24-11/23/24 8 days
On 11/26/24 at 1:15 PM, the Assistant Director of Nursing (ADON) #53 confirmed the skin evaluations were not being completed weekly.
c) Resident #18
On 11/26/24 at 10:45 AM, a record review was completed for Resident #18. The review found the care plan had not been implemented regarding weekly skin evaluations. The following dates of the completed skin evaluations have greater than seven (7) days in between weekly skin evaluations:
--05/21/24-05/30/24 9 days
--08/21/24-08/30/24 9 days
--10/14/24-10/28/24 14 days
On 11/26/24 at 1:15 PM, the Assistant Director of Nursing (ADON) #53 confirmed the skin evaluations were not being completed weekly.
d) Resident #75
On 11/26/24 at 11:00 AM, a record review was completed for Resident #75. The review found the care plan had not been implemented regarding weekly skin evaluations. The following dates of the completed skin evaluations have greater than seven (7) days in between weekly skin evaluations:
--03/14/24-03/28/24 14 days
--03/28/24-04/16/24 19 days
--04/18/24-05/02/24 14 days
--05/16/24-05/30/24 14 days
--06/12/24-06/20/24 8 days
--06/27/24-07/26/24 29 days
--08/29/24-09/06/24 8 days
--09/12/24-10/10/24 28 days
--10/10/24-10/31/24 21 days
On 11/26/24 at 1:15 PM, the Assistant Director of Nursing (ADON) #53 confirmed the skin evaluations were not being completed weekly.
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
Based on record review and staff interview, the facility failed to follow physician's orders regarding weekly skin evaluations for four (4) of five (5) residents reviewed for quality of care. Resident...
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Based on record review and staff interview, the facility failed to follow physician's orders regarding weekly skin evaluations for four (4) of five (5) residents reviewed for quality of care. Resident #30, #76, #18 and #75 were affected by this. Resident identifiers: #30, #76, #18, and #75. Facility Census: 82.
Findings Included:
a) Resident #30
On 11/26/24 at 10:00 AM, a record review was completed for Resident #30. The review found the physician's order regarding weekly skin evaluations had not been followed. The following dates of the completed skin evaluations have greater than seven (7) days in between weekly skin evaluations:
--02/19/24-02/27/24 8 days
--03/04/24-03/19/24 15 days
--04/15/24-04/23/24 8 days
--05/14/24-05/28/24 14 days
--06/04/24-06/18/24 14 days
--07/16/24-08/01/24 16 days
--08/06/24-08/20/24 14 days
--08/20/24-09/02/24 13 days
--09/02/24-09/17/24 15 days
--09/30/24-10/14/24 15 days
On 11/26/24 at 1:15 PM, the Assistant Director of Nursing (ADON) #53 confirmed the skin evaluations were not being completed weekly.
b) Resident #76
On 11/26/24 at 10:30 AM, a record review was completed for Resident #76. The review found the physician's order had not been followed regarding weekly skin evaluations. The following dates of the completed skin evaluations have greater than seven (7) days in between weekly skin evaluations:
--02/05/24-02/13/24 8 days
--02/20/24-03/12/24 21 days
--04/01/24-04/09/24 8 days
--04/16/24-05/21/24 35 days
--05/21/24-06/04/24 14 days
--06/11/24-06/21/24 10 days
--07/19/24-07/29/24 10 days
--08/01/24-08/09/24 8 days
--08/30/24-09/13/24 14 days
--09/13/24-09/27/24 14 days
--09/27/24-10/10/24 13 days
--11/15/24-11/23/24 8 days
On 11/26/24 at 1:15 PM, the Assistant Director of Nursing (ADON) #53 confirmed the skin evaluations were not being completed weekly.
c) Resident #18
On 11/26/24 at 10:45 AM, a record review was completed for Resident #18. The review found the physician's order regarding weekly skin evaluations had not been followed. The following dates of the completed skin evaluations have greater than seven (7) days in between weekly skin evaluations:
--05/21/24-05/30/24 9 days
--08/21/24-08/30/24 9 days
--10/14/24-10/28/24 14 days
On 11/26/24 at 1:15 PM, the Assistant Director of Nursing (ADON) #53 confirmed the skin evaluations were not being completed weekly.
d) Resident #75
On 11/26/24 at 11:00 AM, a record review was completed for Resident #75. The review found the physician's order regarding weekly skin evaluations had not been followed. The following dates of the completed skin evaluations have greater than seven (7) days in between weekly skin evaluations:
--03/14/24-03/28/24 14 days
--03/28/24-04/16/24 19 days
--04/18/24-05/02/24 14 days
--05/16/24-05/30/24 14 days
--06/12/24-06/20/24 8 days
--06/27/24-07/26/24 29 days
--08/29/24-09/06/24 8 days
--09/12/24-10/10/24 28 days
--10/10/24-10/31/24 21 days
On 11/26/24 at 1:15 PM, the Assistant Director of Nursing (ADON) #53 confirmed the skin evaluations were not being completed weekly.
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
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, the facility failed to provide an accurate and complete medical record for Resident #75, #30 and #18. This was true for three (3) of five (5) residents revi...
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Based on record review and staff interview, the facility failed to provide an accurate and complete medical record for Resident #75, #30 and #18. This was true for three (3) of five (5) residents reviewed during the survey process. Resident Identifiers: #30, #75 and #18. Facility Census: 82.
Findings Included:
a) Resident #75
On 11/25/24 at 1:00 PM, a record review was completed for Resident #75. The review found the Physician Orders for Scope of Treatment (POST) form was incomplete. The preparer's signature and date were left blank.
On 11/25/24 at 3:30 PM, Social Worker (SW) #48 confirmed the POST form was incomplete.
b) Resident #30
On 11/25/24 at 1:15 PM, a record review was completed for Resident #30. The review found white correction fluid on the area of the physician's signature and the preparer's signature and date were left blank on the POST form.
On 11/25/24 at 3:30 PM, Social Worker (SW) #48 confirmed the POST form was incomplete and white correction fluid was used on the area of the physician's signature.
c) Resident #18
On 11/25/24 at 1:30 PM, a record review was completed for Resident #18. The review found the POST form was incomplete in section B which lists the medical intervention choices; section C which lists the medically administered fluids and nutrition; and, the preparer's signature and date were left blank.
On 11/25/24 at 3:30 PM, Social Worker (SW) #48 confirmed the POST form was incomplete.
Feb 2024
24 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interviews, the facility failed to ensure that the resident's Pre-admission Screening (PAS) r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interviews, the facility failed to ensure that the resident's Pre-admission Screening (PAS) reflected pre-admission diagnoses for two (2) of two (2) residents reviewed for the category of Pre-admission Screening and Resident Review (PASARR), during the long-term care survey. Resident identifiers: #31 and #28. Facility Census 59.
Findings Included:
a) Resident #31
On 02/20/24, a record review of the resident's electronic medical record (EMR) revealed the resident's most recent PAS, dated 11/03/23, indicated no level II not required.
The record also revealed the resident had a developmental disability diagnosis of Moderate Intellectual Disabilities on admission [DATE]. The resident did not receive a new PAS to address whether specialized services were needed.
On 02/22/24 at 11:33 AM, the Director of Nursing (DON) and Administrator verified, Resident #31's PAS did not reveal his diagnosis of Moderate Intellectual Disabilities. The DON confirmed a new PAS was not completed.
b) Resident #28
During record review for Resident #28 at approximately 1:52 PM on 02/20/24, it was noted Resident #28 was admitted to the facility on [DATE] with no diagnosis of dementia on the PASARR. On 06/22/21, Resident #28 was given the following diagnosis: Alcohol Dependence with Alcohol -induced persisting Dementia. The PASARR for Resident #28 was not updated to reflect the diagnosis.
At approximately 2:15 PM on 02/20/24, the Director of Nursing was notified and acknowledged there was no updated PASARR to reflect the diagnosis.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on medical record review and interview, the facility failed to revise a person-centered comprehensive care plan. The facility failed to revise care plans for ambulation. This practice affected o...
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Based on medical record review and interview, the facility failed to revise a person-centered comprehensive care plan. The facility failed to revise care plans for ambulation. This practice affected one (1) of seventeen (17) resident's care plans reviewed during the Long-Term Care Survey Process (LTCSP). The failure to ensure the comprehensive care plan was reviewed and revised for the resident's highest practicable well-being placed the residents at risk of not receiving services that would meet their desires or wants and a decreased quality of life. Resident Identifier #61. Facility census: 59.
Findings included:
a) Resident #61
On 02/19/24 an observation of Resident (R#61's) found him walking around in his room and the hallway independently without an assistive device. Staff passing and communication with Resident #61.
A review of R#61's medical record revealed a Physicians order:
--Patient to ambulate with staff assist x1 person using front wheeled walker and gait belt to decrease fall risk. Staff encourage out of bedtime daily to prevent functional decline every shift. Start date 02/2/2024.
A review of the current care plan with the review date of 11/28/21 showed there was an active care plan addressing falls:
Focus:
Risk for falls related to unable to ambulate on own or transfer self in/out of bed related to general weakness.
Goal:
Current Mobility status will be maintained / improved, and he will be free from major injuries related to falls throughout review.
Interventions:
One staff assist with transfer and ambulation using a front wheeled walker and gait belt. Encourage out of bedtime.
On 02/20/24 at 2:39 PM a second observation revealed Resident #61 ambulating around in his room and the hallway independently without an assistive device. Staff passing and communication with Resident #61.
During an interview on 02/20/24 at 2:44 PM Nurse Aide (NA) #32 stated that he was fine to ambulate around independently.
An interview on 02/22/24 at 11:45 AM with the Director of Nursing (DON) and Administrator, verified that R #61's care plan was not revised to reflect the resident's current status. The Administrator stated that he needed more assistance when he was admitted to the facility.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, record review, and staff interview the facility failed to ensure Resident #44 received the necessary services to maintain good grooming and personal hygiene. This was a random op...
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Based on observation, record review, and staff interview the facility failed to ensure Resident #44 received the necessary services to maintain good grooming and personal hygiene. This was a random opportunity for discovery and had the potential to affect a limited number of residents that currently reside in the facility. Facility census 56.
Findings included:
a) Resident #44
On 02/20/24 at 10:03 AM an observation of Resident #44 found she was unable to wake by calling out name and was wearing blue leopard print top and bottom. hair appears oily and standing up on it own. In general, she appeared disheveled.
On 02/21/24 at 11:32 AM Resident #44 was in her bed wearing different clothes. It was a red shirt and tan pants. Her hair appeared to be very wet. One could see a comb was used on her hair as it was pressed against her scalp.
On 02/21/24 at 2:52 PM, Resident #44 was in her bed with eyes closed. The comb marks were still visible and her hair was unmoved and still plastered to her scalp.
On 02/22/24 at 8:30 AM Resident #44 hair appeared to be stuck to her scalp and had no movement. The back of her head the hair was messy but was stuck to her scalp as well. Resident #44 was wearing the same clothes as the day before, red top and tan pants. NA #38 was asked if Resident #44 was showered yesterday, and she said no.
A review of the medical records for Resident #44 found on a look back from 01/01/24 to 02/21/24. For the month of January Resident #44 only received a on 01/29/24 all other days it was recorded ADL (activities of daily living) did not occur.
For the month of February, the following dates it was recorded as ADL did not occur.
*02/02/24 thru 02/11/24
*02/14/24, 02/16/24, 02/17/24, 02/18/24, 02/19/24, 02/21/24.
It was document Resident #44 received part help with bathing on the following days:
02/08/24, 02/12/24, 02/13/24 and 02/15/24.
On 02/21/24 at 2:42 PM the Director of Nursing (DON) agreed there have not been any showers given since 01/29/24. The DON stated Resident should be getting showers twice a week and full bed baths on the day between. At this time DON was informed of the above findings. DON was asked if there was any documentation of any refusals.
At the close of this survey no additional information was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
.
Based on record review, policy review, and staff interview, the facility failed to complete neurological assessments after an unwitnessed fall. This was true for one (1) of one (1) residents reviewe...
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Based on record review, policy review, and staff interview, the facility failed to complete neurological assessments after an unwitnessed fall. This was true for one (1) of one (1) residents reviewed for neurological (neuro) assessments during the long-term care survey process. Resident identifier: #57. Facility census: 59.
Findings included:
Upon review of the facility's policy as it pertains to neurological assessments, residents are to be assessed following a known, suspected (unwitnessed) if the resident is unable to verbalize or has a BIMS score under 9, or a verbalized head injury. Per the facility's policy, neurological assessments are to be completed every 15 minutes x 3, every 30 minutes x 2, 1 hour x 4, and q shift x 6.
a) Resident #57
At approximately 10:00 AM on 02/20/24, a record review was conducted for Resident #57. During the record review, it was discovered that Resident #57 sustained an unwitnessed fall with major injury on 08/30/23. According to the incident report, Resident #57 fell face first out of their geri chair and was found on the floor by staff. Resident #57 was sent out to the hospital and was found to have facial fractures and lacerations.
Record review indicated there were four (4) neuro checks completed after the resident's unwitnessed fall.
Resident #57 was unable to be assessed for a Brief Interview of Mental Status (BIMS) score due to memory issues and suffered an unwitnessed fall. The neurological assessments that are on file as being completed are on 08/30/23 at 7:50 PM, 08/30/23 at 10:50 PM, 08/31/23 at 5:28 AM, and 08/31/23 at 8:00 AM.
At approximately 12:20 PM on 02/21/24, the Director of Nursing (DON) was notified and acknowledged the lack of neurological assessments after Resident #57's unwitnessed fall
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, record review, and resident and staff interview, the facility failed to ensure each resident receives necessary respiratory care and services in accordance with professional stan...
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Based on observation, record review, and resident and staff interview, the facility failed to ensure each resident receives necessary respiratory care and services in accordance with professional standards of practice, the resident's care plan, and the resident's choice, by failing to change the O2 tubing and humidifier for Resident #43 per orders. Resident Identifier: #43. Facility census: 59.
Findings included:
a) Resident #43
At approximately 1:56 PM on 02/19/24, an observation of Resident #43's oxygen concentrator was made while conducting an interview for the long-term care survey process. The humidifier and tubing were dated for 02/11/24. Upon review of Resident #43's orders, it was determined there were orders for the oxygen tubing and humidifier to be changed once a week.
At approximately 1:56 PM on 02/20/24, an interview was conducted with Resident #43 in which they stated, This oxygen is putting water into my nose. An observation of the tubing and humidifier was made and it was determined it had not been changed and was still dated for 02/11/24.
At approximately 2:09 PM on 02/20/24, the Director of Nursing (DON) was made aware of the oxygen tubing and humidifier dated 02/11/24, along with the orders for them to be changed each week. The DON acknowledged the tubing and humidifier had not been changed according to orders.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to adequately document mood and behaviors for the use of psychotropic medications and failed to attempt a gradual dose reduction. This...
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Based on record review and staff interview, the facility failed to adequately document mood and behaviors for the use of psychotropic medications and failed to attempt a gradual dose reduction. This failed practice was true for two (2) out of five (5) reviewed in the care area of unnecessary medications. Resident identifier: #44, and #28. Facility census: 56.
Findings included:
a) Resident #44
A review of records revealed Resident #44 was diagnosed with schizophrenia and paranoid disorder.
Records showed Resident #44 was receiving the following medications:
Risperdal IM 37.5 mg every Friday morning for schizophrenia and paranoia.
Risperdal 3 mg every morning.
Lorazepam every night.
After a review of the medical chart for Resident #44 found there was no evidence of behavior monitoring.
On 02/21/24 at 1:19 PM the Director of Nursing (DON) was asked for the Mood/Behavior monitoring forms.
At 3:39 PM on 02/21/24 the DON stated that there were no Mood/Behavior monitoring forms for Resident #44, however, she was going to correct that. The DON agreed it was unclear if Resident #44 was having any mood and/or behaviors to warrant the need for the psychotropic medications.
b) At approximately 1:00 PM on 02/20/24, a record review was conducted for Resident #28. During record review, it was determined for the last year, three (3) medication regimen reviews and two gradual dose reductions were completed for Resident #28. The dates for those medication regimen reviews are August 2023, September 2023, and December 2023.The dates for the gradual dose reductions are August 2023 and September 2023.
At approximately 12:28 PM on 02/21/24, the Director of Nursing (DON) acknowledged only three medication regimen reviews and two gradual dose reductions were completed for Resident #28 for the last year. The DON stated there were no other medication regimen reviews on file to produce. The DON was unable to find any other gradual dose reductions, or evidence that any more were recommended in the last year.
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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 ensure there were no expired medications in the medication refrigerator on the South Hall. This failed practice had the potential to ...
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Based on observation and staff interview, the facility failed to ensure there were no expired medications in the medication refrigerator on the South Hall. This failed practice had the potential to affect a limited number of residents. Facility census: 59.
Findings included:
On 02/21/24 at 12:05 PM in the Medication room on the South Hall, an open multidose vial of Purified Protein Derivative (PPD) was found dated 12/01/23 as the opened date. The vial had been punctured. According to the manufacturer's directions the PPD is only available for use for 30 days after the vial is punctured. Licensed Practical Nurse (LPN) #15 confirmed the PPD was expired and immediately removed the vial.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
.
Based on observation, and staff interview, the facility failed to ensure residents have a right to a dignified existence. The staff failed to knock on the door while Resident #44 was receiving cathe...
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Based on observation, and staff interview, the facility failed to ensure residents have a right to a dignified existence. The staff failed to knock on the door while Resident #44 was receiving catheter care and failed to ensure a dignifying dining service. These failed practices were random opportunities for discovery and had the potential to affect a limited number of residents that currently reside at the facility. Resident identifiers: #44. Facility census 59.
Findings included:
a) Resident #44
While observing catheter care on 02/22/24 at 8:52 AM on Resident #44, a Housekeeper #21 walked into the room without knocking.
On 02/22/24 at 9:14 AM, Housekeeper #21 was asked if she always walks in resident rooms without knocking first. Housekeeper #21 said she knocks but she does it very lightly in case someone is sleeping.
b) Dining
At approximately 12:58 PM on 02/19/24, an observation was made during lunch service in the North Dining Room of residents at the same table not being served at the same time. Meals were being served to residents in random order at different tables.
An interview was conducted with Nurse Aide (NA) #13 concerning not serving all residents at the same table, at the same time. NA #13 stated We know that's what we are supposed to do, and typically we try and serve everyone at the same table, at the same time, but sometimes, just whatever way it goes is the way it goes.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0567
(Tag F0567)
Could have caused harm · This affected multiple residents
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Based on observation and resident and staff interview, the facility failed to ensure that each resident had reasonable and ready access to their personal funds held by the facility. This had the pot...
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Based on observation and resident and staff interview, the facility failed to ensure that each resident had reasonable and ready access to their personal funds held by the facility. This had the potential to affect more than a limited number of residents. Resident identifier: #43. Facility census: 59.
Findings included:
a) Resident #43
At approximately 1:56 PM on 02/19/24, an interview was conducted with Resident #43. When asked about the facility holding personal funds and the access they were given to those funds, Resident #43 stated the facility has what is called bank hours, which was designated times residents were allowed to access their funds throughout the day. Resident #43 stated, There have been times that I have not been able to get any money because the bank is not open. If there is a time where the bank is not open and you need money, you just must wait for it to open. If the bank is closed for the day and you need money, you just have to wait for it to open the next day.
At approximately 9:40 AM on 02/21/24, an interview with the Administrator revealed the Activities Director (AD) #76 oversaw resident funds at the facility.
At approximately 9:46 AM, on 02/21/24, an interview was conducted with AD #76 related to the access residents had to their funds while in the facility. AD #76 stated We have bank hours three (3) times a day from 9:30 to 10:00 AM, 3:00 to 3:30 PM, and 7:30 to 8:00 PM when the residents can sign out their money. If they are asleep or are out of the facility during those times, then sometimes we will be lenient and let them sign it out anyway. AD #76 was asked how the facility handled resident requests for funds after those designated times, to which AD #76 stated, There are money boxes at each nurses station and the staff knows where they are and how to get the money to the residents.
At approximately 9:53 AM, on 02/21/24, an interview was conducted with Licensed Practical Nurse (LPN) #63, LPN #15, and Unit Secretary (US) #74 about resident access to personal funds after the facility designated times on the South Wing. LPN #63 stated, I know during the day we can take them to the bank, but I don't know how they get money after that. LPN #15 stated, There are only certain times during the day that we can take them to get money out. US #74 stated, There are three (3)times a day they can get money, if they miss those, they won't be able to get it out until the next day. The employees were unaware of a money box located at the nurse's station.
At approximately 9:57 AM, on 02/21/24, an interview was conducted with LPN #14 about resident access to personal funds after the facility designated times on the North Wing. When asked if residents were able to access their funds after facility designated times, and what the process was, LPN #14 stated, I don't know.
At approximately 10:08 AM on 02/21/24, AD #76 escorted the surveyor to the North nurse station and presented a black box with a key which they stated held resident funds.
At approximately 10:10 AM on 02/21/24, AD #76 escorted the surveyor to the South nurse station, at which time it was discovered the black box that held resident funds was missing.
At approximately 12:30 PM on 02/22/24, the Administrator (NHA) was notified there were staff members in the facility that did not know residents were supposed to have ready access to their personal funds at any time throughout the day. These staff members also did not know how to provide that access. The NHA was also notified there were residents in the facility that did not know they were supposed to have ready access to their funds throughout the day, instead of just during the facility designated times. The NHA agreed the residents were to have access to their funds at any time.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0572
(Tag F0572)
Could have caused harm · This affected multiple residents
Based on resident interview and staff interview, the facility failed to review resident rights during the residents stay. This was a random opportunity for discovery during the Resident Council meetin...
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Based on resident interview and staff interview, the facility failed to review resident rights during the residents stay. This was a random opportunity for discovery during the Resident Council meeting and had the potential to affect all residents in the facility. Resident identifiers: #12, #22, #51, #169, #19, #41, #29, #46, #7, and #21. Facility census: 59.
Findings included:
On 02/20/24 at 11:05 AM during the Resident Council meeting Residents #12, #22, #51, #169, #19, #41, #29, #46, #7, and #21 stated that the facility did not go over resident rights during their stay at facility.
On 02/21/24 at 10:33 AM the Activity Director (AD) stated that she can't provide evidence of resident rights being reviewed in Resident Council because she had not reviewed resident rights for some time.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observations, and staff interviews, the facility failed to ensure the facility had a clean comfortable homelike envir...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observations, and staff interviews, the facility failed to ensure the facility had a clean comfortable homelike environment for all residents. This was a random opportunity for discovery and had the potential to affect a limited number of residents that currently reside at the facility. Facility census 59.
Findings included:
a) Shower Room North Short Hall
On 02/20/24 at 10:24 AM an observation of shower room number N130 on North Short Hall found towels, blue pleated pants, and a white T-shirt on the floor. In addition, a soiled washcloth with brown matter on it, a shower chair had brown matter on the seat and under the seat, chunks of brown matter were on the floor by the shower chair. The door to the shower room was open.
On 02/20/24 at 10:32 AM the Director of Nursing (DON) was shown the shower room and asked Nurse Aide #75 to clean the shower room.
b) Bathroom Temperatures
On 02/21/24 at 11:05 AM, an overheard conversation between Maintenance #96 and a nurse revealed they were saying that the bathroom was cold because the resident did not leave her bathroom door open.
On 02/21/24 at 11:10 AM, Maintenance #96 was asked to look at the bathroom in question which was room [ROOM NUMBER]. The bathroom was used by Resident #120. This was a small single resident room. Resident #120 used the bathroom and took showers in the room. The bathroom felt much cooler than the bedroom did. It was also noted there was a sign on the inside of the bathroom door that read leave the bathroom door open,
On 02/21/24 at 11:15 AM, Maintenance #96 was asked to check the bathroom across the hall in room [ROOM NUMBER]. This bathroom had a noticeable temperature difference than the room as well. Maintenance #96 was asked to check the temperature of the bathrooms with an ambient thermometer.
On 02/21/24 at 11:19 AM Resident #120 stated her bathroom was too cold, and she hates to have to use it even to pee. The resident went on to say they want me to leave my door open so the heat from my room can warm up the bathroom. She said if she does that people will walk in on her using the bathroom or showering. Plus, the opened door would be very close to her bed making it difficult to move around in the room.
Maintenance #96 returned with a type of thermometer used for refrigerators on 02/21/24 at 11:37 AM. He placed the thermometer in bathroom of room [ROOM NUMBER] at this time.
At 11:55 AM on 02/21/24 Maintenance #96 returned, and the temperature was showing 60 degrees Fahrenheit (F). Maintenance #96 stated he was going to find another thermometer.
On 02/21/24 at 12:00 PM Maintenance #96 returned with an ambient thermometer and room [ROOM NUMBER]'s bathroom was 60 degrees F and room [ROOM NUMBER] was 61 degrees.
Maintenance #96 stated he had worked at this facility for 13 years and there have never been any heat vents in the bathroom. There were wall heaters in the bathrooms, however, the knob to turn on the heat appeared to have been removed and only the fan runs. Maintenance #96 said the residents need to keep the door open so the bathroom could warm up. He also said it was only cold in the rooms at the end of the hallway.
On 02/21/24 at 12:20 PM Maintenance #96 was asked to check the temperature of the bathroom in the middle of the building by the nurse's station. The temperature of this bathroom was 66 degrees F.
On 02/21/22 at 12:30 PM the Administrator was informed of the above findings.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility documentation, staff interviews and written statements, the facility failed to complete a thorough investigati...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility documentation, staff interviews and written statements, the facility failed to complete a thorough investigation of an allegation of neglect. This failed practice had the potential to affect more than a limited number of residents who currently reside in the facility. Resident identifiers: #21.
Findings included:
a) Resident #21
A review of the timecard punches for the day of 11/24/23 found the following Nurse Aides (NA) worked the following times on the south side of the facility.
NA #92 worked 7 AM to 11 AM.
NA#67 worked from 7 AM to 7 PM.
NA# 110 worked 7 PM to 3 AM
NA #30 worked 3 PM to 7 AM
NA # 23 worked 3 PM to 11 PM
This left two (2) NA's from 7 AM to 11 AM, and one (1) from 11 AM to 3 PM. At 3 PM NA #23 worked until 11 PM and NA #30 worked until 7 AM. NA #110 worked 7 PM to 3 AM.
A review of the complaint filed named Resident #21, and a review of the reportable was conducted. A report was filed on 11/24/23 at 8:30 PM for Resident #21. The allegation was that Resident #21 was left on a bedpan for an extended period. The five-day follow-up stated the allegation was unsubstantiated due to unable to determine when or who put bedpan on resident.
This was investigated by Social Worker (SW) #45 on 11/29/23. This surveyor was unable to interview SW #45 due to illness and not being at work.
After reviewing the statements given by the staff and the resident's family member, the question of when and who put Resident #21 on the bed pan were both answered. In addition, the witness statements confirmed the resident was left on the bed pan for an extended period.
The written statement by Nurse Aide (NA) #67 stated, I put on bedpan after sister left. Do not recall if I went back to check. Remember giving report that Resident #21 was on bedpan to NA #23 at 3 PM. NA #67 said NA #23 went straight to giving showers to the residents. This was signed by NA #67 dated 12/12/23 at 2:40 PM.
NA #23 wrote, At 3:30 PM I was giving a resident a shower and was with the resident for half an hour assisting resident with dressing and hygiene. Cleared shower. Then assisted co-worker with another shower, was there for an hour assisting resident with dressing, transferring and hygiene. Also assisted with getting residents up for dinner. Some of these residents require two (2) people as they are lifts. At 5 PM, dinner trays did one (1) feed, took a half hour this resident. Picked up trays till 6:40 PM. Assisted co-worker on another putting residents in their beds in their rooms and back in bed. Did not make it to my hallway. Was informed by staff that would be done in the hallway where the incident took place. Became a float on the other side of the building was unaware of the incident. This resident has always pushed call when needing assistance. Was not aware that the resident used it or was on bedpan. This statement did not have a date on it.
Statement by NA #110 wrote.
I (named herself) and (named NA#30) went to do a check at 8:00 PM on (named resident #21). She was discovered on the bed pan. We reported it immediately to (Named Licensed Practical Nurse (LPN) #26) our nurse. I was on the northside from 4:00 PM to 7:10 PM beforehand. (Named NA #23 gave a small rundown and only stated (named Resident #21) needed changed. A resident needed assistance before I did so. This was signed by NA #110 and dated 11/24/23.
Statement by NA #30 wrote.
I, (named herself) and (named NA #110) went into (named Resident #21)'s room to check and change her bed and discovered she was on a bedpan, the bedpan was also placed incorrectly, (we took her off immediately). This was at 8:00 PM. Her entire butt had a bedpan indent, was red, starting to turn purple. Told the floor nurse (named LPN #26) as soon as we found it. Previously I was working on the northside from 4:30 PM to 7:10 PM. This was signed and dated 11/24/23 by NA #30.
Statement by LPN #26 wrote.
At approximately, 8 PM on 11/24/23 NA's (named NA's #30 and #110) asked me to come see resident (named Resident #21). I, (named herself) was made aware of residents' buttock being indented by a bedpan. On viewing resident buttock. I noticed that her buttock was indented and bruised. I told the NA's I would notify the Registered Nurse (RN) (named RN #91). This was signed by LPN #26.
Statement by resident's sister.
Left on bedpan for an extended period. Sister reports she left around four (4) and resident was on bedpan when she left. Could have been as late as 4:30 PM. Saturday 11/25/23 residents' buttocks red and welted in area bedpan was against resident's body.
Nursing notes in the electronic chart.
11/24/2023 8:00 PM
General Nurses Note
Note Text: Alerted by CNAs that resident was on bedpan too long, noted on assessment that buttocks was deep and purple. This note was created on 11/25/23 at 5:10 AM by LPN #26.
Note Text: RN alerted that resident had been found on bedpan during rounds. Upon assessment it appeared the resident had been on bedpan for an extended amount of time. Skin indented and bruised. Skin to be monitored and progressively documented. This note was created by RN # 91 on 11/25/23 at 7:37 AM.
11/25/2023 08:48
General Nurses Note by LPN #63
Note Text: Observed buttocks, no indentation present. Slow but blanchable skin noted to inner buttocks.
11/25/2023 09:10
General Nurses Note by LPN #63
Note Text: (sisters name), sister, at bedside requesting to see buttocks. Resident was agreeable to allow sister to see. [NAME] stated, not as bad as I was imagining but still upset over it happening. The wound nurse notified of slow blanching buttocks.
11/25/2023 18:17
General Nurses Note by LPN #63
Note Text: Skin slowly blanches around inner buttocks but otherwise intact and normal color for resident. Denies c/o pain.
11/25/2023 23:58
General Nurses Note LPN #12
Note Text: skin of inner buttocks light pink, blanching, intact. resident denies pain. denies further complaints or concerns, call light within reach.
1/28/2023 12:44
Skin/Wound Note LPN #84
Note Text: Resident turned to side with x 2 assist. Incontinence care provided. Skin to buttocks assessed at this time. Slight redness noted at sacrum. Linear shaped, light pink discoloration noted to bilateral gluteal creases (at top of thighs) Skin FULLY intact to sacrum and buttocks. Resident denies pain or discomfort. Encouraged to turn and reposition every 2 hours; resident stated understanding. Calcium alginate dressing discontinued to sacrum; as no longer indicated. New treatment order in place for Zinc oxide to sacrum and buttocks Qshift as preventative. Zinc applied per new order at this time. Res. tolerated well; offers no complaints.
11/28/2023 14:07
Skin/Wound Note by LPN #84
Late Entry:
Note Text: Pt seen today 11/28/23 by (name of Nurse Practitioner (NP). Pt presents with shear/friction to sacral area. Upon examination today, area has resolved. Skin is intact. Skin is pink blanchable. Pt does not c/o pain with palpation. Signing of on pt. Continue to monitor in house. Recommend continuing to use moisture barrier/EPC after each incontinent episode.
On 02/22/24 at 9:15 AM Administrator and Director of Nursing (DON) were shown the evidence that was already gathered by their staff. They agreed to the question about when was answered by NA#67 in her statement and the statement from the sister taken by RN #25. They also agree there is no question on whether Resident was left on the bedpan on 11/24/23. They both agree this should have been substantiated by SW #45
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
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Based on staff interview and record review, the facility failed to develop and/or implement a personalized comprehensive care plan for each resident. This included the care areas of implementing mon...
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Based on staff interview and record review, the facility failed to develop and/or implement a personalized comprehensive care plan for each resident. This included the care areas of implementing monitoring use of phsychotropic medications, oxygen care and indwelling Foley catheters. This was true for three (3) out of 17 residents reviewed for care plans and affected a limited number of residents Resident identifiers: #44, #43, and #13. Facility census 56.
Findings included:
a) Resident #44
During a review of the care plan for Resident #44 it revealed the interventions for receiving antipsychotics were:
--Assess for changes in mood, behaviors, depression, vital signs, a decline in cognitive and slurred speech.
-- In the event of sleeplessness/abnormal behavior provide food, fluids, pain assessment, quiet/dark room, massage/aroma therapy.
After a review of the medical chart for Resident #44 found no evidence of behavior monitoring.
On 02/21/24 at 1:19 PM the Director of Nursing (DON) was asked for the Mood/Behavior monitoring forms.
At 3:39 PM on 02/21/24, the DON stated that there were no Mood/Behavior monitoring evidence for Resident #44, however, she was going to correct that.
aa) Resident #44
On 02/20/24 at 10:06 AM, it was discovered the indwelling Foley catheter laying on the floor beside the bed. Also, the Foley catheter collection bag did not have a privacy cover. The collection bag contained dark amber in color.
On 02/20/24 at 10:08 AM, the Activities #85 verified the catheter collection bag was on the floor.
On 02/20/24 at 10:09 AM Nurse Aide (NA) #38 also verified there was not a privacy cover on the bag, and it was on the floor.
At 8:30 AM on 02/22/24 NA #28 was pushing Resident #44 in a wheelchair back to her room. The Foley catheter was under the wheelchair and the tubing was being dragged on the ground from the dining area to her room. Approximately four (4) inches for Foley catheter tubing was touching the floor.
While reviewing the medical chart of Resident #44 found the care plan did not contain interventions for the care of the indwelling Foley catheter, such as using a privacy cover and keeping the collection bag and tubing off of the floor.
During an interview on 02/22/24 at 11:47 AM, the Minimun Data Set (MDS) Coordinator #79 agreed the care plan did not have the interventions mentioned above.
b) Resident #43
1. Oxygen tubing
At approximately 1:56 PM on 02/19/24, an observation of Resident #43's oxygen concentrator was made while conducting an interview for the long-term care survey process. The humidifier and tubing were dated for 02/11/24. Upon review of Resident #43's orders, it was determined there were orders for the oxygen tubing and humidifier to be changed once a week.
At approximately 1:56 PM on 02/20/24, an interview was conducted with Resident #43 stated, This oxygen is putting water into my nose. An observation of the tubing and humidifier was made and it was determined it had not been changed and was still dated for 02/11/24.
At approximately 2:09 PM on 02/20/24, the DON was made aware of the oxygen tubing and humidifier dated 02/11/24, along with the orders for them to be changed each week. The DON acknowledged the tubing and humidifier had not been changed according to orders.
2. Urinary drainage bag
At approximately 1:56 PM on 02/20/24, an observation was made while conducting an interview with Resident #43 of the urinary catheter bag on the floor without a privacy cover over it.
At approximately 2:09 PM on 02/20/24, the DON was made aware, and acknowledged the urinary drainage bag was on the floor without a privacy cover.
Upon care plan review, it was determined Resident #43 was not care planned for a privacy cover for the urinary drainage bag, nor for the bag to stay off of the floor.
At approximately 2:20 PM on 02/20/24, the DON was made aware of, and acknowledged, Resident #43's care plan did not include a privacy cover or a provision to remain off of the floor.
At approximately 11:45 AM on 02/22/24, an interview was conducted with the MDS Coordinator (MDSC) #79. MDSC #79 acknowledged the care plan did not include the need for a privacy cover on the urinary drainage bag, nor include the need to keep the bag itself off of the floor. MDSC stated You probably won't find either of those in the care plan.
c) Resident #13
On 02/19/24 at 1:08 PM observed the resident in bed with urine drainage bag hanging on the right side facing the door with no privacy cover.
On 02/20/24 at 8:47 AM observed the resident in bed with urine drainage bag hanging on the right side facing the door with no privacy cover.
02/20/24 at 10:46 AM observed the resident in bed with urine drainage bag hanging on the right side facing the door with no privacy cover. This was confirmed by Licensed Practical Nurse (LPN) #18.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected multiple residents
Based on observation, Facility policy, and staff interview, the facility failed to provide indwelling Foley catheter care at the current professional standard of practice. This is true for one (1) out...
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Based on observation, Facility policy, and staff interview, the facility failed to provide indwelling Foley catheter care at the current professional standard of practice. This is true for one (1) out of three (3) residents who had indwelling Foley catheters. Resident identifiers: #44, #43, and #13. Facility census 56.
Findings included:
a) Resident #44
On 02/20/24 at 10:06 AM, it was discovered the indwelling Foley catheter collection bag was laying on the floor beside the bed. Also, the Foley catheter collection bag did not have a privacy bag cover. The collection bag contained dark amber urine in color.
On 02/20/24 at 10:08 AM, Activities #85 verified the catheter collection bag was on the floor.
On 02/20/24 at 10:09 AM Nurse Aide (NA) #38 also verified there was not a privacy cover on the bag, and it was on the floor.
At 8:30 AM on 02/22/24 NA #28 was pushing Resident #44 in a wheelchair back to her room. The Foley catheter collection bag was under the wheelchair and the tubing was being dragged on the ground from the dining area to her room. Approximately four (4) inches for Foley catheter collection bag tubing was touching the floor.
While attempting to get Resident #44 from her wheelchair to the bed for Peri care, NA #28 placed the collection bag between her thighs, but the collection bag fell to the floor, NA #28 stepped on the collection bag, then kicked it under the bed.
NA #75 was also in the room assisting with the peri care for Resident #44. After the resident was on the bed NA #75 pulled the collection bag up onto the bed by using the tubing. The collection bag was placed at the bottom of the bed on top of blankets and pillows. Placing the collection bag there allowed for back flow of urine into the bladder.
While the care was being provided it was discovered Resident #44 was very red and had large amounts of white chunky discharge. NA #75 left to notify a nurse.
Nurse #16 evaluated the peri area and said he would get some zinc. The NA's waited for him to bring the zinc.
The collection bag was above bladder level for approximately 10 minutes.
At 9:10 AM on 02/22/24 NA #75 and NA #38 were transferring Resident #44 from the bed to the wheelchair. This is when NA #75 placed the Foley catheter collection bag over her left shoulder. At this time, it was noted the dark amber urine was flowing downward from the collection bag through the clear tubing back to the resident.
After the two NA's got the resident back in the wheelchair NA #38 stated the hook used to hang the collection bag on was missing.
On 02/22/24 at 10:15 AM the Director of Nursing was informed of the above care.
b) Resident #43
At approximately 1:56 PM on 02/20/24, an observation was made while conducting an interview with Resident #43 of the Foley catheter bag on the floor without a privacy cover over it.
At approximately 2:09 PM on 2/20/24, the DON was made aware, and acknowledged the Foley catheter bag on the floor without a privacy cover.
c) Resident #13
A record review done on 02/22/24 at 10:15 AM found the care plan for Resident #13 did not contain intervention/goals for providing a privacy cover for a catheter bag.
During an interview on 02/22/24 at 1:00 PM with the Minimum Data Set (MDS) coordinator, verified the care plan did not contain a goal/intervention for Resident #13 to be provided a privacy cover for the catheter bag.
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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
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected multiple residents
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Based on record review and staff interview, the facility failed to complete a performance review of every Nurse Aides at least once every 12 months, and provide regular in-service education based on...
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Based on record review and staff interview, the facility failed to complete a performance review of every Nurse Aides at least once every 12 months, and provide regular in-service education based on the outcome of those reviews. This was true for three (3) out of (5) staff members reviewed for performance reviews during the long-term care survey process. Facility census: 59.
Findings included:
a) Nurse Aide (NA) #100
At approximately 5:00 PM on 02/21/24, during record review for facility staffing, NA #100 was found to be missing a yearly performance evaluation.
At approximately11:00 AM on 02/22/24, an interview was conducted with Human Resources (HR) #52, in which they acknowledged and confirmed that NA #100 was missing their annual performance evaluation. HR #52 stated that they were unable to locate the evaluations and were unsure as to whether they were missing or just not done.
b) NA #72
At approximately 5:00 PM on 02/21/24, during record review for facility staffing, NA #72 was found to be missing a yearly performance evaluation.
At approximately 11:00 AM on 02/22/24, an interview was conducted with HR #52, in which they acknowledged and confirmed that NA #72 was missing their annual performance evaluation. HR #52 stated that they were unable to locate the evaluations and were unsure as to whether they were missing or just not done.
c) NA #81
At approximately 5:00 PM on 02/21/24, during record review for facility staffing, NA #81 was found to be missing a yearly performance evaluation.
At approximately 11:00 AM on 02/22/24, an interview was conducted with HR #52, in which they acknowledged and confirmed that NA #81 was missing their annual performance evaluation. HR #52 stated that they were unable to locate the evaluations and were unsure as to whether they were missing or just not done.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected multiple residents
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Based on record review and staff interview, the facility failed to ensure all posted nurse staffing information was up-to-date and accurate. This was true for four (4) out of five (5) days reviewed ...
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Based on record review and staff interview, the facility failed to ensure all posted nurse staffing information was up-to-date and accurate. This was true for four (4) out of five (5) days reviewed for posted nurse staffing information during the long-term care survey process. Facility census: 59.
Findings included:
a) At approximately 5:00 PM on 02/21/24, during record review for facility staffing, it was determined that the facility failed to update their daily nurse staff postings to accurately reflect the number of staff and hours for the days reviewed.
The following days for daily nurse staff postings were reviewed:
08/12/23-
The daily nurse staff posting for the day stated there were a total of 264 hours worked with a total census of 59 residents, resulting in an average of 4.47 hours per patient day.
The facility hours per patient day (HPPD) report lists the average hours per patient day as 3.59.
08/13/23-
The daily nurse staff posting for the day stated there were a total of 248 hours worked with a total census of 58 residents, resulting in an average of 4.28 hours per patient day.
The facility HPPD report lists the average hours per patient day as 3.45.
08/20/23-
The daily nurse staff posting for the day stated there were a total of 228 hours worked with a total census of 60 residents, resulting in an average of 3.80 hours per patient day.
The facility HPPD report lists the average hours per patient day as 3.27.
09/03/23-
The daily nurse staff posting for the day stated there were a total of 204 hours worked with a total census of 61 residents, resulting in an average of 3.34 hours per patient day.
The facility HPPD report lists the average hours per patient day as 3.21.
At approximately 11:00 AM on 02/22/24, the Director of Nursing (DON) was notified and acknowledged the discrepancies in the staffing postings and the actual HPPD numbers.
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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 failed to have a pharmacist review each resident's medication regimen monthly in order to identify irregularities and maintain record of the identifi...
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Based on record review, and staff interview, the failed to have a pharmacist review each resident's medication regimen monthly in order to identify irregularities and maintain record of the identified irregularities and did not follow through with a regimen reccomendation. This was true for five (5) residents reviewed for unecessary medications. Resident identifiers: #24, #61 #44, #28 and #13. Facility census: 59.
Findings included:
a) Resident #24
A review for Unnecessary Medication for Resident #24 on 02/21/23 found the record did not contain medication regimen reviews or gradual dose reductions for April 2023, June 2023, August 2023, September 2023, October 2023 or December 2023.
During an interview on 02/21/23, at 11:10 AM, the Director of Nursing (DON) verified that the facility was unable to find documentation that pharmacy reviews were completed.
b) Resident #61
A review for Unnecessary Medication for Resident #61 on 02/21/23 found the record did contain a medication regimen review completed on 02/09/24. The Recommendation for an Abnormal Involuntary Movement Scale (AIMS) to be completed due to Resident #61 be on antipsychotics. An AIMS could not be located.
During an interview on 02/22/23 at 12:41 PM the DON verified that the facility did not follow through with Pharmacy Review.
c) Resident #44
Medication regimen review (MRR) was reviewed and found they were not done every month for the past year.
On 02/21/24 at 11:10 AM during staff interview with DON verified no MRR's was completed for the following months 01/24, 07/23, 05/23, 03/23, 02/23.
The findings above were verified with the DON,on 02/21/24 at 2:33 PM and at the close of the survey no additional information was provided.
d) Resident #28
At approximately 1:00 PM, on 02/20/24, a record review was conducted for Resident #28. During record review, it was determined for the last year, three (3) medication regimen reviews were completed for Resident #28. The dates for those medication regimen reviews were August 2023, September 2023, and December 2023.
At approximately 12:28 PM, on 02/21/24, the DON acknowledged only three (3) medication regimen reviews were completed for Resident #28 for the last year. The DON stated there were no other medication regimen reviews on file to produce.
e) Resident #13
On 02/21/24 at 10:00 AM a record review of Med Regimen Review (MRR) for Resident #13 found no MRR's were completed in the months of 02/23, 03/23, 05/23, 08/23, 11/23.
During staff interview, on 02/21/24 at 11:10 AM, the DON verified no MRR's were completed for the following months 02/23, 03/23, 05/23, 08/23, 11/23.
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CONCERN
(E)
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 and resident and staff interview, the facility failed to follow menus for meals and post accurate menus prior to mealtimes. This had the ability to affect more than a limited nu...
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Based on observation and resident and staff interview, the facility failed to follow menus for meals and post accurate menus prior to mealtimes. This had the ability to affect more than a limited number of residents. Resident identifier: #16. Facility census: 59.
Findings included:
a) Resident #16
At approximately 12:47 PM on 02/19/24, an observation was conducted during lunch service in the North Dining Room of menus being hung up late and for the wrong day. Lunch service was scheduled to begin at 12:00 PM, at approximately 12:47 PM, menus were being placed in the hallway on the North wing of the facility. Menus were hung with the meal served that day listed, however, a mark was made through the main course, which was kielbasa, and a new one was handwritten in, pork chops. Tuesday was written at the top of the menu, despite them being for Monday's meal. Nurse Aide (NA) #38 confirmed menus were hung late and listed the wrong day.
At approximately 2:19 PM on 02/19/24, an interview was conducted with Resident #16. Resident #16 stated, We never know what we are having for any meal. The menus are never hung up in the hallways. They will come around and ask us what we want for our meals the next day, but the next day, it's completely different from what we were asked.
At approximately 9:16 AM on 02/20/24, the same menus were placed in the hallway. The Director of Nursing (DON) was notified and acknowledged the menus were placed from the previous day, were the wrong date, and were not accurate. The DON removed the menus.
At approximately 12:05 PM on 02/20/24, there were no menus placed in the hallway for that day after removal of the old ones.
At approximately 12:31 PM on 02/20/24, menus were placed in the hallways of the facility roughly 30 minutes after meal service had begun. The DON was notified and acknowledged at that time.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
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Based on observation and staff interview, the facility failed to serve milk at appetizing temperature. This was a random opportunity for discovery and had the potential to affect a limited number of...
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Based on observation and staff interview, the facility failed to serve milk at appetizing temperature. This was a random opportunity for discovery and had the potential to affect a limited number of residents. Facility census: 59
Findings included:
a) On 02/19/24 at 1:00 PM holding and serving temps were checked with Dietary Manager (DM). The milk temperature was 47.3 degrees Fahrenheit (F).
On 02/19/23 at 1:04 PM the DM confirmed the milk should be served no more than 41.0 degrees F.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
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Based on record review and staff interview, the facility failed to maintain complete, accurate, and readily accessible medical records for each resident, by failing to include care plan meeting note...
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Based on record review and staff interview, the facility failed to maintain complete, accurate, and readily accessible medical records for each resident, by failing to include care plan meeting notes in the resident medical records. This was true for three (3) of three (3) residents reviewed for care plan meetings during the long-term care survey process. Resident identifiers: #57, #28,and #43. Facility census: 59.
Findings include:
a) Resident #57
At approximately 10:00 AM on 02/20/24, a record review was conducted for Resident #57. During record review, no care plan meeting notes were found in the resident's medical record.
At approximately 12:00 PM on 02/20/24, care plan meeting notes were requested from the Administrator.
At approximately 1:15 PM on 02/20/24, the Administrator was able to produce social services notes, but no notes pertaining to care plan meetings. The Administrator stated the care plan meetings were being done, but no documentation had been put into the electronic health record of the resident.
At approximately 11:45 AM on 02/22/24, an interview was conducted with MDS Coordinator (MDSC) #79. MDSC #79 stated they are involved in the care plan meetings, and they are usually the ones taking care of the documentation for the meetings. MDSC #79 stated the documentation is done on paper and kept somewhere in the social worker's office but the social worker was out sick, and they did not know where it was being kept. MDSC #79 stated they would try to find the documentation for the care plan meetings.
At approximately 12:45 PM on 02/22/24, MDSC #79 was able to obtain the documentation for the care plan meetings after searching the social worker's office. MDSC #79 stated they were aware the records should be readily accessible and scanned in, but they had not done it yet.
b) Resident #28
At approximately 10:15 AM on 02/20/24, a record review was conducted for Resident #57. During record review, no care plan meeting notes were found in the resident's medical record.
At approximately 12:00 PM on 02/20/24, care plan meeting notes were requested from the Administrator.
At approximately 01:15 PM on 02/20/24, the Administrator was able to produce social services notes, but no notes pertaining to care plan meetings. The Administrator stated the care plan meetings were being done, but no documentation had been put into the electronic health record of the resident.
At approximately 11:45 AM on 02/22/24, an interview was conducted with MDS Coordinator (MDSC) #79. MDSC #79 stated they are involved in the care plan meetings, and they are usually the ones taking care of the documentation for the meetings. MDSC #79 stated the documentation is done on paper and kept somewhere in the social worker's office but the social worker was out sick, and they did not know where it was being kept. MDSC #79 stated they would try to find the documentation for the care plan meetings.
At approximately 12:45 PM on 02/22/24, the MDSC #79 was able to obtain the documentation for the care plan meetings after searching the social worker's office. MDSC #79 stated they were aware the records should be readily accessible and scanned in, but they had not done it yet.
c) Resident #43
At approximately 10:30 AM on 02/20/24, a record review was conducted for Resident #57. During record review, no care plan meeting notes were found in the resident's medical record.
At approximately 12:00 PM on 02/20/24, care plan meeting notes were requested from the Administrator.
At approximately 01:15 PM on 02/20/24, the Administrator was able to produce social services notes, but no notes pertaining to care plan meetings. The Administrator stated the care plan meetings were being done, but no documentation had been put into the electronic health record of the resident.
At approximately 11:45 AM on 02/22/24, an interview was conducted with MDS Coordinator (MDSC) #79. MDSC #79 stated they are involved in the care plan meetings, and they are usually the ones taking care of the documentation for the meetings. MDSC #79 stated the documentation is done on paper and kept somewhere in the social worker's office but the social worker was out sick, and they did not know where it was being kept. MDSC #79 stated they would try to find the documentation for the care plan meetings.
At approximately 12:45 PM on 02/22/24, MDSC #79 were able to obtain the documentation for the care plan meetings after searching the social worker's office. MDSC #79 stated they were aware the records should be readily accessible and scanned in, but they had not done it yet.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Data
(Tag F0851)
Could have caused harm · This affected multiple residents
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Based on record review and staff interview, the facility failed to report accurate payroll-based journal information. This was true for five (5) of five (5) days reviewed during the long-term care s...
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Based on record review and staff interview, the facility failed to report accurate payroll-based journal information. This was true for five (5) of five (5) days reviewed during the long-term care survey process. This has the potential to affect more than a limited number of residents. Facility census: 59.
Findings included:
a) During record review of facility staffing, it was determined the facility failed to have at least 8 hours of RN coverage and 24 hours of licensed nursing coverage on 08/12/23, 08/13/23, 08/20/23, 09/03/23, and 09/09/23.
According to the facilities punch in and out reports, there was no RN coverage or 24-hour licensed nurse coverage on those days.
At approximately 11:00 AM on 02/22/24, an interview was conducted with Human Resources (HR) #52, in which they stated the facility was using multiple staffing agencies at that time, and the process for reporting was to make an excel spreadsheet of agency employees' time worked and send it to corporate for reporting purposes. HR #52 stated it appeared that had not been done, but they would be able to pull reports from their system that shows detailed staffing assignments for those days.
At approximately 11:30 AM on 02/22/24, HR #52 provided staffing assignment sheets for the requested dates, showing the facility had at least 8 hours of RN coverage and 24-hour licensed nursing coverage, when agency employees were included.
At approximately 11:30 AM on 02/22/24, the Director of Nursing and Administrator were notified and acknowledged the payroll-based journal information had been reported inaccurately.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected multiple residents
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Based on record review and staff interview, the facility failed to ensure Nurse Aides (NA) received the required 12 hours of training each year. These training's needed to include dementia training,...
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Based on record review and staff interview, the facility failed to ensure Nurse Aides (NA) received the required 12 hours of training each year. These training's needed to include dementia training, abuse prevention training, areas of weakness as determined in performance reviews, facility assessment, special needs of residents determined by facility staff, and care of the cognitively impaired resident for those NA's providing care for individuals with cognitive impairments. This was true for three (3) of five (5) NA's reviewed for yearly in-services. Facility census: 59.
Findings included:
a) Nurse Aide (NA) #100
At approximately 5:00 PM on 02/21/24, a record review was conducted. During that review, it was determined NA #100 had not completed at least 12 hours of annual in-services. NA #100 had not completed the following in-services: Dementia training, infection prevention and control, wandering management and elopement prevention, and hand hygiene.
At approximately 11:00 AM on 02/22/24, the Director of Nursing (DON) was notified and acknowledged the missing yearly in-services for NA #100.
b) Nurse Aide (NA) #38
At approximately 5:00 PM on 02/21/24, a record review was conducted. During that review, it was determined NA #38 had not completed at least 12 hours of annual in-services. NA #38 had not completed the following in-services: Dementia training, infection prevention and control, and hand hygiene.
At approximately 11:00 AM on 02/22/24, the DON was notified and acknowledged the missing yearly in-services for NA #38.
c) Nurse Aide (NA) #72
At approximately 5:00 PM on 02/21/24, a record review was conducted. During that review, it was determined NA #72 had not completed at least 12 hours of annual in-services. NA #72 had not completed the following in-services: Psychosocial needs of older adults and trauma informed care.
At approximately 11:00 AM on 02/22/24, the DON was notified and acknowledged the missing yearly in-services for NA #72.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected most or all residents
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Based on record review and staff interview, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure r...
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Based on record review and staff interview, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population. This was true for five (5) of five (5) staff members reviewed for competencies. Facility census: 59.
a) Nurse Aide (NA) #100
At approximately 5:00 PM on 02/21/24, a record review was conducted for the facility's staffing. During that review, it was determined NA #100 had not completed any competencies.
At approximately 11:00 AM on 02/22/24, the Director of Nursing (DON) was notified and acknowledged the missing competencies for NA #100.
b) Nurse Aide (NA) #38
At approximately 5:00 PM on 02/21/24, a record review was conducted for the facility's staffing. During that review, it was determined NA #38 had not completed any competencies.
At approximately 11:00 AM on 02/22/24, the DON was notified and acknowledged the missing competencies for NA #38.
a) Nurse Aide (NA) #72
At approximately 5:00 PM on 02/21/24, a record review was conducted for the facility's staffing. During that review, it was determined NA #72 had not completed any competencies.
At approximately 11:00 AM on 02/22/24, the DON was notified and acknowledged the missing competencies for NA #72.
a) Nurse Aide (NA) #24
At approximately 5:00 PM on 02/21/24, a record review was conducted for the facility's staffing. During that review, it was determined NA #24 had not completed any competencies.
At approximately 11:00 AM on 02/22/24, the DON was notified and acknowledged the missing competencies for NA #24.
a) Nurse Aide (NA) #81
At approximately 5:00 PM on 02/21/24, a record review was conducted for the facility's staffing. During that review, it was determined NA #81 had not completed any competencies.
At approximately 11:00 AM on 02/22/24, the DON was notified and acknowledged the missing competencies for NA #81.
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CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention program to help prevent the development and transmission of communicable...
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Based on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention program to help prevent the development and transmission of communicable diseases and infections. The facility failed to provide appropriate infection surveillance, hand hygiene and catheter care. This failed practice had the potential to affect every resident currently residing in the facility. Resident Identifiers: #43 and #44. Facility census: 59.
Findings included:
a) Infection Surveillance
Record review of the facility's Infection control practices found the facility was unable to provide the required infection surveillance documentation of communicable illnesses.
During an interview, on 02/22/24 at 11:25 PM, the Infection Preventionist stated they were unable to locate the documentation of the infection control surveillance prior to her starting in November 2023.
No other information was provided prior to the end of the survey on 02/22/24 at 4:00 PM.
b) Resident #43
At approximately 1:56 PM on 02/20/24, an observation was made while conducting an interview with Resident #43 of the foley catheter bag on the floor without a privacy cover over it.
At approximately 2:09 PM on 02/20/24, the DON was made aware, and acknowledged the foley catheter bag on the floor without a privacy cover.
Upon care plan review, it was determined Resident #43 did not have a care plan for a privacy cover for the foley catheter bag, nor care planned for the bag to stay off the floor.
At approximately 2:20 PM on 02/20/24, the DON was made aware of, and acknowledged, Resident #43's care plan not including a privacy cover or a provision to remain off the floor.
d) Resident # 44
On 02/20/24 at 10:06 AM, the indwelling Foley catheter was discovered laying on the floor beside of the resident's bed. Also, the Foley catheter collection bag did not have privacy bag. The collection bag contained dark amber in color.
On 02/20/24 at 10:08 AM, Activities #85 verified the catheter collection bag was on the floor.
On 02/20/24 at 10:09 AM Nurse Aide (NA) #38 also verified there was not a privacy cover on the bag, and it was on the floor.
At 8:30 AM on 02/22/24 NA #28 was pushing Resident #44 in a wheelchair back to her room. The Foley catheter was under the wheelchair and the tubing was being dragged on the ground from the dining area to her room. Approximately four (4) inches for Foley catheter tubing was touching the floor.
While attempting to get Resident #44 from her wheelchair to the bed for Peri care, NA #28 placed the collection bag between her thighs, but the collection bag fell to the floor, NA #28 stepped on the collection bag, then kicked it under the bed.
d) Hand Hygiene
During the medication pass on 02/20/24 at 9:56 AM, Licensed Practical Nurse (LPN) #14 dropped a medication on the floor, picked up the pill and threw it in the trash and continued to pour medications without completing hand hygiene. When asked if LPN #14 if there was anything else that needed to be done and he stated that he should have performed hand hygiene. LPN #14 stated that he did not do hand hygiene.
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Jun 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
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Based on medical record review, reportable allegation review and staff interviews, the facility failed to report an allegation of verbal and physical abuse to the appropriate state agencies. Residen...
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Based on medical record review, reportable allegation review and staff interviews, the facility failed to report an allegation of verbal and physical abuse to the appropriate state agencies. Resident #1 alleged a staff member ran over her toes and scrubbed her back with a hard brush. This failed practice had the potential to affect a limited number of residents. Resident identifier: #1. Facility census: 64.
Findings included:
a) Resident #1
On 04/19/23 at 2:58 PM, Resident #1 reported to the Business Office Manager/Medical Records a CNA (Certified Nursing Assistant) had ran her feet over with a wheel chair; back and forth, intentionally. (Name of resident). Resident #1 also stated she had another incident with the same CNA five days prior. Resident #1 stated that the CNA was in the shower with (name of resident), and was scrubbing her with a stick, not even a wash cloth. Resident #1 said the CNA hurt her, and was very rude, yelling. Left her in the shower, up against the wall. Resident #1 stated that it was a blonde with long hair.
A review of the electronic medical found that Resident #1 had a Brief Interview of Mental Status (BIMS) score of 00 which indicates severe cognitive impairment on the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/01/23. Diagnoses included depression, Diabetes Mellitus and hypertension.
A review of reportables from April 2023 to current found no evidence that Resident #1's allegation had been reported to the required state agencies.
On 06/08/23 at 11:26 AM an interview, the Nursing Home Administrator (NHA) stated the allegation was not reported to the state agencies. In addition, the NHA stated the facility investigated the allegation and obtained statements from staff but felt the allegation was unsubstantiated and did not need to be reported. The NHA stated that the allegation would be reported to the state agencies immediately.
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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, policy review, and staff interview, the facility failed to timely administer insulin to residents in a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, policy review, and staff interview, the facility failed to timely administer insulin to residents in a timely manner. This was true for three (3) residents and affected more than a limited number of residents. Resident identifiers: #1, #2, and #3. Facility census: 64.
Findings included:
Policy
A review of the policy titled Medication Administration dated 11/17 stated that medications are to be administered with 60 minutes prior to or after scheduled time unless otherwise ordered by physician.
a) Resident #1
This resident was admitted on [DATE]. Medical diagnoses included Hypertension, Diabetes Type 1 (insulin dependent) with hyperglycemia. This resident had a Brief Interview of Mental Status (BIMS) score of 15 which indicates cognitively intact.
A review of the physician orders on 06/06/23 at 9:31 AM found the following:
Basaglar (long acting insulin) KwikPen 70 units twice a day for diabetes. Order date of 04/05/23.
Novolog (rapid acting insulin) 17 units at 7:30 AM. Hold if less than 50% of meal is consumed. Order date of 05/23/23
Novolog 20 units at 12:30 PM. Hold if less than 50% of meal is consumed. Order date of 05/23/23.
Novolog 25 units at 5:30 PM. Hold if less than 50% of meal is consumed. Order date of 05/23/23.
A review of report titled Medication Admin Audit Report on 06/06/23 at 9:57 AM found the following:
In reviewing the the scheduled time of administration and when the medication was administered, the lag time of one (1) hour lag time before and after the scheduled time was adjusted in the findings.
--05/01/23 Basaglar was scheduled to be given at 8:00 AM and was not administered until 12:48 PM which was three (3) hours and 48 minutes after the scheduled dose.
--On 05/02/23 Basaglar was scheduled to be given at 8:00 AM and was not administered until 1:21 PM which was four (4) hours and 21 minutes after the scheduled dose.
--On 05/06/23 Basaglar was scheduled to be given at 8:00 AM and was not administered until 12:32 PM which was two (2) hours and 32 minutes after the scheduled dose.
--On 05/19/23 Basaglar was scheduled to be given at 8:00 AM and was not administered until 10:20 AM which was one (1) hour and 20 minutes after the scheduled dose. The 8:00 PM dose was not administered until 1:23 AM which was four (4) hours and 23 minutes after the scheduled dose.
--On 05/26/23 Novolog was scheduled to be given at 7:30 AM and was not administered until 10:37 AM which was two (2) hours and 37 minutes after the scheduled dose. The Basaglar 8:00 AM dose was not administered until 10:37 AM which was one (1) hour and 37 minutes after the scheduled dose.
In addition, the 8:00 PM dose of Basaglar was not given until 11:18 PM.
--On 05/28/23 Basaglar was scheduled to be given at 8:00 AM and was not administered until 12:16 AM which was three (3) hours and 16 minutes after the scheduled dose. The 7:30 AM of Novolog
dose was not administered until 12:14 AM which was four (4) hours and 16 minutes after the scheduled dose. Accu checks (blood glucose monitoring) at 6:30 AM was 243, at 11:30 AM was 499 and at 4:30 PM was 374.
b) Resident # 2
This resident was admitted on [DATE]. Medical diagnoses of Diabetes Type 2 with no complications. This resident had a BIMS score of 11 which indicates moderate cognition intact.
A review of the physician orders on 06/06/23 at 10:18 AM found the following:
--Lantus 30 units at bedtime. Ordered on 12/19/22.
A review of report titled Medication Admin Audit Report on 06/06/23 at 10:18 AM found the following:
--05/02/23 Lantus was scheduled to be given at 9:00 PM and was not administered until 12:21 AM which was two (2) hours and 21 minutes after the scheduled dose.
--05/04/23 Lantus was scheduled to be given at 9:00 PM and was not administered until 11:05 PM which was one (1) hour and 5 minutes after the scheduled dose.
--05/09/23 Lantus was scheduled to be given at 9:00 PM and was not administered until 11:05 PM which was one (1) hour and 48 minutes after the scheduled dose.
--05/16/23 Lantus was scheduled to be given at 9:00 PM and was not administered until 11:43 PM which was one (1) hour and 43 minutes after the scheduled dose.
--05/29/23 Lantus was scheduled to be given at 9:00 PM and was not administered until 12:24 AM which was two (2) hours and 24 minutes after the scheduled dose.
c) Resident #3
This resident was admitted on [DATE]. Medical diagnoses included Hypertension, Diabetes Type 2 with no complication. This resident had a BIMS score of 15 which indicates cognitively intact.
A review of the physician orders on 06/06/32 at 12:15 PM found the following:
Lantus 64 units twice a day at 8:00 AM and 8:00 PM. Order dated 01/17/22.
Lispro Insulin sliding scale 200-250 = 5 units; 251-350 = 10 units; 351-400 = 15 units; and 401-600 = 20 units.
A review of report titled Medication Admin Audit Report on 06/06/23 at 12:15 PM found the following:
--05/29/23 Lantus was scheduled to be given at 9:00 PM and was not administered until 12:24 AM which was two (2) hours and 24 minutes after the scheduled dose.
In an interview with the Nursing Home Administrator (NHA) on 06/06/23 at 10:50 AM the NHA stated mediations are to be given one (1) hour prior to the scheduled administration time or one (1) hour after the scheduled time. In addition, the NHA stated they had a problem with insulin's. The NHA verified the insulin's were not given on time.
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May 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
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Based on observation, staff interview and record review, the facility failed to implement the care plan in the care area of falls. This was true for one (1) of four (4) residents reviewed in the car...
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Based on observation, staff interview and record review, the facility failed to implement the care plan in the care area of falls. This was true for one (1) of four (4) residents reviewed in the care area of falls. Resident Identifier: #53. Facility Census: 69.
Findings Included:
a) Resident #53
On 05/16/23 at 1:00 PM, the care plan for Resident #53 was reviewed. An intervention of mats on the floor beside the bed was noted under the focus area of falls on 03/08/23. However, upon observation of the resident in his room, the floor mat was not next to the bed.
On 05/16/23 at 1:50 PM, Unit Secretary #51 confirmed the floor mat was not next to the bed as listed as a fall intervention on the care plan.
On 05/16/23 at 3:00 PM, the Administrator was notified and confirmed the care plan was not implemented as written regarding fall interventions.
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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
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Based on record review and staff interview, the facility failed to complete neurological (neuro) checks for Resident #53 and Resident #18's unwitnessed falls. This was true for two (2) of four (4) r...
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Based on record review and staff interview, the facility failed to complete neurological (neuro) checks for Resident #53 and Resident #18's unwitnessed falls. This was true for two (2) of four (4) residents reviewed under the care area of falls. Resident Identifiers: #53 and #18. Facility census: 69.
Findings Included:
a) Resident #53
On 05/15/23 at 1:00 PM, a record review was completed for Resident #53. The record review found the resident had an unwitnessed fall on 05/02/23 at 8:30 PM. The following progress note dated 05/02/23 states, At 0830, patient was found on floor of room next to bed. Patient had small area on top of his head that was bleeding measuring approximately 2 cm (centimeters) X 3 cm in length and width. VS (vital signs) - 115/46, 96.4, P (pulse) - 116, R (respirations) - 17 and Ox (oxygen) - 95% (percent). Patient stated there wasn't any pain anywhere, but he felt a little dizzy. We got patient up in wheelchair and began neuro checks. (Name of facility physician) was informed of situation and orders were to observe. (Typed as written.) The record review, also, found the neurological checks were not completed for the unwitnessed fall on 05/02/23.
An interview was completed with Registered Nurse (RN) #106 on 05/16/23 at 12:00 PM. RN #106 stated we use the paper form for neuro checks as a guideline because the computer does not identify the correct follow up times for the neuro checks.
An additional interview was completed with Licensed Practical Nurse (LPN) #81 on 05/16/23 at 12:05 PM. LPN # 81 stated, the incident report is supposed to trigger the times the neuro checks are due .but it doesn't .
On 05/16/23 at 10:22 AM, the Administrator stated, that's all the neuro checks I could find . On 05/16/23 at 10:35 AM, the Administrator confirmed the neurological checks were incomplete.
b) Resident #18
On 05/15/23 at 2:00 PM, a record review was completed for Resident #18. The record review found the resident had an unwitnessed fall on 04/11/23 at 4:20 AM. The following progress note dated 04/11/23 at 4:20 AM states, Summoned to resident room, on entering, noted resident sitting on floor with buttocks against dresser facing walker, sitting on floor with legs outstretched in front, hands touching floor, urine noted, nonslip socks on, walker facing bed in front of resident. C/O (complain of) minor discomfort in right arm, right thigh, noted left buttock small bruise. Right arm lateral forearm old bruise from last fall. Denies hitting head, all limbs freely moving on assessment, x 1 (one) staff assist to standing position, assisted to bedside toilet for care. x 1 assist to bed. (Typed as written.) The record review, also, found the neurological checks were not completed for the unwitnessed fall on 04/11/23.
An interview was completed with Registered Nurse (RN) #106 on 05/16/23 at 12:00 PM. RN #106 stated we use the paper form for neuro checks as a guideline because the computer does not identify the correct follow up times for the neuro checks.
An additional interview was completed with Licensed Practical Nurse (LPN) #81 on 05/16/23 at 12:05 PM. LPN # 81 stated, the incident report is supposed to trigger the times the neuro checks are due .but it doesn't .
On 05/16/23 at 10:22 AM, the Administrator stated, I'll check and see if I can find anymore documentation . On 05/16/23 at 10:25 AM, the Administrator confirmed the neurological checks were incomplete.
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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
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview, the facility failed to ensure respiratory care was provided according to professional standards of practice. This was a random opportunity of discovery. Res...
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Based on observation and staff interview, the facility failed to ensure respiratory care was provided according to professional standards of practice. This was a random opportunity of discovery. Resident Identifier: #53. Facility census: 69.
Findings included:
a) Resident #53
On 05/16/23 at 1:45 PM, the nebulizer mask was observed laying on top of the nebulizer (breathing treatment) machine without being stored in a respiratory bag.
On 05/16/23 at 1:50 PM, the Unit Secretary #51 confirmed the the nebulizer mask was not in a respiratory bag. Unit Secretary #51 stated, I'll get a bag .I'll get a new mask.
On 05/16/23 at 3:00 PM, the Administrator confirmed the nebulizer mask should be stored in a respiratory bag
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Dec 2022
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
Deficiency F0602
(Tag F0602)
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 #57 was free from misappropriation of reside...
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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 #57 was free from misappropriation of resident property. Resident #57 was ordered liquid ativan, a controlled substance. The facility was unable to provide evidence to indicate this medication was not diverted for another use. This was true for one (1) of six (6) residents reviewed for controlled substance reconciliation. Resident Identifier: #57. Facility Census: 65.
Findings included:
a) Resident #57
A review of Resident #57 medical record found this resident expired at the facility on [DATE]. A review of Resident #57's physician orders found the resident was ordered Ativan Oral Concentrate .5 mg by mouth every four (4) hours as needed for anxiety and comfort This medication was ordered on [DATE].
A review of Resident #57's Medication Administration Record (MAR) for the month of 07/2022 found Resident #57 never received this medication.
The Director of Nursing (DON) provided an E-Mail between her and the consultant pharmacy which contained the following correspondence:
An email sent from the DON to the pharmacist at 1:09 PM on [DATE] read as follows: The surveyors are requesting the Ativan controlled log for (First and Last Name of Resident #57) [DATE]. I see an order for it but it was never administered. Can you verify if it was even sent.
A response email from the pharmacist to the DON on [DATE] at 3:12 PM read as follows:
Looks like on [DATE] ativan intensol was sent a 30 ml (milliliter) bottle.
An additional email sent from the pharmacist to the DON on [DATE] at 3:22 PM, read as follows:
Looks like on [DATE] we destroyed (First name of Resident #57) morphine and hydrocodone but no ativan. Maybe still in fridge?
An interview with the DON on [DATE] at 3:40 PM, confirmed the Ativan was not in the refrigerator. When asked if she was able to provide the controlled substance log for review and/or provide the ativan, she stated she was not. She confirmed she has no way of knowing where this medication is. She confirmed, she could not prove that this medication was not diverted and used for purposes other than providing it to Resident #57 as ordered.
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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
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 information from the resident's medical record was c...
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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 information from the resident's medical record was communicated/provided to the receiving hospital when three (3) of three (3) residents were transferred to the hospital. Resident identifiers: #81, #51, and #82. Facility census: 65.
Findings included:
a) Resident #81
Record review found on 11/30/22 the resident experienced a change in condition. A nurse's note dated, 11/30/22 at 10:59 AM: General Nurses Note Note Text: Spoke with (Name of physician) and made him aware of change in condition, oxygen saturations, and current cognitive status. Received order to give Albuterol nebulizer treatment now and if no change may send to ER if family requests.
On 11/30/2022 at 11:07 AM General Nurse's Note Text: DON (Director of Nursing) spoke with (Name of physician) and updated him on condition.
On 11/30/2022 at 11:15 AM, General Nurse's Note Text: (Name of Physician) in facility and assessed resident.
On 11/30/2022 at 11:28 AM General Nurse's Note Text: (Order received per (Name of Physician) to send to ER (emergency room.)
On 12/1/2022 at 9:10 Discharge Summary Note Text: This [AGE] year-old male admitted on [DATE] from (Name of hospital) to services of (Name of physician.) Stay basically uneventful. He had a Stage II pressure ulcer on sacrum present on admission. On 11/30/2022 at 10:45 SPO2 (oxygen saturation) 77-80% on O2. Unable to arouse resident at this time with verbal or tactile stimuli. 11:00 HHN (hand held nebulizer) treatment given. At 11:45 he was transported via (Name of ambulance) to (Name of hospital) for evaluation. At 16:15 he was admitted to (Name of Hospital) , intubated, with diagnosis of respiratory arrest/failure.
b) Resident #51
Record review found a nurse's note dated 12/8/2022 at 3:28 AM, Called in to see resident due to shaking and gray color. upon arrival to room, resident was attempting to sit on the side of bed, poor trunk control, leaning to the left, ashen in color. He had removed his Bipap, wanting to replace it with O2 (oxygen) cannula. He was unable to do so. Nurse applied O2, obtained PRN (as needed) Albuterol neb (nebulizer) tx (treatment,) he was unable to hold the pipe, becoming unresponsive, bipap reapplied. This nurse and CNA positioned resident in bed, HOB (head of bed) elevated. VS (vital signs) 113/78, pulse 90-152, respirations 56, SPo2 80-94%, temp 102.6. cool cloth applied to forehead, back of neck. Asked resident if he would like to go to the hospital for an eval, he agreed, 911 called, called to give report to ER, nurse was busy, will call (name of nursing home) with questions.
A second nurse's note dated 12/8/2022 at 12:36 AM, General Nurse's Note Text: Phone call from (Name of hospital) resident admitted with diagnosis of Flu A & Leukocytosis.
c) Resident #82
Record review found a nurse's note dated 12/04/22 at 2:01 PM, called (Name of physician) explained the status changes, she isnt eating, not drinking, hasnt voided, she had a bowel movement pink, red tint noted on the pad, sp02 (oxygen saturation) 92 % 02-2l (2 liters) nasal came up to 94 %. unable to obtain a b/p (blood pressure) with manual or electric cuff. she is opening her eye, but not following commands. Verbal order to send to the (Name of hospital- emergency room.)
A second nursing note dated 12/04/22 at 10:53 PM, resident being admitted to (Name of hospital) for UTI (urinary tract infection) as main dx. (diagnosis.)
On 12/12/22 at 1:15 PM, the DON was asked, what information was sent with the above 3 residents when they were transferred to the hospital? The DON asked what information would we send? We can call them or they call us if they need to know something.
The surveyor responded, do you have verification the following information was conveyed to the receiving hospital: Contact information of the practitioner who was responsible for the care of the resident; Resident representative information, including contact information; Advance directive information; current medications, when last provided; and other pertinent information needed to provide treatment. Do you have a transfer report you use when you send a resident to the hospital?
No further information was provided before the close of the survey.
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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
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Based on observation and staff interview the facility failed to ensure the resident environment over which it had control was a free of accident hazards as possible. Three (3) of Three (3) shower ro...
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Based on observation and staff interview the facility failed to ensure the resident environment over which it had control was a free of accident hazards as possible. Three (3) of Three (3) shower rooms in the facility were unlocked and disposable razors laying on carts which were accessible to the residents. This failed practice had the potential to affect more than a limited number of Residents. Facility Census: 65.
Findings Included:
a) North Shower Room.
An observation of the North Shower room at 9:12 am on 12/13/22 found the shower room to be unlocked. There was five (5) disposable razors laying on the cart in the North Shower room which would have been accessible to any resident entering the shower room.
An interview with Registered Nurse (RN) #74 on 12/13/22 at 9:15 am, confirmed the razors should not be out were the residents could access them.
b) South Side Shower rooms.
Observations in both South Side shower rooms at 9:20 am on 12/13/22 found both shower rooms to be unlocked. There was five (5) disposable razors in the South Side shower room labeled S163.
In the South Side shower room labeled S130 was one (1) disposable razor.
An interview with Licensed Practical Nurse (LPN) #41 at 9:26 am on 12/13/22 confirmed the razors in shower room needed to be removed. She agreed they should not be where residents can access them.
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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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
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b) Resident #14
A review of Resident #14's medical record on 12/12/22 found the following physician orders for a controlled substance:
Hydrocodone - Acetaminophen 10- 325 milligrams give every fou...
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b) Resident #14
A review of Resident #14's medical record on 12/12/22 found the following physician orders for a controlled substance:
Hydrocodone - Acetaminophen 10- 325 milligrams give every four (4) hours as needed for pain. This medication was ordered on 11/22/22.
A review of the medication administration record (MAR) for 12/2022 and the controlled substance record for the hydrocodone found on the following occasions the medication was signed out on the controlled substance log but was not documented as administered on the MAR.
-- 12/04/22 at 11:00 am
-- 12/04/22 at 9:00 pm
-- 12/06/22 at 9:00 am
-- 12/06/22 at 1:00 pm and
-- 12/09/22 at 12:00 pm.
An interview with the Director of Nursing (DON) on 12/12/22 at 1:41 PM, confirmed on the above mentioned dates the hydrocodone was signed out on the controlled substance log but not documented on the MAR.
c) Resident #83
A review of Resident #83 medical record on 12/13/22 found the following physician orders for a controlled substance:
Morphine Sulfate Oral Solution 20 mg/ml Give .25 ml by mouth every hour as needed for pain and comfort. This was ordered on 07/26/22.
A review of the medication administration record (MAR) for 08/2022 and the controlled substance record for the hydrocodone found on the following occasions the medication was signed out on the controlled substance log but was not documented as administered on the MAR.
-- 08/01/22 at 4:20 pm.
-- 08/11/22 at 05:15 am.
An interview with the DON on 12/13/22 at 1:43 pm confirmed on the above mentioned dates the morphine was signed out on the controlled substance log but not documented on the MAR.
d) Resident #55
A review of Resident #55's medical record on 12/13/22 found the following physician orders for a controlled substance.
Morphine Sulfate Oral Solution 20 mg/ml Give .25 ml by mouth every hour as needed for pain and comfort. This was ordered on 08/15/22.
A review of the medication administration record (MAR) for 09/2022 and the controlled substance record for the morphine found on the following occasions the medication was signed out on the controlled substance log but was not documented as administered on the MAR.
-- 09/03/22 at 4:30 am.
-- 09/04/22 at 2:45 pm.
-- 09/05/22 at 2:00 pm.
-- 09/08/22 at 12:00 am.
-- 09/09/22 at 9:00 am.
-- 09/11/22 at 6:30 pm and,
-- 09/30/22 at 11:20 am.
An interview with the DON on 12/13/22 at 1:43 pm confirmed on the above mentioned dates the morphine was signed out on the controlled substance log but not documented on the MAR.
Based on observation, record review, and staff interview, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and prompt identification of loss or potential diversion of controlled medications. This was true for three (3) of six (6) residents. Resident identifiers: #82, #14, and #83. Facility census: 65.
Findings included:
a) Resident #82
Review of Resident #82's medical record found the resident was receiving Hydrocodone-Acetaminophen 7.5 - 325 milligrams by mouth every six (6) hours as needed (PRN) for pain related to primary osteoarthritis of the hands and knees.
Review of the medication administration record (MAR) for November 2022 found the resident received one dose of the medication on seven (7) occasions during the month:
11/02/22 at 5:43 AM
11/09/22 at 8:00 PM
11/10/22 at 6:34 AM
11/15/22 at 8:26 AM
11/25/22 at 4:26 PM
11/28/22 at 9:13 PM
11/30/22 at 9:56 PM
Review of the resident's controlled substance record confirmed the medication was signed out on the following days when the MAR did not indicate the medication was administered to the resident:
11/01/22 at 11:00 PM
11/01/22 at 6:00 AM
11/10/22 at 11:00 AM
11/25/22 at 12:30 AM
11/26/22 at 9:00 AM
11/28/22 at 11:00 PM, 6:00 AM
11/29/22 at 6:00 AM
11/30/22 at 6:00 PM and 11:53 PM
At least nine (9) doses of the controlled substance, Hydrocodone-Acetaminophen 7.5 - 325 are unaccounted for during the month of November 2022. The nurse on duty signed the controlled substance record indicating the medication was removed; however, the MAR did not indicate the resident received the medication.
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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
Deficiency F0886
(Tag F0886)
Could have caused harm · This affected multiple residents
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Based on record review and staff interview, the facility failed to conduct testing on staff members exposed after an outbreak of COVID 19. This was a random opportunity for discovery. Resident ident...
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Based on record review and staff interview, the facility failed to conduct testing on staff members exposed after an outbreak of COVID 19. This was a random opportunity for discovery. Resident identifiers: #15, #32, and #68. Facility census: 65.
Findings included:
a) Facility policy
Review of the facility policy for Outbreak Response Plan-Testing policy for Coronavirus (COVID-19,) Testing Summary updated 10-2022:
Testing trigger: Newly identified COVID 19 positive staff or resident in a facility that can identify close contacts:
Test all staff, regardless of vaccination status, that had a higher-risk exposure with a COVID - 19 positive individual.
b) Review of the current outbreak line list for COVID - 19
On 11:50 AM on 12/13/22, the outbreak line listing was reviewed with Licensed Practical Nurse (LPN) #25, the Infection Preventionist (IP) found an outbreak occurred on 12/09/22 when two (2) roommates (Residents #15 and #32) tested positive for COVID - 19. On 12/12/22 a third Resident #68 tested positive for COVID - 19. All three (3) residents resided on the South side of the facility. IP #25 said the facility did not test any residents because it was confirmed through contact tracing, these resident's never leave their rooms. IP #25 confirmed no staff members were tested. IP #25 offered no explanation as to why staff members who provided care to the residents were not tested.
Review of the outbreak line list for COVID 19 revealed two residents tested positive on 12/09/22, Resident's #15 and #32. On 12/12/22 a third resident #68 tested positive.
On 12/13/22 at 11:05 AM, the infection preventionist, said staff were not tested because she didn't think they needed to be.
Review of the guidance from the Centers for Medicare and Medicaid Services (CMS) memo QSO-20-38 NH, revised on 09/23/22 directs the same guidance for staff testing as the facility's policy. Test all staff, regardless of vaccination status, that had a higher-risk exposure with a COVID - 19 positive individual.
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Jul 2022
24 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
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Based on observation and interview, the facility failed to ensure a Resident's catheter bag was covered with a privacy bag. This was a random opportunity for discovery. Resident identifier #45. Faci...
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Based on observation and interview, the facility failed to ensure a Resident's catheter bag was covered with a privacy bag. This was a random opportunity for discovery. Resident identifier #45. Facility census: 55.
Findings included:
Observation on 07/05/22 at 12:19 PM of Resident #45 found her catheter bag hanging on her bed in view of other residents, and visitors.
During an interview with Resident # 45 on 07/05/22 at 12:19 PM, she stated that she would prefer the catheter bag be covered.
Resident #45's Minimum Data Set (MDS) admission Assessment with an Assessment Reference Date (ARD) of 05/32/22 noted the resident had a score of 15 on the Brief Interview for Mental Status (BIMS). A BIMS score of 15 indicates the resident is cognitively intact and has capacity. A BIMS score of 15 is the highest score on the scale.
During an interview nn 07/05/22 at 12:34 PM, the Licensed Practical Nurse (LPN) #86, verified the catheter bag was not covered. She stated that it should be covered when in view. LPN #86 replaced the privacy bag.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0574
(Tag F0574)
Could have caused harm · This affected 1 resident
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Based on interview and record review, the facility failed to ensure each resident was provided a verbal and written description of the State Long-Term Care Ombudsman program, the name of the Ombudsm...
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Based on interview and record review, the facility failed to ensure each resident was provided a verbal and written description of the State Long-Term Care Ombudsman program, the name of the Ombudsman, and contact information in a manner they understood. This had the potential to affect more than a limited number of residents. Resident identifiers: #33, #39, #316, #8, #49, and #16. Facility census: 65.
a) Resident Council Meeting - Residents #33, #39, #316, #8, #49, and #16
During a resident council meeting, on 07/06/22 at 1:40 PM, six (6) out of six (6) residents were unable to report where (or if) the Ombudsman's contact information was posted within the facility. No one recognized the Ombudsman by name or by job description. Resident #11 stated, I didn't know someone like that existed or we could speak to someone else about the care we receive. How do we reach her? The other five (5) residents agreed they were unaware of the right to let someone like the Ombudsman know about their care if they ever had a concern.
A subsequent review of resident council minutes from July 2021 to present produced no evidence the residents in attendance at each of the resident council meetings were provided information about the Ombudsman's name and contact information.
During an interview on 07/07/22 at 9:00 AM, the Administrator stated the facility would need to do a better job of educating the residents of who the state long-term care Ombudsman was and where her contact information was located in the building.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
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Based on record review and interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF-ABN) form to three (3) of three (3) reside...
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Based on record review and interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF-ABN) form to three (3) of three (3) residents reviewed for the facility's beneficiary protection notification. This failure placed residents at risk of not being informed of their rights prior to the end of Medicare Part A covered services. Resident identifiers: #35, #63, and #65. Facility census: 65.
Findings included:
a) Skilled Nursing Facility Advanced Beneficiary Notice on Non-Coverage Form Instructions
Review of Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice on Non-Coverage (SNF ABN) Form CMS-10055 (2018) denoted Medicare requires skilled nursing facilities to issue the SNF ABN to Medicare beneficiaries prior to providing care that Medicare usually covers, but may not pay for because the care is not medically reasonable and necessary; or considered custodial.
b) Residents #35, 63, and 65
On 07/07/22 at 9:15 AM, a review was completed regarding the beneficiary protection notification liability notices given for the following three (3) residents who remained at the facility following their last covered day of Medicare Part A services:
--Resident #35 began Medicare Part A skilled services on 02/17/22. The last covered day of Part A service was 02/26/22. There was no evidence a SNF ABN form was provided.
--Resident #63 began Medicare Part A skilled services on 02/24/22. The last covered day of Part A service was 03/24/22. There was no evidence a SNF ABN form was provided.
--Resident #65 began Medicare Part A skilled services on 02/17/22. The last covered day of Part A service was 02/26/22. There was no evidence a SNF ABN form was provided.
In an interview on 07/07/22 at 10:18 AM, the Administrator confirmed the facility could not provide evidence a SNF-ABN form was given to any of the three (3) residents.
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CONCERN
(D)
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 interview, the facility failed to protect resident right to privacy and confidentiality for all aspects of care and services. Signs posted in resident rooms and visible to o...
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Based on observation and interview, the facility failed to protect resident right to privacy and confidentiality for all aspects of care and services. Signs posted in resident rooms and visible to others included clinical and personal care information. Resident identifiers: #50 and #37. Facility census: 65.
Findings included:
a) Resident #50
Observation on 07/05/22 at 2:07 PM, found signs posted in Resident #50's room directing staff on the correct way to transfer resident.
A second observation, on 07/06/22 at 12:27 PM, revealed three (3) signs with the following wording, [Resident #50's Name] is now transferring using a sliding board for increased safety. Please see therapy if any concerns with this change. Thank you. Slide board is in bathroom. The first sign was on the wall by Resident #50's television and clock. The second sign was to the right side of the resident's bed. The third sign was positioned on the right of the headboard. A fourth sign with the wording, Use Slide board only for transfers. Hoyer lift has been discontinued was also found to the right side of the headboard.
During an interview on 07/06/22 at 12:28 PM, Assistant Director of Nursing (ADON) stated that the Physical Therapy department would have assessed Resident #50's transfer needs and communicated what was safest by posting the signs. The ADON relayed the signs were the staff members' way of knowing how to correctly transfer resident.
b) Resident #37
Observation on 07/05/22 at 12:15 PM, found sign a sign above Resident #37's bed noting care directives of resident in plain view of anyone entering the room. The posting included the following:
- Bed and chair alarms until stronger to alert staff of positional changes and reduce fall risk.
- Supervision at all times when sitting up in wheelchair, no exceptions until stronger.
- Upgraded to nectar thickened liquids and small/bite-sized foods. Sit up in bed or supervised in chair for all meals with good lighting. Encourage to complete meal as independent as possible. Help when fatigued.
- Transfer with one (1) assist and use gait belt. Not ready to ambulate with staff yet. Non- skid socks at all times.
- Wear brief pull-ups daily for toileting routine. Encourage clothing management.
- Please alert therapy to any concerns.
During an interview at 12:20 PM, Nurse Aide #60 stated the information is posted in resident's room because it makes it easier for Physical Therapy to communicate the care for the resident.
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CONCERN
(D)
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 and record review, the facility failed to make prompt efforts to resolve a grievance and to keep the resident notified of progress toward resolution. This is true for two (2) of t...
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Based on interview and record review, the facility failed to make prompt efforts to resolve a grievance and to keep the resident notified of progress toward resolution. This is true for two (2) of two (2) reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifiers: #45 and #28. Facility census: 55.
Findings Included:
a) Resident #45
On 07/05/22 at 12:23 PM during an interview, Resident #45 stated that she doesn't sleep well, due to the Resident next-door yelling, all the time. She stated that she has talked to the social worker about the issue of the other Residents yelling.
A record review on 07/06/22 of grievances, revealed no grievance form was filled out for this issue.
Resident #45's Minimum Data Set (MDS) admission Assessment with an Assessment Reference Date (ARD) of 05/32/22 noted the resident had a score of Brief Interview for Mental Status (BIMS) of 15 the highest score obtainable.
During an interview with the Social Services Director (SSD) on 07/12/22 at 9:52 AM, she stated she was aware of the complaint about the noise of the other resident but had never offered a room change to Resident #45 or completed a grievance form. She stated that she would offer a room change now.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
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Based on record review and interview, the facility failed to ensure the direct monitoring and supervision provided during the use of physical restraint for a resident including documentation of the ...
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Based on record review and interview, the facility failed to ensure the direct monitoring and supervision provided during the use of physical restraint for a resident including documentation of the monitoring. This was true for one (1) of three (3) residents reviewed for physical restraint. Resident identifier: #43. Facility census: 65.
Findings included:
a) Resident #43
Observation, on 07/05/22 at 12:57 PM, found Resident #43 wore a safety belt when up in wheelchair.
An electronic health record review was completed on 07/11/22 at 11:39 AM. There was a physician order, dated 01/28/22, directing: Restraint: seat belt while in w/c (wheelchair). Release seat belt every two (2) hours and prn (as needed) for repositioning visual check every 30 minutes on every shift.
The facility's Use of Restraints Policy, dated July 2019, directed: The following safety guidelines shall be implemented and documented while a resident is in restraints .
- A resident placed in a restraint will be observed at least every thirty (30) minutes by nursing personnel and an account of the resident's condition shall be recorded in the resident's medical record.
The electronic health record review did not reveal any documentation regarding the visual check every 30 minutes.
During an interview 07/11/22 at 3:50 PM, the Director of Nursing (DON) stated the facility could not produce evidence of nursing documentation regarding 30-minute checks by nursing personnel and an account of resident's condition.
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CONCERN
(D)
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 record review and staff interview, the facility failed to complete thorough investigations of two (2) resident-to-resident physical altercations, maintain documentation that the incidents w...
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Based on record review and staff interview, the facility failed to complete thorough investigations of two (2) resident-to-resident physical altercations, maintain documentation that the incidents were thoroughly investigated, and report the results to Adult Protective Services and the State Survey Agency, within five (5) working days of the incidents in accordance with State law. Resident identifier: #1. Facility census: 65
Findings included:
a) Resident #1 Resident-to-Resident Physical Altercation on 04/16/22 at 8:00 AM
An electronic medical record review was completed on 07/11/22 at 11:00 AM. A general nurses' note, on 04/16/22 at 8:00 AM, revealed, Resident yelling and agitated. Shoved [another female resident] 's wheelchair. [The other female resident] was heading for breakfast cart, but nurse ran over and stopped the wheelchair.
A subsequent review of the facility's reportable log revealed the incident was not reported to designated state agencies.
During an interview, on 07/11/22 at 3:45 PM, the DON reported the facility did not have an incident report for the resident-to-resident altercation.
On 07/12/22 at 9:30 AM, the Social Worker stated the incident should have been reported to the appropriate state agencies. The Social Worker reported it would have been the nursing department's responsibility to complete an incident report outlining the details of the resident-to -resident altercation. The Social Worker also reported it would have been her responsibility to report it. The Social Worker stated she was never aware of the incident. The Social Worker verbalized since the incident itself was never reported, the agency did not conduct a thorough investigation, put precautionary measures in place to help prevent any further physical resident-to-resident altercations from occurring while the investigation was being conducted, or take any action based on the findings of the investigation.
b) Resident #1 Resident-to-Resident Physical Altercation on 04/16/22 at 11:15 AM
An electronic medical record review was completed on 07/11/22 at 11:05 AM. A general nurses' note, on 04/16/22 at 11:15 AM, revealed, Resident loud and arguing with another [male] resident. Resident grabbed [the male resident's] arm and shook vigorously. Resident attempted to slap [the male resident], but [nurse aide] stepped in between them.
A subsequent review of the facility's reportable log revealed the incident was not reported to designated state agencies.
During an interview, on 07/11/22 at 3:49 PM, the DON reported the facility did not have an incident report for the resident-to-resident altercation.
On 07/12/22 at 9:35 AM, the Social Worker stated the incident should have been reported to the appropriate state agencies. The Social Worker reported it would have been the nursing department's responsibility to complete an incident report outlining the details of the resident-to -resident altercation. The Social Worker also reported it would have been her responsibility to report it. The Social Worker stated she was never aware of the incident. The Social Worker verbalized since the incident itself was never reported, the agency did not conduct a thorough investigation, put precautionary measures in place to help prevent any further physical resident-to-resident altercations from occurring while the investigation was being conducted, or take any action based on the findings of the investigation.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
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Based on record review and interview, the facility failed to provide wound care treatment order by the physician for Resident #18. This was true for one (1) of four (4) residents reviewed for pressu...
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Based on record review and interview, the facility failed to provide wound care treatment order by the physician for Resident #18. This was true for one (1) of four (4) residents reviewed for pressure ulcers. Resident identifier: #18. Facility census: 65.
Findings included:
a) Resident #18
A review of Resident #18's medical record showed a physician order dated 06/07/22 stated, weekly wound assessments and documentation on Tuesday. A review of the June 2022 Medication Administration Review (MAR) showed that there was no assessment or wound care provided for the date of 06/14/22. There was no evidence of a progress note that revealed wound care documentation for 06/14/22.
During an interview on 07/06/22 at 2:02 PM, Director of Nursing (DON) stated that the wound care for 06/14/22 was not available for that day as the Assistant Director of Nursing (ADON) who provided wound care for the facility right now may be have been pulled to work the med cart that day.
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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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b) Resident #25
Observation, on 07/05/22 at 2:10 PM, found Resident #25's O2 nasal canula stored on top of the oxygen concentrator, not in a sterile bag. Additionally, the resident's nebulizer mask ...
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b) Resident #25
Observation, on 07/05/22 at 2:10 PM, found Resident #25's O2 nasal canula stored on top of the oxygen concentrator, not in a sterile bag. Additionally, the resident's nebulizer mask was not bagged and was resting on top of nebulizer machine.
During an interview on, 07/05/22 at 2:20 PM, Nurse Aide #8 confirmed the oxygen supplies were laying on top of their respective devices and not stored as per facility protocol / policy.
Based on observation, medical record review, and interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. Oxygen supplies were not properly stored. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #46, and #25. Facility census: 55.
Findings included:
a) Resident #46
An observation on 07/05/22 at 12:05 PM found, Resident #46's's nasal cannula and tubing (an oxygen delivery device) from an oxygen concentrator laying on concentrator without being placed in a protective bag.
An interview on 07/05/22 at 12:36 PM with License Practical Nurse (LPN) #86 confirmed that Resident #46's nasal cannula should be placed in a protective bag when not in use.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to provide the necessary behavioral health care services to attain or maintain the highest practicable mental and psychosocial well-be...
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Based on record review and staff interview, the facility failed to provide the necessary behavioral health care services to attain or maintain the highest practicable mental and psychosocial well-being. Resident identifier: #1. Facility census: 65.
Findings included:
a) Resident #1
An electronic medical record review, completed on 07/06/22 at 1:33 PM, revealed the following documented behaviors:
04/09/22 22:10 General Nurses' Note
making rude comments to residents and staff. Calling people fat, and ugly, and stupid and talking very loudly to other residents when they were trying to speak to her or others. Resident noted to be agitated, pacing back and forth, and talking very loudly while pointing her finger at staff / residents.
04/16/22 08:00 General Nurses' Note
Resident yelling and agitated. Shoved [another female resident's] wheelchair. Wheelchair was heading for breakfast cart, but nurse ran over and stopped the wheelchair.
04/16/22 11:15 General Nurses' Note
Resident loud and arguing with [a male] resident. Resident grabbed [the male resident's] arm and shook vigorously. Resident attempted to slap [the male resident] but nurse aide stepped in between them.
04/16/22 15:50 General Nurses' Note
Resident cussing and yelling at other residents in dining room. Accused [another Resident] of stealing her shirt.
04/16/22 16:10 General Nurses' Note
Resident asks to be taken outside so she can cool off. Activities accompanied her outside.
04/16/22 16:20 General Nurses' Note
Resident returned from outside. Behaviors were noted upon return to the unit. Resident aggressive to other residents and staff.
04/26/22 12:46 General Nurses' Note
Resident is being loud and aggressive towards staff and other residents. Unable to redirect.
07/02/22 21:00 General Nurses' Note
Delusional, pacing on unit, delusions of grandeur, fictional, broken pieced stories, irritable with staff and other residents, not easily redirected.
07/03/22 05:00 General Nurses' Note
Up pacing on unit, irritable with staff, care, and other residents, fictional delusions, not easily redirected.
07/03/22 16:00 General Nurses' Notes
Sitting in dining room at this time. Verbally aggressive and delusional. Flight of ideas noted. Difficult to redirect. Denies pain.
07/03/22 18:00 General Nurses' Notes
Resident sitting in chair in dining room. Pointing at people passing by stating, This has to stop. Remains delusional. I'm tired of this job. I'm going to find another one. I'm a lawyer and can work anywhere. Difficult to redirect.
07/03/22 23:00 General Nurses' Note
Resident walked into shower room on another resident, delusional and confrontational, and chose not to leave until redirected out to dining room by staff.
07/04/22 02:00 General Nurses' Note
Delusional loud disruptive noises, pacing on unit, confrontational with staff and other residents, not easily redirected, or distracted.
07/04/22 07:30 General Nurses' Note
Resident became verbally aggressive toward another resident in dining hall. Had one of the aides move another resident and attempted redirection with success. Will continue to monitor for behaviors.
07/04/22 17:42 General Nurses' Note
Resident in dining room. Easily agitated and verbally inappropriate toward other residents. Difficult to redirect.
07/04/22 18:21 General Nurses' Note
Resident still in dining room verbally abuse to other residents, difficult to redirect. Resident thinks everyone is talking about her. Will continue to monitor.
07/04/22 18:34 General Nurses' Note
Resident was arguing with another resident in dining hall. Both parties were using foul language and yelling at one another. Separated these 2 residents. This resident is still very agitated and is not easily redirected.
07/05/22 21:09 General Nurses' Note
Resident noted to be up on unit in dining room. Noted to be delusional and yelling out random verbalizations towards staff and other residents. Unable to redirect resident. Declines offer of snack / activity. Resident remains in dining room yelling out.
Review of Resident #1's care plan found it noted that resident had daily behaviors during the last review. It noted resident had frequently changing moods and periods of agitation. It also noted resident had yelled at staff and other residents and has made disruptive sounds and had disruptive behaviors daily. The following interventions were outlined: Maintain consistent routine, respond to requests timely, provide care and treatment per MD orders, consider psychiatric review, set realistic limits, be calm but firm, give resident space, re-approach, provide choices (return to room until feeling better), engage resident prior to direct care. Do not react. Remain calm. The care plan did not provide specific behavioral health interventions and services to assist Resident #1 in attaining or maintaining the highest practicable mental and psychosocial well-being. There was no mention of how staff should intervene in the event Resident #1 became physical with other residents and or staff members.
During an interview, on 07/12/22 at 9:32 AM, the Social Worker acknowledged she had a difficult time formulating an individualized, person-centered care plan addressing Resident #1's behaviors and appropriate interventions / approaches. The Social Worker noted, Nothing is consistently successful as an intervention. That makes it difficult to care plan interventions. The Social Worker was unable to provide evidence the care plan had been evaluated for effectiveness.
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CONCERN
(D)
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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Based on observation, record review and interview, the facility failed to ensure narcotics were reconciled per shift. This failed practice had the potential to affect a limited number of residents. ...
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Based on observation, record review and interview, the facility failed to ensure narcotics were reconciled per shift. This failed practice had the potential to affect a limited number of residents. Facility census: 65.
Findings included:
a) Narcotic Count
A review of the narcotic count on the North Hall was conducted on 07/06/22 at 7:48 AM with Licensed Practical Nurse (LPN) #68. The narcotic count sheets were found in a spiral notebook. The narcotic note book had no information regarding a card count of the narcotics. The Director of Nursing (DON) confirmed there was no narcotic card count for July 2022 for the North Hall on 07/06/22 at 8:26 AM. LPN #68 stated that she used to count cards but there was no way with the current system to tell if a narcotic sheet and/or medications were missing she understood this could be a problem.
On 07/06/22 at 2:34 PM in an interview with the Director of Nursing (DON) regarding narcotic counts agreed there was no way to tell if the narcotic count was correct with the documentation system. The DON confirmed this presented an opportunity for diversion with not having understandable entries and days when there were blanks in the count sheet.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
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Based on record review and interview, the facility failed to ensure Resident #54 was free from unnecessary medications. This was true for one (1) of five (5) reviewed for unnecessary medications. Re...
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Based on record review and interview, the facility failed to ensure Resident #54 was free from unnecessary medications. This was true for one (1) of five (5) reviewed for unnecessary medications. Resident identifier #54. Facility census: 55.
Finding included:
A review for unnecessary medication for Resident #54 on 07/06/22 found the record did not contain Physicians responses to the Pharmacist recommendations in March 2022, May 2022, and June 2022.
During an interview on 07/07/22 at 10:57 AM the Director of Nursing (DON) stated that there is no documentation for Physician responses from pharmacy reviews on 03/28/22, 5/25/22 or 06/27/22.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
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Based on resident interview, staff interview, and medical record review, the facility failed to obtain needed dental services when Resident #28 had missing dentures. This failed practice had the pot...
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Based on resident interview, staff interview, and medical record review, the facility failed to obtain needed dental services when Resident #28 had missing dentures. This failed practice had the potential to affect a limited number of residents. Resident identifier: #28. Facility census: 65.
Findings included:
a) Resident #28
On 07/05/22 at 12:25 PM an interview with spouse stated that he (Resident #28) had both lower and upper dentures when admitted to the facility. Further stated that staff think he threw them away. Resident #28 tells spouse he wants his dentures. Spouse stated that she had talked to staff about replacing the dentures but she had not heard back from staff and this had been over a month ago.
Licensed Practical Nurse (LPN) #68 on 07/06/22 at 10:45 AM confirmed R #28 had no dentures in place.
On 07/06/22 at 11:05 AM in an interview with LPN #68 stated that Resident #28 flushed both upper and lower dentures down the toilet.
The Director of Nursing (DON) entered the conference room on 07/06/22 at 2:43 PM and stated the dentures were lost and replaced once and now they are lost again. Another survey team member over heard a conversation between the DON and the Business Office Manager (BOM) #89 that no dentures were ever replaced.
In an interview with the BOM #89 on 07/06/22 at 4:29 PM stated that she was not sure the dentures were ever replaced. The BOM #89 further stated that she remembers he lost the bottom set and used the top denture. The BOM #89 stated he balls things up and places on meal tray. Although the BOM #89 stated she contacted the insurance company to see if they would pay for replacing the dentures, and notified the wife that the would maybe pay 50/50, the BOM #89 could not produced any evidence of dates or times of the telephone calls or a response from the wife but that occurred about 6-7 months ago.
On 07/11/22 at 2:57 PM in an interview was held with the Regional Administrator regarding the missing dentures. He stated that he was aware that there was a three (3) day time frame for the a resolution to residents who have lost or missing dentures according to the Center for Medicare and Medicaid Services (CMS). He stated the Nursing Home Administrator (NHA) had a written report regarding the missing dentures and would provide a copy of the report.
A review of the form titled Complaint Resolution on 07//12/22 at 9:17 AM found the spouse had filled the report with the Licensed Social Worker (LSW) on 02/08/22. The problem/concern stated After room move from quarantine, (resident's name) bottom dentures were not found in his room. Action taken: Staff have been informed of the missing bottom dentures & currently looking for them in all departments. The LSW dated the form 2/10/22.
Additional comments under Action Taken included Unable to get replacement paid for by Medicaid. Resident has history of wrapping his dentures in paper towels. No signature of the author of these notes or date or time of this information was noted.
Was problem resolved? was marked No.
Follow-up: Po (oral) intake steady at 50-70% Eats better at lunch & dinner than breakfast. No signature of author of the note and/or date/time of entry.
The complaint resolution form was signed by the NHA and former DON on 02/17/22.
The LSW was interviewed on 07/12/22 at 9:56 AM. The LSW confirmed she completed the Complaint Resolution form. When asked about the complaint date of 02/08/22 and then dated by LSW on 02/10/22 the LSW stated she just dates when the form she did the report. She stated that there was a three (3) day resolution timeframe for lost or broken dentures and stated will get right on it.
No further evidence was provided by the faclity upon exit on 07/13/22.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
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 provide a resident with a peanut allergy an alternative nourishing snack when other residents were receiving p...
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Based on resident interview, record review, and staff interview, the facility failed to provide a resident with a peanut allergy an alternative nourishing snack when other residents were receiving peanut butter cookies for the bedtime snack. This practice had the potential to affect a limited number of residents. Resident identifier #33. Facility census: 65.
Findings included:
a) Resident #33
During a resident council meeting, on 07/06/22 at 1:40 PM, Resident #33 stated there are times when the only evening / bedtime snack offered is peanut butter cookies. Resident #33 reported she is allergic to peanuts and cannot eat the cookies. The resident went on to report the staff have replied they do not have an alternative to offer resident and she has gone without an evening / bedtime snack at those times.
A brief medical record review, completed on 07/06/22 at 1:35 PM, revealed a nutrition evaluation noting resident was allergic to peanuts and peanut butter. The nutritional evaluation was dated 11/20/21.
During an interview on 07/07/22 at 10:00 AM, the Administrator acknowledged the need to provide a healthy alternative snack for Resident #33 in the event the evening snack was going to be peanut butter based.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0810
(Tag F0810)
Could have caused harm · This affected 1 resident
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Based on observation and interview, the facility failed to provide appropriate assistive devices to residents who need them to maintain or improve their ability to eat independently. This failed pra...
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Based on observation and interview, the facility failed to provide appropriate assistive devices to residents who need them to maintain or improve their ability to eat independently. This failed practice had the potential to affect a limited number of residents. Resident #46. Facility census: 55.
Findings included:
a) Resident #46
An observation on 07/05/22 of the noon meal, found Resident #46 had issues holding the silverware to eat.
A record review on 07/06/22 at 9:12 AM revealed a physician order:
--Large-handled utensils with all meals, assistive device. Order date on 04/24/22.
A second observation on 07/06/22 at the noon meal, found Resident #46 had issues holding the silverware to eat, even dropping the spoon.
During an interview on 07/06/22 at 12:29 PM, Resident #46 stated that he was having a little problem with eating because his hands were cold, and he could not grip the utensils.
An interview on 07/06/22 at 12:35 PM with Licensed Practical Nurse (LPN) #6 verified Resident #64 had a physician's order for assistive devices for meals. LPN #6 confirmed Resident #46 did not have large-handled utensils to use as ordered by the physician.
During an interview on 07/06/22 12:51 PM the Director of Nursing (DON) stated that the kitchen did not receive the assistive device physician order on 04/24/22 for Resident #46. The DON stated that the issue will be corrected.
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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 interview, the facility failed to keep soiled cloths in sanitized bucket and failed to label and date food upon opening or use. This failed practice had the potential to aff...
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Based on observation and interview, the facility failed to keep soiled cloths in sanitized bucket and failed to label and date food upon opening or use. This failed practice had the potential to affect a limited number of residents who receive nutrients from the kitchen. Facility Census 65
Findings included:
a) Soiled cloths
On 07/05/22 at 11:45 AM, on the initial tour with the Dietary Manager revealed two (2) soiled cloths laying on the counter and on the tray line belt and not in a sanitized bucket.
During the initial tour the Dietary Manager agreed soiled cloths should not be laying around and should be in sanitized bucket. The Dietary Manager immediately removed the soiled cloths.
b) Unlabeled and dated food item
During the same initial tour, revealed two (2) undated or labeled bowls of coleslaw in the reach in refrigerator.
The Dietary Manager verified the bowls of coleslaw should not be in reach in refrigerator without being label and dated as to when they were first opened or used. The Dietary Manager immediately removed the bowls of coleslaw.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0888
(Tag F0888)
Could have caused harm · This affected 1 resident
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Based on facility documentation and interview, the facility failed to ensure current staff were fully COVID-19 vaccinated. This was true for one (1) of eight (8) staff members reviewed for complianc...
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Based on facility documentation and interview, the facility failed to ensure current staff were fully COVID-19 vaccinated. This was true for one (1) of eight (8) staff members reviewed for compliance with COVID-19 vaccinations. Facility Census: 65.
Findings Included:
a) Staff Covid-19 Vaccinations
A review of the facility's Infection Control practices found the facility was unable to provide the required evidence of staff Covid-19 completed vaccination in a two-dose series for Nurse Aide (NA) #9.
Continued review of facility documentation found NA #9's first vaccine was administered on 05/27/22. There was no evidence the second dose was administered.
During an interview on 07/12/22 at 11:36 AM, the Assistant Director of Nursing (ADON) stated that NA #9 was only partial vaccinated. The ADON stated they missed the second dose of the two-dose series. The ADON verified NA #9 was still working in the facility and should have had the second vaccine within 30 days after the first dose.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
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e) Resident #44
On 07/05/22 2 at 2:34 PM, review of medical record found no Physician Orders for Scope of Treatment (POST) form.
On 07/5/22 at 2:50 PM, requested a copy of resident #44 POST form fr...
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e) Resident #44
On 07/05/22 2 at 2:34 PM, review of medical record found no Physician Orders for Scope of Treatment (POST) form.
On 07/5/22 at 2:50 PM, requested a copy of resident #44 POST form from Director of Nursing (DON). DON stated, no code status order is on chart nor is there a POST form completed. DON went on to say maybe Social Service Director (SSD) had Resident #44 completed POST form.
On 07/12/22 at 12:25 PM, interview with SSD revealed a POST form was given to Resident #44 to complete on 06/09/22 and they have not received it back.
Resident was admitted to facility on 01/13/22.
Based on record review and staff interview, the facility failed to ensure two (2) of 22 residents reviewed during the long-term care survey process had a Physician Orders for Scope of Treatment (POST) form completed correctly. Additionally, the facility failed to ensure three (3) of 22 residents or their legal representative were informed of his or her right to develop an advance directive. Resident identifiers: #1, #25, #30, #37, and #44. Facility census: 65.
Findings included:
a) Resident #1
A medical record review, completed on 07/06/22 at 3:33 PM, found the following:
--Health Care Surrogate paperwork indicated a Department of Health and Human Resources (DHHR) employee was Resident #1's legal decision-maker.
--POST form, dated 06/27/22, 2016 edition.
The POST form was not signed or dated by the physician. The Using the POST Guidance for Healthcare Professionals, 2016 Edition, stated a physician's signature is mandatory. A form lacking a physician's signature is not valid.
During an interview on 07/07/22 at 10:51 AM, the Administrator acknowledged the POST form was lacking the physician's signature and not valid.
b) Resident #25
A medical record review completed on 07/06/22 at 3:37 PM, found the following:
- Medical Power of Attorney (MPOA) paperwork indicating Resident #25's family member was her legal decision-maker.
-POST form, dated by the physician on 07/30/20, 2020 edition.
Section E of the POST form left the name, address, and telephone number of the MPOA blank. The Using the POST Guidance for Healthcare Professionals, 2020 Edition states that for situations when the person loses or has lost decision-making capacity, the name, address, and phone number of the person legally authorized to make healthcare decisions for the incapacitated person are to be listed on the lines marked Name/Address/Phone.
During an interview on 07/07/22 at 10:53 AM, the Administrator acknowledged the Section E had been left blank and the POST form was incomplete.
c) Resident #30
A medical record review, completed on 07/05/22 at 1:40 PM, found no code status (the type of emergency treatment a person would or would not receive if their heart or breathing were to stop) in physician orders. Additionally, there was no POST form on file. Review of Social Service notes in Resident #30's electronic medical record did reveal a discussion had ever been had about Resident #30's right to formulate advance directives.
On 07/06/22 at 12:24 PM, the Director of Nursing (DON) confirmed there was no physician order for code status or a POST form on file for Resident #30. Additionally, the DON could not produce (in the Social Worker's absence) any evidence that Resident #30 or their legal representative had been educated regarding the right to develop an advance directive.
d) Resident #37
A medical record review completed on 07/05/22 at 1:47 PM, found no code status (the type of emergency treatment a person would or would not receive if their heart or breathing were to stop) in physician orders. Additionally, there was no POST form on file. Review of Social Service notes in Resident #37's electronic medical record did not reveal a discussion had ever been had about Resident #37's right to formulate advance directives.
On 07/06/22 at 12:30 PM, the Director of Nursing (DON) confirmed that there was no physician order for code status or a POST form on file for Resident #37. Additionally, the DON could not produce (in the Social Worker's absence) any evidence that Resident #37 or their legal representative had been educated regarding the right to develop an advance directive.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
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Based on record review and interview, the facility failed to ensure a resident fall resulting in serious bodily injury and two (2) resident-to-resident physical altercations were reported in a timel...
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Based on record review and interview, the facility failed to ensure a resident fall resulting in serious bodily injury and two (2) resident-to-resident physical altercations were reported in a timely manner to the appropriate state agencies. Resident identifiers: #266 and #1. Facility census: 65.
Findings included:
a) The Federal regulation 483.12(c)(1) directs incidents involving serious bodily injury must be reported to the state survey agency within two (2) hours after the injury is noted.
b) The Office of Health Facility Licensure and Certification (OHFLAC) Long-Term Care Reporting Requirements guidance, dated December 4, 2019, instructs that OHFLAC and Adult Protective Services (APS) should receive the serious bodily injury report within two (2) hours.
c) Resident #266 fall resulting in serious bodily injury
A review of facility reportables revealed Resident #266 experienced a fall on 12/23/21 at 6:00 AM and was sent to the hospital for evaluation. A subsequent nursing note, on 12/23/21 at 10:50 PM, revealed resident's x-ray showed a displaced intertrochanteric fracture of proximal right femur [hip fracture] and that the orthopedics department had been consulted for surgery.
The incident was reported on 12/24/21 at 7:58 PM as an unusual occurrence. A copy of the unusual occurrence report was faxed to OHFLAC and the long-term care Ombudsman. Adult Protective Services (APS) did NOT receive a faxed report.
The Administrator, during an interview on 07/06/22 at 11:00 AM, acknowledged the facility failed to report within the two-hour time frame required for a serious bodily injury occurrence and that a copy of the report had never been sent to APS as required.
b) Resident #1 Resident-to-Resident Physical Altercation on 04/16/22 at 8:00 AM
An electronic medical record review was completed on 07/11/22 at 11:00 AM. A general nurses' note, on 04/16/22 at 8:00 AM, revealed, Resident yelling and agitated. Shoved [another female resident] 's wheelchair. [The other female resident] was heading for breakfast cart, but nurse ran over and stopped the wheelchair.
A subsequent review of the facility's reportable log revealed the incident was not reported to designated state agencies.
During an interview, on 07/11/22 at 3:45 PM, the DON reported the facility did not have an incident report for the resident-to-resident altercation.
On 07/12/22 at 9:30 AM, the Social Worker stated the incident should have been reported to the appropriate state agencies. The Social Worker reported it would have been the nursing department's responsibility to complete an incident report outlining the details of the resident-to -resident altercation. The Social Worker also reported it would have been her responsibility to report it. The Social Worker stated she was never aware of the incident.
c) Resident #1 Resident-to-Resident Physical Altercation on 04/16/22 at 11:15 AM
An electronic medical record review was completed on 07/11/22 at 11:05 AM. A general nurses' note, on 04/16/22 at 11:15 AM, revealed, Resident loud and arguing with another [male] resident. Resident grabbed [the male resident's] arm and shook vigorously. Resident attempted to slap [the male resident], but [nurse aide] stepped in between them.
A subsequent review of the facility's reportable log revealed the incident was not reported to designated state agencies.
During an interview, on 07/11/22 at 3:49 PM, the DON reported the facility did not have an incident report for the resident-to-resident altercation.
On 07/12/22 at 9:35 AM, the Social Worker stated the incident should have been reported to the appropriate state agencies. The Social Worker reported it would have been the nursing department's responsibility to complete an incident report outlining the details of the resident-to -resident altercation. The Social Worker also reported it would have been her responsibility to report it. The Social Worker stated she was never aware of the incident.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
d) Resident #37 alarms
On 07/12/22 at 9:47 AM, review of resident #37 electronic medical record found resident #37 has orders ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
d) Resident #37 alarms
On 07/12/22 at 9:47 AM, review of resident #37 electronic medical record found resident #37 has orders for alarm on bed and chair. In review of resident #37 care plan found there was not a care plan in place for the bed and chair alarms.
On 7/12/22 at 9 AM, interview with director of nursing (DON) in regards to resident #37 care plan for alarm for bed and chair, DON stated, there is not one initiated.
On 7/12/22 at 9:15 AM, Interview with nurse aide (NA) #60 if resident #37 had bed alarm placed on bed or alarm placed in wheelchair. Went in resident #37 room with NA #60 to observe bed alarm in place. NA #60 stated, resident #37 does not utilize wheelchair too often but there was an alarm on resident #37 wheelchair.
e) Resident #37 meals
On 7/6/22 at 11:45 AM review of resident #37 orders and care plans found resident #37 did not have
care plan in place for supervision for feeding/eating and rest periods during meals. During meals remain in an upright position for 30 minutes after meals and 90 degrees hip flexion.
Small bites/sips, moisten dry oral for three (3) days is what order reads.
Resident also has order for aspiration precautions which is not addressed in care plan either.
Based on medical record review and interview, the facility failed to develop person-centered comprehensive care plans. The facility failed to develop care plans for dialysis care, a skin condition, loss of dentures, meal supervision, safety alarms, and an indwelling urinary catheter. This practice affected five (5) of (22) resident's care plans reviewed during the Long-Term Care Survey Process (LTCSP). The failure to ensure the comprehensive care plan was developed for the resident's highest practicable well-being placed the residents at risk of not receiving services that would meet their desires or wants and a decreased quality of life. Resident Identifiers: #19, #6, #28, #37, and #18. Facility census: 55.
Findings included:
a) Resident #19
On 07/06/22 a review of Resident (R#19's) medical records revealed, a physician's order: Dialysis three (3) times a week with the order date 04/07/22.
A review of the current care plan with the initiated date of 05/03/22 showed there was no care plan addressing dialysis care in collaboration with the dialysis center, with interventions and goals. This showed it was not updated to reflect the resident's current status.
During an interview on 07/11/22 at 3:55 PM the Director of Nursing (DON) confirmed there was no dialysis care plan for Resident #19. She states that she will have to talk to the care plan nurse. The DON state that she was unaware they had to be that specific.
f) Resident #18
A review of Resident #18's medical record showed a physician order dated 06/01/22 that stated, Foley Cath 18 FR/Balloon Size 10 ML DX: Assist with wound healing. To be changed by Dr. [NAME] ONLY every month. The June 2022 medication administration recorded (MAR) showed that catheter care was being provided. The care plan did not show catheter care or the use of a catheter for Resident #18.
During an interview on 07/06/22 03:57 PM, Director of Nursing (DON) stated that catheter use and services should have been a focus on the care plan and was not.
b) Resident #6
A review of the care plan on 07/05/22 at 4:02 PM found an intervention dated 04/13/22 for weekly skin audits. No weekly skin assessments were found for 05/13/22, 05/16/22,05/23/22, 05/30/22, 06/06/22 and 06/20/22.
In an interview with the Director of Nursing (DON) on 07/07/22 at 10:17 AM she verified weekly skin assessments were not completed in accordance with the care plan intervention.
c) Resident #28
A complaint was filed on 02/08/22 by Resident #28's responsible party regarding missing lower dentures. At an unknown time by the facility, the lower dentures were missing.
A review of Resident #28's care plan found no focus, goal and/or interventions to deal with the missing dentures.
In an interview with the Director of Nursing (DON), on 07/12/22 at 10:38 AM, stated that the care plan should have been developed regarding the missing dentures. In addition she stated that we need to work on our care plans.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
b) Resident #1
An electronic medical record review, completed on 07/06/22 at 1:33 PM, revealed the following documented behavi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
b) Resident #1
An electronic medical record review, completed on 07/06/22 at 1:33 PM, revealed the following documented behaviors:
04/09/22 22:10 General Nurses' Note
making rude comments to residents and staff. Calling people fat, and ugly, and stupid and talking very loudly to other residents when they were trying to speak to her or others. Resident noted to be agitated, pacing back and forth, and talking very loudly while pointing her finger at staff / residents.
04/16/22 08:00 General Nurses' Note
Resident yelling and agitated. Shoved [another female resident's] wheelchair. Wheelchair was heading for breakfast cart, but nurse ran over and stopped the wheelchair.
04/16/22 11:15 General Nurses' Note
Resident loud and arguing with [a male] resident. Resident grabbed [the male resident's] arm and shook vigorously. Resident attempted to slap [the male resident] but nurse aide stepped in between them.
04/16/22 15:50 General Nurses' Note
Resident cussing and yelling at other residents in dining room. Accused [another Resident] of stealing her shirt.
04/16/22 16:10 General Nurses' Note
Resident asks to be taken outside so she can cool off. Activities accompanied her outside.
04/16/22 16:20 General Nurses' Note
Resident returned from outside. Behaviors were noted upon return to the unit. Resident aggressive to other residents and staff.
04/26/22 12:46 General Nurses' Note
Resident is being loud and aggressive towards staff and other residents. Unable to redirect.
07/02/22 21:00 General Nurses' Note
Delusional, pacing on unit, delusions of grandeur, fictional, broken pieced stories, irritable with staff and other residents, not easily redirected.
07/03/22 05:00 General Nurses' Note
Up pacing on unit, irritable with staff, care, and other residents, fictional delusions, not easily redirected.
07/03/22 16:00 General Nurses' Notes
Sitting in dining room at this time. Verbally aggressive and delusional. Flight of ideas noted. Difficult to redirect. Denies pain.
07/03/22 18:00 General Nurses' Notes
Resident sitting in chair in dining room. Pointing at people passing by stating, 'This has to stop.' Remains delusional. 'I'm tired of this job. I'm going to find another one. I'm a lawyer and can work anywhere.' Difficult to redirect.
07/03/22 23:00 General Nurses' Note
Resident walked into shower room on another resident, delusional and confrontational, and chose not to leave until redirected out to dining room by staff.
07/04/22 02:00 General Nurses' Note
Delusional loud disruptive noises, pacing on unit, confrontational with staff and other residents, not easily redirected, or distracted.
07/04/22 07:30 General Nurses' Note
Resident became verbally aggressive toward another resident in dining hall. Had one of the aides move another resident and attempted redirection with success. Will continue to monitor for behaviors.
07/04/22 17:42 General Nurses' Note
Resident in dining room. Easily agitated and verbally inappropriate toward other residents. Difficult to redirect.
07/04/22 18:21 General Nurses' Note
Resident still in dining room verbally abusive to other residents, difficult to redirect. Resident thinks everyone is talking about her. Will continue to monitor.
07/04/22 18:34 General Nurses' Note
Resident was arguing with another resident in dining hall. Both parties were using foul language and yelling at one another. Separated these 2 residents. This resident is still very agitated and is not easily redirected.
07/05/22 21:09 General Nurses' Note
Resident noted to be up on unit in dining room. Noted to be delusional and yelling out random verbalizations towards staff and other residents. Unable to redirect resident. Declines offer of snack / activity. Resident remains in dining room yelling out.
Review of Resident #1's care plan found it noted that resident had daily behaviors during the last review. It noted resident had frequently changing moods and periods of agitation. It also noted resident had yelled at staff and other residents and has made disruptive sounds and had disruptive behaviors daily. The following interventions were outlined: Maintain consistent routine, respond to requests timely, provide care and treatment per MD orders, consider psychiatric review, set realistic limits, be calm but firm, give resident space, re-approach, provide choices (return to room until feeling better), engage resident prior to direct care. Do not react. Remain calm. The care plan did not provide specific behavioral health interventions and services to assist Resident #1 in attaining or maintaining the highest practicable mental and psychosocial well-being. There was no mention of how staff should intervene in the event Resident #1 became physical with other residents and or staff members.
During an interview, on 07/12/22 at 9:32 AM, the Social Worker acknowledged Resident #1 consistently needs to be redirected when agitated, angry, and delusional. The Social Worker noted, Nothing is consistently successful as an intervention. That makes it difficult to care plan interventions. The Social Worker was unable to provide evidence the care plan had been evaluated for effectiveness and revised as needed. She then stated she would address the need to re-evaluate the care plan with members of the interdisciplinary team.
c) Resident #11
A review of Resident #11's medical record showed the care plan stated, The resident had an actual fall on 05/28/22 with major injury due to unsteady gait and refusal to accept assistance from staff. The resident's fractured hip will resolve without complication by review date.
A review of the facility's May 2022 reportables showed no evidence that Resident #11 had a fall with major injury on 05/28/22.
During an interview on 07/06/22 at 1:42 PM, the Minimal Data Set (MDS) Coordinator #38 stated that on 05/28/22 Resident # 11 did not have a fall with major injury and Resident # 11's hip was not fractured.
Further record review of Resident #11's medical record showed a hospital discharge summary from [NAME] Medical Center. The hospital summary showed Resident #11 was admitted on [DATE] and discharged on 06/03/22 with both an admitting and discharge diagnosis of an Urinary Tract Infection (UTI) and severe sepsis.
During an interview on 07/06/22 at 3:09 PM, Director of Nursing (DON) stated that the care plan was revised in error as Resident # 11 did not have a hip fracture.
Based on observation, record review and staff interviews, the facility failed to revise care plans for a resident with weight loss, a resident with a fall and effectiveness of staff interventions with a resident with behaviors. This was true for three (3) of 22 sample residents reviewed for care plans. Resident identifiers: #28, #11, #1. Facility census: 65.
Findings included:
a) Resident #28
Resident #28 was observed at 07/06/22 at 7:31 AM during breakfast. The Resident's tray had been set up and was feeding himself. Nurses Aide (NA) #60 stated that his wife brings him in things to eat.
A review of the care plan on 07/07/22 at 9:48 AM found the following:
Focus
.Refuses to be fed by staff, refuses supplements at times and refuses other foods offered. Initiated 05/17/22.
Goal
Will be clean, dry and free from odors and will participate in AM care as evidenced by wash face, hands and upper body every AM after supplies are set up and placed within reach by next review. Revised on 07/02/22.
Interventions
.Explain the importance of adequate nutrition/hydration and encourage to comply. Initiated 05/17/22.
There were no goal(s) for weight loss and or interventions to assist the Resident to gain and/or maintain weight. Resident #28 had experienced a 14.6 pound weight loss in six (6) months.
In an interview with the Director of Nursing (DON) on 07/07/22 at 10:17 AM she verified the care plan did not have interventions to address weight loss.
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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
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Based on record review, observation and interview, the facility failed to have accurate or follow orders for residents with wander guard, special diet orders, contact precautions, oxygen saturation ...
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Based on record review, observation and interview, the facility failed to have accurate or follow orders for residents with wander guard, special diet orders, contact precautions, oxygen saturation monitoring and weekly weights. These failed practices had the potential to affect more than a limited number of residents reviewed in survey sample. Resident identifiers #54, #50, #37, #48, #25,#51, #15, #31, #18 #26. Facility Census 65
Findings included;
a) Resident #15
On 07/11/22 at 2:56 PM, review of Resident #15's electronic medical record found an order for weekly weights starting 02/23/22 . Review of weights documented by the facility since weekly weights ordered on 02/23/22 revealed:
--02/23/22 - 265.6 punds (lbs)
--03/04/22 - 268.6 lbs
--03/21/22 - 284 lbs
--03/24/22 - 277.4 lbs
--03/25/22 - 273 lbs
--04/07/22 - 255.6 lbs
--04/13/22 - 254.4 lbs
--04/22/22 - 251.4 lbs
--04/28/22 - 252 lbs
--05/13/22 - 259.4 lbs
--06/20/22 - 247.6 lbs
On 7/11/22 at 1:45 PM, interview with Director of Nursing (DON) regarding weekly weights missing. DON stated, Resident #15 does have weekly weights missing. Weights were consistent for a while and then some were missed.
b) Resident #51
On 07/11/22 at 12:58 PM, review of resident electronic medical record found Resident #51 had an order for weekly weights starting 06/23/22. Review of weights documented by the facility since weekly weights ordered on 06/23/22 revealed:
--07/08/22 - 106.4 lbs
On 7/11/22 at 12:10 PM, interview with DON regarding accurate weekly weights. DON stated, I agree there were weekly weights missing.
c) Resident #31
On 7/5/22 at 3:14 PM, review of Resident #31's electronic medical record found a physician order dated 06/23/22 for weekly weights. Review of weights documented by the facility since weekly weights ordered on 06/23/22 revealed:
--07/07/22 - 175.1 lbs
On 7/11/22 at 2:50 PM, interview with Director of Nursing (DON) regarding missing weekly weights for resident #31. DON stated, there are missing weekly weights.
i) Resident #50
An electronic medical record review, completed on 07/06/22 at 9:05 AM, revealed Resident #50 had two (2) physician transfer orders that were conflicting:
-Physician order, dated 02/15/22, directed, Assist of two with all transfers - pivot FWB (full weight bearing).
-Physician order, dated 06/08/22, directed, Slide board for transfers.
During an interview, on 07/06/22 at 12:35 PM, the Assistant Director of Nursing (ADON) reported the assist of two with all transfers - pivot full weight bearing order should have been discontinued when the new order was given for staff to utilize the slide board for resident safety.
j) Resident #48
During an interview on 07/05/22 at 12:40 PM, Resident #48 reported, This is tight [pointing to the wander guard bracelet, a bracelet to help prevent elopement from the facility]. They said the Medical Director. Can you help? Observation showed the wander guard bracelet was indeed too tight on the resident's right wrist. It was snug against his skin and there was no room to insert a finger between bracelet and skin.
During an interview on 07/05/22 at 12:48 PM, the Director of Nursing (DON) confirmed the wander guard bracelet was too tight and went to get help in removing it. When asked, Resident #48 stated the bracelet had been on a while and guessed it might have been about two weeks since it had been placed on him. When the bracelet was removed, the outside of resident's right wrist was red and irritated.
A brief record review revealed physician orders dated 02/17/22 directing, Wander guard bracelet, every evening shift check for function, and Wander guard bracelet, every shift check for placement.
The DON confirmed, on 07/06/22 at 1:35 PM, Resident #48's wrist remained red and irritated. The DON was unable to produce evidence of when the wander guard bracelet had been placed on Resident #48's wrist and stated that nursing staff should have identified the fact the bracelet was too tight against the resident's wrist.
k) Resident #25
A brief medical record review, completed on 07/11/22 at 3:00 PM, found the following physician order: Oxygen saturation (O2 sats) every shift, if 90% apply 02 at 2 LPM via nasal canula. Further record review revealed the following dates and times the nursing staff failed to obtain O2 sats for Resident #48:
--06/20/22 No O2 sats taken on midnight or afternoon shifts
--06/23/22 No O2 sats taken on morning or afternoon shifts
--06/24/22 No O2 sats taken on morning shift
--06/25/22 No O2 sats taken on morning or afternoon shifts
--06/26/22 No O2 sats taken on afternoon shift
--06/27/22 No O2 sats taken on morning or afternoon shifts
--06/28/22 No O2 sats taken on morning or afternoon shifts
--06/29/22 No O2 sats taken on afternoon shift
--06/30/22 No O2 sats taken on morning or afternoon shifts
--07/01/22 No O2 sats taken on morning or afternoon shifts
--07/02/22 No O2 sats taken on morning or afternoon shifts
--07/03/22 No O2 sats taken on afternoon shift
--07/04/22 No O2 sats taken on morning or afternoon shifts
During an interview, on 07/11/22 at 3:35 PM, LPN #68 stated 02 sats should be charted under the vitals section in the resident's chart and it appeared the physician order for O2 sats on every shift had not been consistently followed.
f) Resident #54
An observation on 07/05/22 at 12:54 PM found an elopement wander guard in place to Resident #54's left wrist. She was unable to maneuver her wheelchair independently.
A record Review on 07/06/22 at 9:55 AM showed, it did not contain a physician order for a wander guard. Further review revealed there were no active wandering or elopement care plans.
On 07/06/22 at 12:20 PM a second observation of Resident #54 up in dining room with a wander guard in place on left wrist.
An interview on 07/06/22 12:25 PM with Licensed Practical Nurse (LPN) #6 verified, Resident #54 has a wander guard in place, with a no order.
g) Resident #54
A record review on 07/12/22 at 8:45 AM found, two (2) conflicting orders for diet:
--No concentrated sweets diet, regular texture, regular consistency diet. Order date 06/03/22.
--No concentrated sweets diet, pureed texture, thin liquids consistency. Order date 07/08/22.
An interview 07/12/22 at 8:48 AM the Director of Nursing (DON) verified Resident #54 had two (2) different diet orders on her active chart. The DON stated that they should have discontinued the regular texture diet out of the active orders.
h) Resident #37
An observation on 07/11/22 at 12:45 PM found Resident #37 in contact isolation precautions. A contact isolation sign on her door with an isolation cart in place at the door.
On 07/12/22 at 9:44 AM a record review for Resident #37 revealed that it did not contain a physician order for isolation precautions.
An interview with the Director of Nursing (DON) verified there was not an active Physician order for Isolation precautions.
d) Resident #18
A review of Resident #18's medical record showed a physician order dated 06/23/22 stated, weekly weights due to weight loss and wounds. Review of weekly weights showed resident was last weighed 06/20/22.
During an interview on 07/06/22 at 2:00 PM, Director of Nursing (DON) stated the weekly weights were not completed.
e) Resident #26
A review of Resident #26's medical record showed a physician order dated 06/23/22 stated, weekly weight due to change in weight. Review of weekly weights showed Resident #26 was last weighed 06/20/22.
During an interview on 07/06/22 at 2:00 PM, Director of Nursing (DON) stated the weekly weights were not completed.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
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Based on observation and staff interview, the facility failed to label and store all medications according to acceptable standards of practice. Three (3) of four (4) residents receiving insulin did ...
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Based on observation and staff interview, the facility failed to label and store all medications according to acceptable standards of practice. Three (3) of four (4) residents receiving insulin did not have the insulin dated as to when the insulin was opened. Medication refrigerators failed to have evidence of refrigerator temperatures being monitored daily. Resident identifiers: #35 #62, # 50 and #3. Facility census: 65.
Findings included:
a) Resident #35
On 07/06/22 at 7:41 AM observed with Licensed Practical Nurse (LPN) #68, Resident #35's Ozempic (non-insulin used to treat Type 2 Diabetes) pen with no date on the pen to verify the date when opened. LPN #68 confirmed the pen should be dated when opened.
b) Resident #62
On 07/06/22 at 7:41 AM observed with Licensed Practical Nurse (LPN) #68, Resident #62 Basaglar (insulin) pen with no date on the pen to verify the date the insulin was opened. LPN #68 confirmed the pen should be dated when opened.
c) Resident #50
On 07/06/22 at 7:41 AM observed with Licensed Practical Nurse (LPN) #68, Resident #50's Ozempic pen dated 04/04/22. According to manufacturers directions the Ozempic pen should be discarded 56 days after being opened whether stored at room temperature or in the refrigerator.
d) Resident #3
On 07/06/22 at 7:41 AM observed with Licensed Practical Nurse (LPN) #68, Resident #3's Victoza (an antidiabetic medication used to treat Type 2 Diabetes) pen with no date on the pen to verify the date opened. LPN #68 confirmed the pen should be dated when opened.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
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Based on record review and interview, the facility failed to have complete, accurate, and readily accessible medical record, including documentation related to legal representation, and advanced dir...
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Based on record review and interview, the facility failed to have complete, accurate, and readily accessible medical record, including documentation related to legal representation, and advanced directives (Physician Orders of Scope of Treatment or POST form) were not part of the resident's charts or readily accessible for all shifts. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers #17, #51, #15, #43, #50, #48, #30, #1, and #25. Facility Census 65.
Findings included:
a) Location of POST forms (advance directives) and Staff Interviews
During an interview on 07/05/22 at 1:45 PM, with Minimum Data Set Coordinator (MDS) regarding POST forms and where they are located. The MDS coordinator stated, they are kept in a binder in my office for all residents. When asked if that was the only location for resident POST forms in the facility, the MDS coordinator verified that was correct. During an interview with the Director of Nursing (DON) on 07/05/22 at 3:15 PM, she verified that nursing staff would have to access to the MDS Coordinator's office through the MDS Coordinator or by obtaining a key from the North Side Nurse Supervisors Key chain.
a) Resident #15
On 07/05/22 at 2:56 PM, review of resident's electronic medical record and found Resident #15 to have an order for full code, however, the Physician Orders of Scope of Treatment (POST) form was not in Resident #15's chart that is readily accessible to nursing staff while providing care and treatment.
During an interview with the Director of Nursing (DON) on 07/05/22 at 3:15 PM, she verified the chart did not contain a copy of the POST form.
b) Resident #17
On 07/06/22 at 11:43 AM, review of electronic medical record found resident to have a physician's order in place for full code, however, the Physician Orders of Scope of Treatment (POST) form was not in Resident #17's chart that is readily accessible to nursing staff while providing care and treatment.
On 7/6/22 at 12:45 PM during an interview with DON she verified the chart did not contain a copy of the POST form.
c) Resident #51
On 7/6/22 at 9 AM, review of electronic medical record found resident to have an order for Full Code, however, the Physician Orders of Scope of Treatment (POST) form was not in Resident #17's chart that is readily accessible to nursing staff while providing care and treatment.
On 7/6/22 at 12:45 PM during an interview with DON she verified the chart did not contain a copy of the POST form.
On 7/11/22 at 2:10 PM, interview with Licensed Practical Nurse (LPN) #86 asked if a resident was found unresponsive how would she find the residents code status. LPN #86 stated look at orders or under miscellaneous tab. If the information is not there then LPN #86 stated, I would call doctor or family. If no answer to either one I would immediately state a Full Code.
Asked LPN #86 if there was a key available to get into MDS Coordinators office to get book with POST forms. LPN #86 stated, I do not know anything about a key.
d) Resident #43
A medical record review, completed on 07/06/22 at 8:00 AM, revealed the WV Department of Health and Human Resources served as Resident #43's Health Care Surrogate (HCS).
During an interview, on 07/06/22 at 11:30 AM, the Director of Nursing (DON) stated the facility did not have a copy of resident's HCS paperwork available for review.
e) Resident #50
A medical record review, completed on 07/06/22 at 8:05 AM, revealed a family member served as Resident #50's HCS.
During an interview, on 07/06/22 at 11:30 AM, the DON stated the facility did not have a copy of resident's HCS paperwork available for review.
f) Resident #48
A medical record review, completed on 07/06/22 8:10 AM, revealed a family member served as Resident #48's HCS.
During an interview, on 07/06/22 at 11:30 AM, the DON stated the facility did not have a copy of resident's HCS paperwork available for review.
g) Resident #30
A medical record review, completed on 07/06/22 at 8:15 AM, revealed Resident #30 lacked capacity to make his own medical decisions, but no information was available about who the resident's legal decision maker was.
During an interview, on 07/12/22 at 9:06 AM, the Social Worker stated Resident #30's family member had been appointed as the HCS. The Social Worker was unable to provide any evidence the facility had a copy of the HCS paperwork.
h) Resident #1
A medical record review, completed on 07/06/22 at 8:30 AM, revealed the WV Department of Health and Human Resources served as Resident #1's Health Care Surrogate (HCS).
During an interview, on 07/06/22 at 11:45 AM, the DON stated the facility did not have a copy of resident's HCS paperwork available for review.
i) Resident #25
A medical record review, completed on 07/06/22 at 8:20 AM, revealed a family member served as Resident #25's Medical Power of Attorney (MPOA).
During an interview, on 07/06/22 at 11:30 AM, the DON stated the facility did not have a copy of resident's MPOA paperwork available for review.
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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
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most West Virginia facilities.
Concerns
- • 78 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade F (35/100). Below average facility with significant concerns.
- • 69% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Trust Score of 35/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Autumn Lake Healthcare At Crystal Springs's CMS Rating?
CMS assigns AUTUMN LAKE HEALTHCARE AT CRYSTAL SPRINGS an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within West Virginia, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Autumn Lake Healthcare At Crystal Springs Staffed?
CMS rates AUTUMN LAKE HEALTHCARE AT CRYSTAL SPRINGS's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 69%, which is 22 percentage points above the West Virginia average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 67%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Autumn Lake Healthcare At Crystal Springs?
State health inspectors documented 78 deficiencies at AUTUMN LAKE HEALTHCARE AT CRYSTAL SPRINGS during 2022 to 2025. These included: 78 with potential for harm. While no single deficiency reached the most serious levels, the total volume warrants attention from prospective families.
Who Owns and Operates Autumn Lake Healthcare At Crystal Springs?
AUTUMN LAKE HEALTHCARE AT CRYSTAL SPRINGS 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 AUTUMN LAKE HEALTHCARE, a chain that manages multiple nursing homes. With 84 certified beds and approximately 80 residents (about 95% occupancy), it is a smaller facility located in ELKINS, West Virginia.
How Does Autumn Lake Healthcare At Crystal Springs Compare to Other West Virginia Nursing Homes?
Compared to the 100 nursing homes in West Virginia, AUTUMN LAKE HEALTHCARE AT CRYSTAL SPRINGS's overall rating (1 stars) is below the state average of 2.7, staff turnover (69%) is significantly higher than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Autumn Lake Healthcare At Crystal Springs?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.
Is Autumn Lake Healthcare At Crystal Springs Safe?
Based on CMS inspection data, AUTUMN LAKE HEALTHCARE AT CRYSTAL SPRINGS has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in 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 Autumn Lake Healthcare At Crystal Springs Stick Around?
Staff turnover at AUTUMN LAKE HEALTHCARE AT CRYSTAL SPRINGS is high. At 69%, the facility is 22 percentage points above the West Virginia average of 46%. Registered Nurse turnover is particularly concerning at 67%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Autumn Lake Healthcare At Crystal Springs Ever Fined?
AUTUMN LAKE HEALTHCARE AT CRYSTAL SPRINGS has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Autumn Lake Healthcare At Crystal Springs on Any Federal Watch List?
AUTUMN LAKE HEALTHCARE AT CRYSTAL SPRINGS 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.