GLASGOW HILLS OF JOURNEY
For profit - Corporation
112 Beds
JOURNEY HEALTHCARE
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
0/100
#98 of 122 in WV
Photo by Glasgow Hills
Photo by Glasgow Hills
Photo by Glasgow Hills
1 / 5 photos
Last Inspection: June 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Glasgow Hills of Journey has received a Trust Grade of F, which indicates significant concerns about the facility's care and operations. Ranking #98 out of 122 nursing homes in West Virginia places it in the bottom half of the state, and it is #10 out of 11 in Kanawha County, meaning only one local facility is rated lower. Unfortunately, the situation is worsening, with the number of reported issues increasing from 13 in 2024 to 22 in 2025. Staffing is a relative strength, with a turnover rate of 0%, but the overall staffing rating is below average at 2 out of 5 stars. The facility has been fined $72,444, which is concerning and higher than 84% of other West Virginia facilities, indicating repeated compliance problems. Specific incidents reported include a failure to protect a resident from sexual abuse, which caused actual harm, and another case where a resident experienced uncontrolled pain, leading to an emergency room visit. Additionally, there was a critical finding related to improper medication storage, raising concerns about safety and care standards. Overall, while there are some strengths, such as staffing stability, the numerous serious issues highlight significant weaknesses that families should consider.
- Trust Score
- F
- In West Virginia
- #98/122
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- Turnover data not reported for this facility.
- Penalties ✓ Good
- $72,444 in fines. Lower than most West Virginia facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 42 minutes of Registered Nurse (RN) attention daily — more than average for West Virginia. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 91 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 20%
Review needed
13 → 22 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★☆
4.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 13 issues
2025: 22 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
1-Star Overall Rating
Below West Virginia average (2.7)
Significant quality concerns identified by CMS
Federal Fines: $72,444
Well above median ($33,413)
Moderate penalties - review what triggered them
Chain: JOURNEY HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 91 deficiencies on record
1 life-threatening 4 actual harm
Jun 2025
13 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, staff interview and record review the facility failed to ensure Resident #85 received the assistance he needed with eating to enable him to maintain his dignity. This was true fo...
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Based on observation, staff interview and record review the facility failed to ensure Resident #85 received the assistance he needed with eating to enable him to maintain his dignity. This was true for one (1) of five (5) residents reviewed for the care area of Activities of Daily Living (ADL) during the long-term care survey process. Resident Identifier: #85. Facility Census:101.
Findings Include:
a) Resident #85
An observation of the noontime meal on 06/24/25 found Resident #85 was feeding himself with his fingers. He was eating Turkey Tex Mex which contained rice and bake beans. The resident was dropping food on his clothes.
An additional observation of the noon time meal on 06/25/25 found the resident again feeding himself with his fingers. He ate a piece of pineapple upside down cake with his hands. He also had on his plate mashed potatoes, chopped broccoli and ground meatballs with gravy. He attempted to eat some mashed potatoes but had difficulty. An observation of his dining area found there were cake crumbs and bits of food scattered around the floor. He then left the dining room.
During the observations no staff member was observed telling the resident to use his utensils.
An interview with Nurse Aide (NA) #13 and NA #78 at 12:00 PM on 06/25/25 confirmed the resident always uses his hands to feed himself. They indicated the resident can use utensils, but he requires constant supervision and queuing to use the utensils. NA # 13, stated It has to be one on one. They both agreed that once he gets started using his utensils he does very well.
An interview with the speech therapist at 1:45 PM on 06/25/25 confirmed the resident does very well when you get him started with his utensils. She indicated once you show him the utensils and get him started, he will finish eating and will do very well.
A review of Resident #85's care plan found the following related to eating: Eating Assist: The res requires Set-Up, w/ eating. This was added to the care on 05/11/24 and was the active intervention at the time of this review.
This confirmed with the Director of Nursing (DON) on the afternoon of 06/25/25.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
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 provide evidence the required Notification of Medicare Non-Co...
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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 provide evidence the required Notification of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form were issued and signed in a timely fashion for one (1) of three (3) residents reviewed for beneficiary protection notification. This failure had the potential to place the resident's legal representative at risk of not being informed of the resident's rights prior to the end of Medicare Part A covered services. Resident identifier: #102. Facility census: 101.
Findings included:
a) Beneficiary Notice Review
A record review, completed on 06/25/25 at 12:26 PM, revealed:
-Resident #102 was admitted to the facility on [DATE]
-Resident #102's last covered day of Part A Service was on 05/30/25
-The NOMNC and SNF ABN forms were issued on 05/28/25 and signed by Resident #102
- The End of PPS (Prospective Payment System) Part A Minimum Dated Set, dated 05/30/25, reflected a Brief Interview for Mental Status (BIMS) score of 06. A BIMS score of 06 is indicative of severe cognitive impairment.
-A physician determination of capacity, dated 04/25/25, reflected resident did not have capacity.
-The emergency contact number for Resident #102 was listed as a Adult Protective Services (APS) Worker and resident's health care proxy.
During an interview on 06/25/25 at 1:06 PM, the facility's Social Worker reported she would defer to the legal representative to sign for any resident who was determined to not have capacity.
During an interview on 06/25/25 at 1:53 PM, the Administrator stated that the NOMNC form has been considered a financial document from the business office perspective. The Administrator noted it had been an oversight that the correct individual had not signed the form.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** FACILITY
Environment
Based on observation and staff interview the facility failed to ensure the resident environment was clean a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** FACILITY
Environment
Based on observation and staff interview the facility failed to ensure the resident environment was clean and homelike. This was a random opportunity for discovery and as true for the bathroom shared between room [ROOM NUMBER] and 311. Facility Census: 101.
Findings Include:
On 06/30/25 at 11:45 am a tour with the Dementia Unit Director found the toilet seat attached to the toilet shared between room [ROOM NUMBER] and 311 was in poor repair. It appeared to be dirty at first glance, but the director indicated that the plastic coating was off and why it was discolored she stated, I have told maintenance about it. Also, in the same bathroom the baseboard trim was missing along the wall toward room [ROOM NUMBER].
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, record review, and staff interview, the facility failed to ensure complete and accurat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, record review, and staff interview, the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for two (2) of 30 residents reviewed in the long-term care survey sample. Resident Identifiers: #59 and #88. Facility census: 101.
Findings included:
a) Resident #59
On 06/25/25 at 3:08 PM, Resident #59 was interviewed. She was noted to have a tracheostomy tube with a speaking valve. Resident #59 stated she had the tracheostomy placed at the hospital before she was admitted to the facility.
Review of Resident #59's medical records confirmed she had the tracheostomy tube when she was admitted to the facility.
Resident #59's Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 05/22/25 did not indicate the resident had a tracheostomy.
On 06/26/25 on 12:34 PM, the Director of Nursing confirmed Resident #59's MDS with ARD 05/22/25 was incorrect. She stated the MDS was modified to indicate the resident had a tracheostomy.
No further information was provided through the completion of the survey process.
b) Resident #88
A review of Resident #88's medical record found she was admitted to the facility on [DATE]. Further review of the record found a nursing admission assessment dated [DATE] which indicated Resident #88 had fallen prior to admission in the last 31- 180 days.
A review of the admission Minimum Data Set (MDS) dated found section J1700 B. Indicated the resident had not fall prior to admission in the las two (2) to six (6) months.
An interview with the Nursing Home Administrator (NHA) in the afternoon of 06/25/25 confirmed the MDS was inaccurate.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to complete a new Pre-admission Screening and Resident Review (PASARR) for a resident with a newly evident or a possible serious disorde...
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Based on record review and staff interview, the facility failed to complete a new Pre-admission Screening and Resident Review (PASARR) for a resident with a newly evident or a possible serious disorder. This was true for one (1) out of 30 sampled residents reviewed during the Long-Term Care Survey Process. Resident identifier: #35. Facility census: 101
Findings included:
a) Resident #35
A record review, completed on 06/24/25 at 6:18 PM, record review revealed:
-A physician order which read, Divalproex Sodium Oral Tablet Delayed Release 250 MG (Divalproex Sodium). Give one (1) tablet by mouth two times a day for seizures give with 500 mg tab to equal 750 mg two (2) times a day.
-Question #30 Current Diagnosis (Check all that apply) on the Pre-admission Screening and Record Review (PASARR), dated 10/16/24, did not indicate an issue with seizures.
During an interview on 06/25/25 at 10:45 AM, the facility Social Worker acknowledged a new PASARR had not been completed to capture the seizure disorder.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
.
Based on record review and staff interview, the facility failed to develop a comprehensive care plan that accurately reflected resident status and need for assistance. This deficient practice had th...
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.
Based on record review and staff interview, the facility failed to develop a comprehensive care plan that accurately reflected resident status and need for assistance. This deficient practice had the potential to affect two (2) of 30 residents reviewed in the long-term care survey sample. Resident Identifiers: #62 and #85. Facility census: 101.
Findings included:
a) Resident #62
Review of Resident #62's comprehensive care plan showed the following focus:
- [Resident's name] has impaired cognitive function/dementia or impaired thought processes r/t [related to] poor recall. Psychotropic drug. BIMS [Brief Interview for Mental Status] >12.
Date initiated: 05/13/23.
Revision on: 08/24/24.
The Brief Interview for Mental Status is a standardized assessment used to evaluate cognitive function. The BIMS is scored as follows:
13-15: Cognitively intact.
8-12: Moderate cognitive impairment.
0-7: Severe cognitive impairment.
Resident #62's admission Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 05/04/23 indicated the resident's BIMS score was 3. Resident #62's most recent quarterly MDS with ARD 05/15/25 also indicated the resident's BIMS score was 3.
On 06/26/25 at 11:00 AM, the Director of Nursing (DON) confirmed Resident #62's comprehensive care plan was incorrect and the resident had never had a BIMS score of 12 during his time at the facility. The DON provided documentation that when Resident #62's comprehensive care plan was initially developed on 05/15/23, the focus stated, [Resident's name] has impaired cognitive function/dementia of impaired thought process r/t BIMS less than 12. Psychotropic drug use. The DON stated when the resident's care plan was later revised, the resident's BIMS score was incorrectly documented.
No further information was provided through the completion of the survey process.
b) Resident #85
An observation of the noontime meal on 06/24/25 found Resident #85 was feeding himself with his fingers. He was eating Turkey Tex Mex which contained rice, and bake beans. The resident was dropping food on his clothes.
An additional observation of the noon time meal on 06/25/25 found the resident again feeding himself with his fingers. He ate a piece of pineapple upside down cake with his hands. He also had on his plate mashed potatoes , chopped broccoli and ground meatballs with gravy. He attempted to eat some mashed potatoes but had difficulty. An observation of his dining area found there was cake crumbs and bits of food scattered around the floor. He then left the dining room.
During the observations no staff member was observed telling the resident to use his utensils.
An interview with Nurse Aide (NA) #13 and NA #78 at 12:00 PM on 06/25/25 confirmed the resident always uses his hands to feed himself. They indicated the resident can use utensils but he requires constant supervision and queuing to use the utensils. NA # 13, stated It has to be one on one. The both agreed that once he gets started using his utensils he does very well.
An interview with the speech therapist at 1:45 PM on 06/25/25 confirmed the resident does very well when you get him started with his utensils. She indicated once you show him the utensils and get him started he will finish eating and will do very well.
A review of Resident #85's care plan found the following related to eating: Eating Assist: The res requires Set-Up, w/ eating. This was added to the care on 05/11/24 and was the active intervention at the time of this review.
This confirmed with the Director of Nursing (DON) on the afternoon of 06/25/25.
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 observation, resident interview, record review, and staff interview, the facility failed to revise the comprehensive care plan to reflect the resident's choices and when a resident's medicati...
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Based on observation, resident interview, record review, and staff interview, the facility failed to revise the comprehensive care plan to reflect the resident's choices and when a resident's medication dosages changed. This deficient practice had the potential to affect two (2) of 30 residents reviewed in the long-term care survey sample. Resident Identifier: #75 and Resident #101. Facility census: 101.
Findings included:
a) Resident #75
On 06/24/25 at 9:30 AM, Resident #75 was noted to have an indwelling urinary catheter. The urine collection bag was hanging from the resident's bed but did not have a privacy cover to prevent the urine in the bag being seen by others.
On 06/24/25 at 10:02 AM, the Director of Nursing (DON) stated Resident #75 refused to have a privacy bag placed on the urine collection bag for his catheter. She stated this was reflected in the resident's comprehensive care plan.
Review of Resident #75's comprehensive care plan showed the following focus, initiated on 05/16/23, [Resident's name] has a suprapubic Catheter d/t [due to] neurogenic bladder.
Interventions for the focus were as follows:
- [Resident's name] has a 18Fr [French] suprapubic catheter with a 10mL [milliliter] balloon. Position catheter bag and tubing below the level of the bladder and away from entrance room door.
Date Initiated: 05/16/2023
Revision on: 09/17/2024
- Change catheter bag as needed.
Date Initiated: 05/16/2023
Revision on: 09/17/24
- Change dressing to suprapubic cath [catheter] site Q [every] shift per order.
Date Initiated: 04/09/2024
Revision on: 09/17/2024
- Change suprapubic catheter when occluded or unable to flow freely as needed.
Date Initiated: 05/16/2023
Revision on: 09/17/2024
- Enhanced Barrier Precautions for suprapubic catheter.
Date Initiated: 09/19/2023
Revision on: 09/17/2024
- Flush catheter as ordered. See TAR [treatment administration record].
Date Initiated: 06/22/2024
Revision on: 09/17/2024
- Monitor and document intake and output as per facility policy Promote good fluid intake.
Date Initiated: 05/16/2023
Revision on: 09/17/2024
- Monitor for s/sx [signs and symptoms] of discomfort on urination and frequency.
Date Initiated: 05/16/2023
Revision on: 09/17/2024
- Monitor/document for pain/discomfort due to catheter.
Date Initiated: 05/16/2023
Revision on: 09/17/2024
- Monitor/record/report to MD for s/sx UTI [urinary tract infection]: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.
Date Initiated: 05/16/2023
Revision on: 09/17/2024
On 06/25/25 at 3:00 PM, Resident #75 confirmed he did not want a privacy bag on his urine collection bag.
On 06/26/25 at 12:45 PM, the Director of Nursing was asked to identify where Resident #75's comprehensive care plan documented the resident chose not to have a privacy bag for his urine collection bag.
On 06/26/25 at 1:07 PM, the Director of Nursing provided a copy of Resident #75's comprehensive care plan which had been revised as follows:
- Change catheter bag as needed. Resident refuses to allow catheter cover to be placed.
Date Initiated: 05/16/23
Revision on: 06/26/25
No further information was provided through the completion of the survey.
b) Resident #101
Review of Resident #101's physician's orders showed the following orders:
- Seroquel oral tablet 25 milligrams (mg) (Quetiapine Fumarate) two (2) times a day, ordered 04/25/25 and discontinued 05/15/25.
- Seroquel oral tablet 25 mg (Quetiapine Fumarate) one (1) time a day, ordered 05/16/25 and discontinued 05/22/25.
- Seroquel oral tablet 50 mg (Quetiapine Fumarate) one (1) time a day, ordered 05/16/25 and discontinued 05/22/25.
- Seroquel oral tablet 25 mg (Quetiapine Fumarate) two (2) times a day, ordered 5/22/25. This was the resident's current order.
- Hydroxyzine (Vistaril), 75 mg by mouth every eight (8) hours as needed, ordered 04/30/25 for 14 days, renewed 05/15/25, and discontinued 05/21/25.
- Hydroxyzine (Vistaril), 75 mg by mouth three times a day, ordered 05/21/25. This was the resident's current order.
Resident #101's comprehensive care plan contained the following foci:
- Altered Psychosocial needs r/t [related to] Dementia. [Resident's name] is on Seroquel 50 mg q [every] hs [night] and 25 mg in the morning, hydroxyzine 75 mg q 8 hours prn [as needed].
Date Initiated: 03/26/2025
Revision on: 05/16/2025
- The resident uses anti-anxiety medications (Vistaril PRN) r/t Anxiety disorder.
Date Initiated: 04/19/2025
Revision on: 04/19/2025
On 06/30/25 at 12:46 PM, the Director of Nursing confirmed Resident #101's care plan was not revised when the Seroquel (Quetiapine Fumarate) dosage change was ordered and when the Hydroxyzine (Vistaril) was ordered to be administered around-the-clock instead of as needed.
No further information was provided through the completion of the survey.
CONCERN
(D)
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, staff interview and record review the facility failed to ensure Resident #85's care plan accurately reflected the level and type of assistance he needed for eating. This was tr...
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.
Based on observation, staff interview and record review the facility failed to ensure Resident #85's care plan accurately reflected the level and type of assistance he needed for eating. This was true for one (1) of five (5) residents reviewed for the care area of Activities of Daily Living (ADL) during the long term care survey process. Resident Identifier: #85. Facility Census:101.
Findings Include:
a) Resident #85
An observation of the noontime meal on 06/24/25 found Resident #85 was feeding himself with his fingers. He was eating Turkey Tex Mex which contained rice, and bake beans. The resident was dropping food on his clothes.
An additional observation of the noon time meal on 06/25/25 found the resident again feeding himself with his fingers. He ate a piece of pineapple upside down cake with his hands. He also had on his plate mashed potatoes , chopped broccoli and ground meatballs with gravy. He attempted to eat some mashed potatoes but had difficulty. An observation of his dining area found there was cake crumbs and bits of food scattered around the floor. He then left the dining room.
During the observations no staff member was observed telling the resident to use his utensils.
An interview with Nurse Aide (NA) #13 and NA #78 at 12:00 PM on 06/25/25 confirmed the resident always uses his hands to feed himself. They indicated the resident can use utensils but he requires constant supervision and queuing to use the utensils. NA # 13, stated It has to be one on one. The both agreed that once he gets started using his utensils he does very well.
An interview with the speech therapist at 1:45 PM on 06/25/25 confirmed the resident does very well when you get him started with his utensils. She indicated once you show him the utensils and get him started he will finish eating and will do very well.
A review of Resident #85's care plan found the following related to eating: Eating Assist: The res requires Set-Up, w/ eating. This was added to the care on 05/11/24 and was the active intervention at the time of this review.
This confirmed with the Director of Nursing (DON) on the afternoon of 06/25/25.
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 staff interview, the facility failed to ensure the resident's oxygen flow rate was set according to the physician's orders. This deficient practice had the pot...
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Based on observation, record review, and staff interview, the facility failed to ensure the resident's oxygen flow rate was set according to the physician's orders. This deficient practice had the potential to affect one (1) of one (1) residents reviewed for the care area of oxygen. Resident Identifier: #62. Facility census: 101.
Findings included:
a) Resident #62
On 06/24/25 at 11:18 AM, Resident #62 was observed to be using supplement oxygen therapy via nasal cannula at four (4) liters per minute.
Review of Resident #62's physician's orders showed an order written on 12/30/24 for oxygen at two (2) liters via nasal cannula related to: COPD [chronic obstructive pulmonary disorder], respiratory disorder, as needed for short of breath.
On 06/25/25 at 11:04 AM, Resident #62 was again observed to be using supplement oxygen therapy via nasal cannula at four (4) liters per minute.
On 06/26/25 at 2:03 PM, Licensed Practical Nurse (LPN) #40 confirmed Resident #62's supplemental oxygen therapy was set to four (4) liters per minute. LPN #40 asked the resident if he had adjusted his oxygen rate, and the resident stated, no. LPN #40 set the resident's oxygen flow rate to two (2) liters per minute and stated he would check the resident's oxygen saturation level.
No further information was provided through the completion of the survey process.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmi...
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Based on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. The facility failed to follow Enhanced Barrier Precautions (EBP) for a resident with indwelling medical devices. This was a random opportunity for discovery. Resident Identifier: #59. Facility census: 101.
Findings included:
a) Resident #59
The facility's policy titled, Enhanced Barrier Precautions, with implementation date 03/20/25 and revision date 03/20/25, stated Enhanced Barrier Precautions (EBP) would be followed for residents with indwelling medical devices including tracheostomy/ventilator tubes and feeding tubes. The policy also stated personal protective equipment would be worn for high-contact resident care activities for residents in EBP. High-contact resident care activities included care of medical devices, including tracheostomy care and feeding tube care. The policy also stated that enhanced barrier precautions may be followed for residents colonized with a multidrug-resistant organism not targeted by the Center for Disease Control but may be considered epidemiologically important.
Review of Resident #59's physician's orders showed an order written on 03/18/25 for enhanced barrier precautions for history of Extended-Spectrum Beta-Lactamase (ESBL). The resident also had orders for tracheostomy care and percutaneous endoscopic gastrostomy (PEG) tube care.
Outside of Resident #59's room was a sign stating,
Stop. Enhanced Barrier Precautions. Everyone must: Clean their hands, including before entering and when leaving the room.
Providers and staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities.
Dressing
Bathing/showering
Transferring
Changing Linens
Providing Hygiene
Changing Briefs or assisting with toileting
Devise care or use: central line, urinary catheter, feeding tube, tracheostomy
Wound care: any skin opening requiring a dressing.
On 06/26/25 at 09:20 AM, Licensed Practical Nurse (LPN) #27 was observed providing indwelling medical device care to Resident #59. LPN #27 changed the inner cannula of the resident's tracheostomy. LPN #27 also changed the dressing on the resident's PEG tube and cleaned the PEG tube site.
LPN #27 wore gloves for the procedures, but did not wear a gown as was indicated by the facility's EBP policy and procedures.
On 06/26/25 at 10:10 AM, the Director of Nursing confirmed gowns were required to be worn by staff performing tracheostomy care and PEG tube care.
No further information was provided through the completion of the survey process.
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
Based on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. Physician orders were not followe...
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Based on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. Physician orders were not followed for two (2) of 30 residents reviewed in the long-term care survey sample. Resident identifiers: #101 and #33. Facility census: 101.
Findings included:
a) Resident #101
Review of Resident #101's physician's orders showed an order written on 06/01/25 for the antibiotic Cipro 500 milligrams (mg), by mouth, two (2) times a day for seven (7) days for a urinary tract infection. This would equal 14 doses of Cipro.
Resident #101's Medication Administration Record (MAR) showed a notation at bedtime on 06/01/25 that indicated a nursing note had been written regarding the medication. The nursing note stated the medication was not available yet and the physician was aware.
The MAR indicated Cipro was administered in the morning and at bedtime on 06/02/25 through 06/07/25. Cipro was administered only in the morning on 06/08/25. This equaled 13 doses of Cipro.
On 06/30/25 at 1:53 PM, the Director of Nursing confirmed there was no documentation the resident received 14 doses of Cipro as ordered by the physician.
b) Resident #33
Review of Resident #33's order showed the following orders:
- Acetaminophen (Tylenol) 325 milligrams (mg), give two (2) tablets by mouth every six (6) hours as needed for general discomfort, ordered 05/26/25.
- Hydrocodone-Acetaminophen 5-325 mg, give one (1) tablet by mouth every four (4) hours as needed for pain scale six (6) to 10, ordered 05/22/25.
A pain scale is a tool used to help individuals communicate the intensity of their pain. The scale ranges from 0 (no pain) to 10 (worst pain imaginable).
Resident #33's MAR showed the resident received acetaminophen on three (3) occasions since the medication was ordered. These occasions were as follows:
- 05/26/25 at 2:46 PM, for pain level of 3.
- 06/07/25 at 2:01 AM, for pain level of 4.
- o6/17/25 at 11:36 AM, for pain level of 4.
Resident #33's MAR showed the resident received Hydrocodone-Acetaminophen on 54 occasions since the medication was ordered. On ten occasions, the resident's pain was documented at a lower level than required for administration according to the physician's orders. These occasions were as follows:
- 05/23/25 at 11:15 AM, for pain level of 3.
- 05/27/25 at 1:00 PM, for pain level of 5.
- 05/28/25 at 2:05 PM, for pain level of 5.
- 05/31/25 at 8:44 AM, for pain level of 3.
- 05/31/25 at 12:50 PM, for pain level of 4.
- 05/31/25 at 10:55 PM, for pain level of 5.
- 06/01/25 at 11:05 AM, for pain level of 4.
- 06/04/24 at 7:50 AM, for pain level of 0.
- 06/13/54 at 8:50 AM, for pain level of 5.
- 06/21/25 at 2:50 PM, for pain level of 0.
On 06/30/25 at 10:32 AM, the Director of Nursing confirmed Resident #33's Hydrocodone-Acetaminophen was administered outside the pain scale parameters ordered by the physician.
No further information was provided through the completion of the survey.
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 and staff interview the facility failed to ensure food was stored and prepared in a safe and sanitary manne...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to ensure food was stored and prepared in a safe and sanitary manner. This failed practice has the potential to effect more than an isolated number of residents. Facility Census: 101.
Findings Include:
a) Initial tour of the Kitchen and Pantries
An initial tour of the kitchen upon entrance to the facility on [DATE] at 9:15 AM found the kitchen staff had a cyclone floor fan blowing toward the food preparation area. The fan as observed to be covered in dust and was not clean. The dietary manager (DM) stated, I am getting rid of this right now.
On the dementia unit in the refrigerator was two (2) bottles of ranch dressing which were open and not dated, a small carton of vitamin D milk which was open and not dated, and a small bag fiesta shredded cheese which was open and not dated.
06/24/25 09:15 am initial tour of the kitchen with the CDM there was a dirty fan sitting on the floor blowing toward the food prep area. The CDM said she was getting it out of here. She said it was just trying to manage the heat with the fan. The DM then stated all the items should have been dated.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure complete and accurate medical records. The medication ...
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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 complete and accurate medical records. The medication diagnosis was inaccurate for two (2) of 30 sampled residents reviewed in the Long-Term Care Survey Process. Additionally, a resident's psychiatric evaluation notes referred to her as a male. This was true for one (1) of 30 sampled residents reviewed in the Long-Term Care Survey Process. Resident identifiers: #40, #101, and #102. Facility census: 101.
Findings included:
a) Resident #40
A record review, completed on 06/26/25 at 11:15 AM, revealed a physician order for a 5 MG Apixaban tablet noting, Give 1 tablet by mouth two times a day for Pleural Effusion.
During an interview on 06/26/25 at 11:48 AM, the Director of Nursing (DON) stated the order was not accurate. The DON noted that the order should have captured PE as a pulmonary embolism.
b) Resident #101
Review of Resident #101's physician's orders showed an order written on 04/26/25 for Escitalopram Oxalate (Lexapro) 10 milligrams (mg) by mouth one (1) time a day for dementia.
Lexapro is an anti-depressant medication that is also used to treat anxiety disorders.
Resident #101 had diagnoses of dementia and anxiety disorder.
On 06/30/25 at 12:56 PM, the Director of Nursing (DON) confirmed dementia was not an appropriate diagnosis for Lexapro. The DON stated Resident #101 was receiving Lexapro due to anxiety.
No further information was provided through the completion of the survey.
c) Resident #102
A review of Resident #102's medical record on 06/25/25 found Resident #102 was seen by a psychiatrist on 05/20/25 and 06/11/25. A review of each evaluation note for 05/20/25 found the following,
History of Present Illness:
The patient is a [AGE] year-old female presenting with a hx of Dementia and Encephalopathy. The patient is currently residing at Glasgow Hills NF for long-term care.
The patient was originally admitted to the facility on [DATE]. Pt denies any significant past psychiatric history, IP/OP psychiatric services, or SA.
Medication changes at last visit: initial visit
The patient is not able to report when the presenting problem began. Current stressors: Alleviating factors:
The patient reports feeling fine and his mood is fine. Pt denies depression and anxiety. Pt denies hallucinations, delusions, and irritability. Pt denies confusion. Pt reports that his sleep is pretty good and his appetite is good. Pt denies SI/HI. BIMS score of 9. The psychiatrist referred to resident #102 as a male three times in the note.
A review of the note dated 06/11/25 found the following,
History of Present Illness:
The patient is a [AGE] year-old female presenting with a hx of Dementia and Encephalopathy. The patient is currently residing at Glasgow Hills NF for long-term care.
The patient was originally admitted to the facility on [DATE]. Pt denies any significant past psychiatric history, IP/OP psychiatric services, or SA.
Medication changes at last visit: Namenda and Buspar (Checked 06/11/2025)
The patient is not able to report when the presenting problem began. Current stressors: Alleviating factors:
The patient reports feeling pretty good, and his mood is pretty good. Pt denies depression and anxiety. Pt denies hallucinations, delusions, and irritability. Pt denies confusion. Pt reports that his sleep is pretty good and his appetite is good. Pt denies SI/HI. Again the psychiatrist refers to the female patient as a male.
An interview with the Director of Nursing (DON) on 06/25/25 at 11:30 am confirmed the psychiatry note on 05/202/25 and 06/11/25 referred to the female patient as a male. She stated, I will address that with the provider.
May 2025
9 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on Observation, staff and resident interview the facility failed to provide a homelike environment for resident # 78. Resident ' s privacy curtain had several stains. This was true for on (1) of...
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Based on Observation, staff and resident interview the facility failed to provide a homelike environment for resident # 78. Resident ' s privacy curtain had several stains. This was true for on (1) of five (5) residents reviewed for environment. Facility Census 107.
Findings included:
a) An observation on 05/21/25 at 10:30 AM, Resident #78 ' s privacy curtain had several large, red stains and a brown stain. Resident ' s roommate, resident #69 stated that the curtain had been stained for at least a couple of days.
b) During an interview with Nurse Aide (NA) #28 acknowledged that the curtain was stained and in need of cleaning. She reported that when they notice the stains they will notify housekeeping who will change and clean the curtains.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on record review, staff interview the facility failed to keep resident free from verbal abuse. This was true for one (1) of eleven (11) instances of alleged verbal abuse reviewed during this inv...
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Based on record review, staff interview the facility failed to keep resident free from verbal abuse. This was true for one (1) of eleven (11) instances of alleged verbal abuse reviewed during this investigation. Facility census 107.
Findings included:
a) A review of Facility Reported Incident dated 5/13/25 revealed that Resident # 54 reported that laundry staff #124 was argumentative with her and rude and in regard to her laundry. The allegation was verified and the laundry service was notified that the facility did not wish for him to work at this facility.
b) During an interview with with Director of Nursing on 05/20/25 at approximately 2:15 PM, it was acknowledged that the abuse did happen and that the staff member #124 was no longer employed at this facility and that all staff had since been re-educated by reviewing the facilities Freedom from Abuse and Neglect Policy, Identifying types of abuse and reporting.
c) During a review facility ' s policy titled Abuse, Neglect and Exploitation, page one Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on record review and staff interview the facility failed to report an alleged incident of abuse to the appropriate agency. This is true for one (1) of six (6) residents reviewed. Facility Census...
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Based on record review and staff interview the facility failed to report an alleged incident of abuse to the appropriate agency. This is true for one (1) of six (6) residents reviewed. Facility Census 107.
Findings included:
a) During a review of hospital discharge plan dated for 2/18/25 that had updated into resident's electronic medical record, resident #78 reported facility staff had waterboarded her for 36 hours and threw her on the floor. She also reported she was subjected to weekly hour-long cold showers and which staff score water in her face and in her ear.
b) Upon interview with Director of Nursing, Corporate Nurse, and Administrator, on 05/21/25 at approximately 12:44 AM, they acknowledged that it should have been reported and that it was not addressed after receiving the discharge information from the hospital.
c) Interview with resident on 05/20/25 at approximately 3:30 PM who reported that she told unidentified staff she could not stand to be here in this facility anymore, that she can't take it and reported that unidentified staff called her a bitch and stated why don't you just die. The resident reported that she does not remember the exact date but knows that it is during night shift.
d) Review of facility's policy titled Abuse, Neglect, and Exploitation, page four (4) VII. Reporting/Response Section A. number 1. Reporting of all alleged violations to the Administration, state agent, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specific timeframes; a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on record review and staff interview the facility failed to complete an investigation and five-day follow-up for an alleged incident. This is true for one (1) of six (6) instances of alleged ver...
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Based on record review and staff interview the facility failed to complete an investigation and five-day follow-up for an alleged incident. This is true for one (1) of six (6) instances of alleged verbal abuse that was investigated during this survey. Facility Census 107.
Findings included:
a) Rreview of incident report dated 03/26/24 for Resident #110 alleging that resident's daughter heard while on the phone with the alleged victim, a staff member being argumentative with the victim, revealed there was no investigation and no five day follow-up attached.
b) An interview with Director of Nursing (DON) on 05/19/25 at 1:44 PM who reported that the social worker is looking for five-day follow-up and investigation.
c) During an interview with Regional [NAME] President of Clinical Services on 5/20/25 at approximately 12:45 PM, who reported we do not have a five-day follow-up for this incident.
d) Review of the facility's Abuse, Neglect and Exploitation policy on page four (4), section V. Investigation of Alleged Abuse, Neglect and Exploitation stated the following: B. Written procedures for investigations include: 6. Providing complete and thorough documentation of the investigation.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to maintain professional standards of care for residents receiving dialysis. This was true for one (1) of four (4) residents reviewed un...
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Based on record review and staff interview, the facility failed to maintain professional standards of care for residents receiving dialysis. This was true for one (1) of four (4) residents reviewed under the care area of dialysis. Resident Identifier: #91. Facility Census: 107.
Findings Include:
a) Resident #91
On 05/19/25 at 11:00 AM, a record review was completed for Resident #91. The review did not find a physician's order to not take the blood pressure in the restricted limb. However, a physician's order dated 04/17/25 stated, dialysis: check thrill and bruit to fistula on left arm every shift. On the following dates the blood pressure was taken in the restricted limb:
--04/19/25 at 1:55 AM
--04/20/25 at 11:56 PM
--04/22/25 at 6:03 AM
--04/24/25 at 1:11 AM
--04/25/25 at 1:31 AM
--04/25/25 at 11:11 PM
--04/27/25 at 12:42 AM
--05/01/25 at 2:35 AM
--05/07/25 at 7:12 AM
--05/08/25 at 1:14 AM
--05/08/25 at 5:16 PM
--05/11/25 at 1:05 AM
--05/13/25 at 2:27 AM
--05/14/25 at 12:42 AM
--05/15/25 at 6:45 AM
--05/15/25 at 11:02 PM
--05/18/25 at 4:17 AM
On 05/22/24 at 10:00 AM, the DON was notified and confirmed there was no physician's order regarding the restricted limb.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to provide an accurate and complete record for Resident #109's skin assessment. This was true for one (1) of three (3) residents reviewe...
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Based on record review and staff interview, the facility failed to provide an accurate and complete record for Resident #109's skin assessment. This was true for one (1) of three (3) residents reviewed during the survey. Resident Identifier: #109. Facility Census: 107.
Findings Include:
a) Resident #109
On 05/20/25 at 2:00 PM, a record review was completed for Resident #109. The review of the physician's orders, care plan, weekly skin assessment and progress notes did not indicate the resident had any skin concerns. However, the facility provided a document entitled, Nursing Assistant Skin Inspection and Shower sheet dated 11/11/23 that indicated the resident did have a skin concern on the bilateral areas of the buttocks.
On 05/20/25 at 3:30 PM, an interview was held with the Director of Nursing (DON) and the Corporate Registered Nurse (RN) #125 regarding the documentation of the skin issue. The DON and the Corporate RN #125 reviewed the entire medical record regarding any skin issues. The only skin issue documented was a skin tear on the right hand. The DON and the Corporate RN stated, there is no documentation in the record to indicate the resident had any skin concerns other than the skin tear on the right hand .we feel this was documented in error on the wrong resident .all weekly skin observations prior to and after the date of 11/11/23 have no indication of any skin concerns .there was a physician's order dated 06/22/23, apply protective skin ointment with incontinent episodes.
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 F0605
(Tag F0605)
Could have caused harm · This affected multiple residents
Based on record review and staff interview, the facility failed to ensure Resident #108 was free of chemical restraints. This was true for one (1) of six (6) residents reviewed under the care area of ...
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Based on record review and staff interview, the facility failed to ensure Resident #108 was free of chemical restraints. This was true for one (1) of six (6) residents reviewed under the care area of abuse. Resident Identifier: #108. Facility Census: 107.
Findings Include:
a1) Resident #108
On 05/19/25 at 12:30 PM, a record review was completed for Resident #108. The review found the resident had a physician's order for Ativan 0.5mg (milligram) by mouth every 12 hours as needed (PRN) on 05/18/24. The physician's order did not have a time limit. The monthly pharmacy review was completed on 05/23/24 with the recommendation to either discontinue the PRN Ativan or reorder with a specific number of days. The review was signed by the physician on 06/12/24. However, the physician's order was not changed until 07/06/24. At the time of the change, the PRN Ativan was ordered for 60 days. The review, also, found unacceptable reasons for two (2) doses of a PRN psychotropic medication. The first dose of PRN Ativan given on 06/12/24 noted the reason as Res (resident) refuses to stay in bed repeatedly attempting to get up without assistance. When in w/c (wheel chair) Res. attempts to transfer and ambulate unassisted as well. The second dose of PRN Ativan given on 06/26/24 at 10:19 PM was noted as Res. continuously attempting to get up unassisted.
On 05/20/25 at 11:15 AM, the Director of Nursing (DON) was notified regarding the PRN Ativan. The DON stated, the monthly pharmacy recommendation was reviewed by the physician on 06/12/24. I'm not sure why the physician's order was not updated until 07/06/24.
The regulation regarding chemical restraints states, When a medication is indicated to treat a medical symptom, the facility must: use the least restrictive alternative for the least amount of time; provide ongoing re-evaluation of the need for the medication; and not use the medication for discipline or convenience.
a2) Behaviors and Non-Pharmacologic Interventions
On 05/19/24 at 12:30 PM, a record review was completed for Resident #108. The review found the resident was administered 29 doses of PRN Ativan from 05/29/24 through 07/06/24 without any type of behaviors or non-pharmacologic interventions listed. The documentation listed increased agitation (from the physician's order) as the only behavior. The dates of the administration are as follows:
--05/24/24 at 8:49 AM
--05/28/24 at 9:44 PM
--05/29/24 at 10:19 AM
--06/01/24 at 1:25 PM
--06/02/24 at 1:30 AM
--06/03/24 at 10:40 PM
--06/04/24 at 10:22 PM
--06/06/24 at at 1:47 PM
--06/07/24 at 3:12 AM
--06/07/24 at 9:27 PM
--06/10/24 at 7:31 PM
--06/11/24 at 8:13 PM
--06/15/24 at 7:33 PM
--06/20/24 at 9:50 AM
--06/21/24 at 12:19 PM
--06/22/24 at 12:00 AM
--06/22/24 at 12:26 PM
--06/23/24 at 10:24 AM
--06/24/24 at 1:49 PM
--06/25/24 at 6:19 PM
--06/26/24 at 6:45 AM
--06/28/24 at 9:30 PM
--07/01/24 at 8:57 AM
--07/01/24 at 9:00 PM
--07/02/24 at 1:30 PM
--07/03/24 at 2:11 AM
--07/04/24 at 2:00 AM
--07/05/24 at 10:09 AM
--07/06/24 at 12:06 PM
On 05/20/25 at 2:00 PM, the DON was notified regarding the PRN Ativan. The DON stated, it was wrong not to list the behaviors or the interventions .we have changed how we document .education was given to the nurses in January, 2025.
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 develop/implement the care plan for Resident #108 regarding non pharmacological interventions, restricted limb precautions for Reside...
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Based on record review and staff interview, the facility failed to develop/implement the care plan for Resident #108 regarding non pharmacological interventions, restricted limb precautions for Resident #109, #15 and #91. This was true for four (4) of 13 residents reviewed during the survey process. Resident Identifiers: #108, #109, #15, and #91. Census: 107.
Findings Include:
a) Resident #108
On 05/19/25 at 12:30 PM, a record review was completed for Resident #108. The review found the resident did have a physician's order for Ativan 0.5mg (milligram) by mouth every 12 hours as needed (PRN). The care plan was reviewed and an intervention under the focus area of altered psychosocial needs r/t (related to) behaviors of resisting care, physical aggression and agitation exacerbated after family visits of provide non pharmacological interventions such as redirect with activity, offer food/fluid, offer reassurance/conversation, 1:1 (one on one).
However, the review, also found the resident was administered 29 doses of PRN Ativan which did not include specific behaviors or non pharmacological interventions. The dates are as follows:
--05/24/24 at 8:49 AM
--05/28/24 at 9:44 PM
--05/29/24 at 10:19 AM
--06/01/24 at 1:25 PM
--06/02/24 at 1:30 AM
--06/03/24 at 10:40 PM
--06/04/24 at 10:22 PM
--06/06/24 at at 1:47 PM
--06/07/24 at 3:12 AM
--06/07/24 at 9:27 PM
--06/10/24 at 7:31 PM
--06/11/24 at 8:13 PM
--06/15/24 at 7:33 PM
--06/20/24 at 9:50 AM
--06/21/24 at 12:19 PM
--06/22/24 at 12:00 AM
--06/22/24 at 12:26 PM
--06/23/24 at 10:24 AM
--06/24/24 at 1:49 PM
--06/25/24 at 6:19 PM
--06/26/24 at 6:45 AM
--06/28/24 at 9:30 PM
--07/01/24 at 8:57 AM
--07/01/24 at 9:00 PM
--07/02/24 at 1:30 PM
--07/03/24 at 2:11 AM
--07/04/24 at 2:00 AM
--07/05/24 at 10:09 AM
--07/06/24 at 12:06 PM
On 05/20/25 at 2:00 PM, the Director of Nursing (DON) was notified regarding the PRN Ativan not having any specific behaviors or non pharmacological interventions listed. The DON stated, it was wrong not to list the behaviors or the interventions .we have changed how we document .education was given to the nurses in January 2025.
implement care plan regarding the invention of do not draw blood or take b/p in left arm d/t fistula.
b) Resident #109
On 05/19/24 at 9:30 AM, a record review was completed for Resident #109. The review found a physician's order dated 06/22/23 of do not take B/P (blood pressure on left arm and an additional physician's order dated 06/22/23 of location of dialysis fistula: left upper arm. Upon further review, the care plan was not implemented under the focus area of (Name of Resident) receives hemodialysis r/t ESRD (end stage renal disease). The intervention of do not draw blood or take B/P in left arm d/t fistula. The following dates indicate the blood pressure was taken in the left arm:
--06/22/23 at 3:03 PM
--06/23/23 at 3:44 AM
--06/23/23 at 8:38 PM
--06/24/23 at 10:42 PM
--06/26/23 at 12:30 AM
--06/26/23 at 2:59 PM
--06/27/23 at 3:25 PM
--06/30/23 at 12:51 AM
--07/01/23 at 3:48 AM
--07/02/23 at 1:29 PM
--07/05/23 at 1:38 AM
--07/05/23 at 2:07 PM
--07/06/23 at 3:13 AM
--07/06/23 at 11:55 AM
--07/10/23 at 11:02 PM
--07/14/23 at 10:03 PM
--07/18/23 at 11:25 PM
--07/19/23 at 3:30 PM
--07/20/23 at 1:15 AM
--07/21/23 at 4:07 AM
--07/23/23 at 11:04 PM
--07/31/23 at 9:56 AM
--08/06/23 at 2:57 AM
--08/06/23 at 11:33 PM
--08/10/23 at 11:31 PM
--08/11/23 at 10:55 PM
--08/23/23 at 1:21 PM
--09/17/23 at 10:02 AM
--10/23/23 at 1:54 PM
--10/25/23 at 12:17 AM
--10/26/23 at 9:55 AM
--10/27/23 at 4:18 PM
--10/27/23 at 7:38 PM
--10/29/23 at 9:49 AM
--11/03/23 3:18 AM
--11/04/23 at 12:55 AM
--11/05/23 at 8:54 AM
--11/08/23 at 12:09 AM
--11/09/23 at 2:55 AM
--11/10/23 at 12:29 PM
--11/27/23 at 10:54 AM
On 05/22/24 at 10:00 AM, the DON was notified and confirmed the care plan was not implemented regarding the restricted limb.
c) Resident #15
On 05/19/25 at 10:30 AM, a record review was completed for Resident #15. The review found a physician's order dated 12/31/24 Do not take B/P on right arm every shift. The care plan under the focus area of the resident has renal insufficiency r/t d/x (diagnosis) of end stage renal disease and receives dialysis 3x (three times) weekly did list the interventions of Do not take B/P on right arm every shift and location of dialysis shunt is left arm. The documentation under the vitals tab did indicate the B/P was taken on the right arm on the following dates:
--01/01/25 at 1:30 AM
--01/08/25 at 8:08 PM
--02/10/25 at 8:11 AM
--02/17/25 at 8:53 PM
--02/22/25 at 9:26 PM
--02/24/25 at 8:08 AM
--03/03/25 at 9:11 AM
--03/10/25 at 9:28 AM
--03/11/25 at 9:17 AM
--03/15/25 at 8:43 AM
--03/18/25 at 9:35 PM
--03/19/25 at 8:06 AM
--03/20/25 at 9:52 AM
--03/20/25 at 8:17 PM
--03/24/25 at 8:05 AM
--03/24/25 at 9:38 PM
--03/25/25 at 8:37 AM
--03/25/25 at 9:39 AM
--04/07/25 at 8:03 AM
--04/14/25 at 8:07 AM
--04/21/25 at 8:32 AM
On 05/22/24 at 10:00 AM, the DON was notified and confirmed the care plan was not implemented regarding the restricted limb.
d) Resident #91
On 05/19/25 at 11:00 AM, a record review was completed for Resident #91. The review did not find a physician's order to not take the blood pressure in the restricted limb. The review, also, found the care plan had not developed an intervention of under the focus area of the resident has renal insufficiency r/t d/x of end stage renal disease and receives dialysis 3x weekly to not take B/P in the left arm d/t a dialysis shunt. On the following dates the blood pressure was taken in the restricted limb:
--04/19/25 at 1:55 AM
--04/20/25 at 11:56 PM
--04/22/25 at 6:03 AM
--04/24/25 at 1:11 AM
--04/25/25 at 1:31 AM
--04/25/25 at 11:11 PM
--04/27/25 at 12:42 AM
--05/01/25 at 2:35 AM
--05/07/25 at 7:12 AM
--05/08/25 at 1:14 AM
--05/08/25 at 5:16 PM
--05/11/25 at 1:05 AM
--05/13/25 at 2:27 AM
--05/14/25 at 12:42 AM
--05/15/25 at 6:45 AM
--05/15/25 at 11:02 PM
--05/18/25 at 4:17 AM
On 05/22/24 at 10:00 AM, the DON was notified and confirmed the care plan was not developed regarding the restricted limb.
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 restricted limb precautions for Resident #109, #15 and #91. This was true for four (3) of 13 resi...
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Based on record review and staff interview, the facility failed to follow physician's orders regarding restricted limb precautions for Resident #109, #15 and #91. This was true for four (3) of 13 residents reviewed during the survey process. Resident Identifiers: #109, #15, and #91. Census: 107.
Findings Include:
a) Resident #109
On 05/19/24 at 9:30 AM, a record review was completed for Resident #109. The review found a physician's order dated 06/22/23 of do not take B/P (blood pressure on left arm and an additional physician's order dated 06/22/23 of location of dialysis fistula: left upper arm. Upon further review, the physician's order was not followed. The following dates indicate the blood pressure was taken in the left arm:
--06/22/23 at 3:03 PM
--06/23/23 at 3:44 AM
--06/23/23 at 8:38 PM
--06/24/23 at 10:42 PM
--06/26/23 at 12:30 AM
--06/26/23 at 2:59 PM
--06/27/23 at 3:25 PM
--06/30/23 at 12:51 AM
--07/01/23 at 3:48 AM
--07/02/23 at 1:29 PM
--07/05/23 at 1:38 AM
--07/05/23 at 2:07 PM
--07/06/23 at 3:13 AM
--07/06/23 at 11:55 AM
--07/10/23 at 11:02 PM
--07/14/23 at 10:03 PM
--07/18/23 at 11:25 PM
--07/19/23 at 3:30 PM
--07/20/23 at 1:15 AM
--07/21/23 at 4:07 AM
--07/23/23 at 11:04 PM
--07/31/23 at 9:56 AM
--08/06/23 at 2:57 AM
--08/06/23 at 11:33 PM
--08/10/23 at 11:31 PM
--08/11/23 at 10:55 PM
--08/23/23 at 1:21 PM
--09/17/23 at 10:02 AM
--10/23/23 at 1:54 PM
--10/25/23 at 12:17 AM
--10/26/23 at 9:55 AM
--10/27/23 at 4:18 PM
--10/27/23 at 7:38 PM
--10/29/23 at 9:49 AM
--11/03/23 3:18 AM
--11/04/23 at 12:55 AM
--11/05/23 at 8:54 AM
--11/08/23 at 12:09 AM
--11/09/23 at 2:55 AM
--11/10/23 at 12:29 PM
--11/27/23 at 10:54 AM
On 05/22/24 at 10:00 AM, the DON was notified and confirmed the physician's order was not followed regarding the restricted limb.
b) Resident #15
On 05/19/25 at 10:30 AM, a record review was completed for Resident #15. The review found a physician's order dated 12/31/24 Do not take B/P on right arm every shift. The documentation under the vitals tab did indicate the B/P was taken on the right arm on the following dates:
--01/01/25 at 1:30 AM
--01/08/25 at 8:08 PM
--02/10/25 at 8:11 AM
--02/17/25 at 8:53 PM
--02/22/25 at 9:26 PM
--02/24/25 at 8:08 AM
--03/03/25 at 9:11 AM
--03/10/25 at 9:28 AM
--03/11/25 at 9:17 AM
--03/15/25 at 8:43 AM
--03/18/25 at 9:35 PM
--03/19/25 at 8:06 AM
--03/20/25 at 9:52 AM
--03/20/25 at 8:17 PM
--03/24/25 at 8:05 AM
--03/24/25 at 9:38 PM
--03/25/25 at 8:37 AM
--03/25/25 at 9:39 AM
--04/07/25 at 8:03 AM
--04/14/25 at 8:07 AM
--04/21/25 at 8:32 AM
On 05/22/24 at 10:00 AM, the DON was notified and confirmed the physician's order was not followed regarding the restricted limb.
c) Resident #91
On 05/19/25 at 11:00 AM, a record review was completed for Resident #91. The review did not find a physician's order to not take the blood pressure in the restricted limb. On the following dates the blood pressure was taken in the restricted limb:
--04/19/25 at 1:55 AM
--04/20/25 at 11:56 PM
--04/22/25 at 6:03 AM
--04/24/25 at 1:11 AM
--04/25/25 at 1:31 AM
--04/25/25 at 11:11 PM
--04/27/25 at 12:42 AM
--05/01/25 at 2:35 AM
--05/07/25 at 7:12 AM
--05/08/25 at 1:14 AM
--05/08/25 at 5:16 PM
--05/11/25 at 1:05 AM
--05/13/25 at 2:27 AM
--05/14/25 at 12:42 AM
--05/15/25 at 6:45 AM
--05/15/25 at 11:02 PM
--05/18/25 at 4:17 AM
On 05/22/24 at 10:00 AM, the DON was notified and confirmed there was no physician's order regarding the restricted limb.
Apr 2024
11 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 F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on resident interview, record review and staff interview the facility failed to promote and facilitate resident self-det...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on resident interview, record review and staff interview the facility failed to promote and facilitate resident self-determination through support of resident choice, and to ensure residents rights for self-determination was encouraged. This was true for two (2) residents and was a random opportunity for discovery. Resident identifiers: # 95 and #99. Facility 99.
Findings include:
a) Resident #95
Resident #95 is a [AGE] year-old male, who has capacity and is a Paraplegic.
While reviewing a report it was discovered Resident #95 had kissed Resident #99 at the nurses' station on the mouth. The nursing notes stated Residents were separated and educated on inappropriate behavior. DON (Director of Nursing), administrator, and management on call notified. This note was written at 8:53 PM on 03/30/24.
The reportable note stated, Nurse separated both easily redirected and placed on 15-minute checks and skin assessments and both residents stated they consented for the kiss, however, the other resident lacks capacity to consent.
The above nursing notes and reportable were signed by Licensed Practical (LPN) #24.
On 03/31/24 at 8:50 PM:
Nurses Note read as below:
Note Text: Patient observed in wheelchair behind curtain in dark room in (named Resident #99) room. Patient asked to vacate patient's room. Patient education preformed on inappropriate behavior. Primary nurse notified at this time.
Further review of the facility reportable found statements from multiple staff saying Residents #95 and #99 have for months ate lunch and dinner together and attend activities together and holding hands a lot.
An interview was conducted on 04/23/24 at 12:30 PM with Resident #95. The resident reported he and Resident #99 were dating. He stated he had not been told that he could not have a relationship with another resident. Resident #95 reported he had been sitting in his wheelchair talking to Resident #99 in her room and staff told him it was against facility rules. Residents stated this made him feel as if he was doing something wrong.
b) Resident #99
Resident #99 is a [AGE] year-old female who lacks capacity, due to having a stroke. Her brief interview of mental status (BIMS) score was an 11 which indicates her cognitive function was moderately impaired.
Resident #99 was seen receiving a kiss on the mouth at the nursing station on 03/30/24 at 8:50 PM. At the time of the kiss Resident #99 said she welcomed the kiss; this was found in a nursing note in the reportable.
The facility reportable stated at the time of the incident this resident was also placed on 15-minute checks and skin assessments.
A review of the nursing notes found the following notes pertaining to this situation:
A nurses note dated 03/30/24 by Registered Nurse (RN) #2 at 10:47 PM stated Patient and other resident informed that they needed to stop their activity . Patient education performed. Administrator, DON, manager on call, and provider notified at this time.
An interview was completed on 04/23/24 at 11:12 AM, with Resident #99. The resident reported she was never directly told by the facility that she could not have a relationship with another resident. Resident #99 reported that she enjoys the company of Resident #95 and stated several times he has done nothing wrong. Resident #99 reported I'm a grown woman and can have a relationship with anyone I want.
c) Interview
On 04/24/24 at 2:00 PM an interview with the DON and Administrator found the 15-minutes checks (monitoring residents' movements) were presently still ongoing.
The DON was asked how long the residents were above going to remain on the 15-minute checks. The DON stated, she and the Administrator were discussing it today and she decided to continue them for 90 days.
The Administrator and DON were asked why the facility was preventing the two (2) residents from having a relationship if both parties want to have a relationship. They both stated that no one was preventing them from having a relationship. They were shown the nursing notes about Resident #95 being vacate her room and was re-educated about appropriateness. It was also noted the residents have not been together during the survey.
At the close of the survey on 04/29/24 at 4:30 PM, the residents were never observed together.
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
Employment Screening
(Tag F0606)
Could have caused harm · This affected 1 resident
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Based on review of facility documents, staff interview, and interview via phone with the [NAME] Virginia licensing board of nursing. The facility failed to report nurses who had a disciplinary actio...
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Based on review of facility documents, staff interview, and interview via phone with the [NAME] Virginia licensing board of nursing. The facility failed to report nurses who had a disciplinary action in effect taken and/or released from their employment at the facility due to unaccounted for or missing controlled medications and not administering medications as ordered, along with falsified documentation about marking a medication as given when it was not given. Resident Identifier: # 101. Facility census: 99.
Findings include:
a) Resident #101
During a review of the facility reportable for an incident which took place on 12/25/23 or 12/26/23, the brief description of the incident was: Narcotic count off. Discrepancy of (liquid) Morphine amount on 12/25/23 at 3:00 PM and discrepancy of Neurontin on 12/26/23 at 3:20 PM.
Immediate action taken to protect residents: Count Corrected, Perpetrator suspended pending investigation.
This incident was not reported until 12/26/23 at 3:27 PM, even though the first discrepancy occurred on 12/25/23.
On 12/25/23 Licensed Practical Nurse #115 was given a Coaching/teachable Moment , by ADON. (This indicates the facility first obtained knowledge of the incident on 12/25/23).
Violation did not thoroughly count liquid narcotics.
Reason for Warning/Notice: count correction.
To avoid disciplinary action, employees should: Visualize each liquid narcotic amounts.
This was signed by both LPN#115 and the ADON on 12/25/23.
The same form as mentioned above was completed by the DON on 12/26/23.
At the top it was handwritten Suspension
Violation: Incorrect administration of narcotic
Reason for warning/notice: Discrepancy of ordered Morphine sulfate solution on 12/25/23 at 10:30 AM. Narcotic sheet states 3.5 ml available. On 12/25/23 at 2:30 PM the amount available was 0.25 ML. This was visible in bottle per the ADON.
Resulting in discrepancy of unaccounted 3.5 ML of Morphine Sulfate and missing Neurontin on 12/26/23 at 3:40 PM. Nurse unable to produce missing medication or account for missing pill during hand off cart and narcotic count.
Employee response: I have no excuse I don't know what happened.
Facility requested an extension for the five-day follow-up pending on police report on 12/28/23.
Final report was faxed 01/04/24 at 12:23 PM.
Conclusion: Employee terminated, unable to prove or disprove allegation.
On 04/24/24 at 10:22 AM the Administrator was asked if the above events were reported to the nursing board. The initial answer was yes. The administrator was asked for the reportable number and could not provide one.
On 04/24/24 at 11:40 AM a phone call was made to the [NAME] Virginia board of Nursing (LPN). It was reported that no complaint had been made on LPN #115.
On 04/24/24 at 12:12 PM, the administration was informed that no complaints had been filed for LPN #115. And no further information was provided.
b) LPN #113
Resident #31
It was discovered that on 03/31/24 Resident #31 went without having an acu-check and insulin from 6 AM to 7 PM. This was reported by Resident #31 and investigated by the facility and found to be true.
LPN #113 was the assigned nurse for Resident #31.
2) Resident #71
A review of the Nursing Home initial reporting allegation form found LPN # 113 documented an antibiotic was given to Resident #71 on 03/30/24. However, the antibiotic was found in the medication cart on 04/01/24 at 8:45 AM by LPN #24. This was also witnessed by Registered Nurse # 19.
3) Resident # 20
A review of the Nursing Home initial reporting allegation form found LPN # 113 documented a controlled medication Neurontin was given to Resident #20 on 03/30/24 at 1:00 PM. However, the medication was found in the medication cart on 04/01/24 at 8:45 AM by LPN #24. This was also witnessed by Registered Nurse # 19.
4) Resident # 45
A review of the Nursing Home initial reporting allegation form found LPN # 113 documented a controlled medication Ativan was given to Resident #45 on 03/30/24. However, the medication was found in the medication cart on 04/01/24 at 8:45 AM by LPN #24. This was also witnessed by Registered Nurse # 19.
The five-day follow-up resulted in LPN #113 being terminated on 04/05/24.
On 04/24/24 at 10:22 AM the Administrator was asked if the above events were reported to the nursing board. The initial answer was yes. The administrator was asked for the reportable number and could not provide one.
On 04/24/24 at 11:40 AM a phone call was made to the [NAME] Virginia board of Nursing (LPN). It was reported that no complaint has been made on LPN #113.
On 04/24/24 at 12:12 PM the administration was informed that no complaints had been filed for LPN #113. No further information was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
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Based on medical record review and staff interview the facility failed to ensure all handwritten skin assessments were clear and accurate and contained enough information to accurately identify the ...
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Based on medical record review and staff interview the facility failed to ensure all handwritten skin assessments were clear and accurate and contained enough information to accurately identify the resident. This failed practice had the potential to effect more than a limited number of residents. Facility census: 99.
Findings include:
a) Skin assessment
While reviewing the medical records of residents that have had skin assessments because of a sexual behavior allegation of another resident. 12 forms were found where the name of the resident was unidentifiable or was missing altogether.
On 04/23/24 at 1:10 PM the Director of Nursing (DON) was shown the skin assessment forms and agreed that six (6) had unidentifiable names and six (6) had no names. It was also pointed out that the forms did not have a date or shift on the form. The DON confirmed all 12 pages had the signature of the Assistant Director of Nursing.
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 F0577
(Tag F0577)
Could have caused harm · This affected multiple residents
.
Based on observation, record review and staff interview the facility failed to ensure the most recent survey was accessible to residents, family members, and legal representatives of residents. This...
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Based on observation, record review and staff interview the facility failed to ensure the most recent survey was accessible to residents, family members, and legal representatives of residents. This failed practice had the potential to affect more than an isolated number of residents. Facility census: 99.
Findings included:
a) Survey documentation
On 04/22/24 at 3:35 PM, a review of the current Survey Documentation located in the lobby of the facility for public access revealed the survey book did not contain the most recent survey results for November 2023.
An interview was conducted on 04/22/24 at 3:50 PM with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) who acknowledged the most recent survey was not in the survey binder located in the front lobby for general access. ADON reported he could not locate the current survey results in the facility and stated the Administrator could email the survey results to him from outside of the office.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected multiple residents
Based on record review and staff interviews the facility failed to ensure residents were free from neglect. Residents #13, #90 and #100 had physician orders for hourly checks for fall prevention. Due ...
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Based on record review and staff interviews the facility failed to ensure residents were free from neglect. Residents #13, #90 and #100 had physician orders for hourly checks for fall prevention. Due to the facility's failure to complete the hourly checks, resulting in the residents continuing to fall. Resident #2 was on 15-minute checks but was able to place himself in the room of a female resident and did not have pants on. Resident identifiers: #13, #90, #100. Facility Census: 99.
Findings included:
a) Policy Review
A review of the facility policy titled Abuse Prevention Program with a revision date on 12/06 reads as follows:
Neglect/Deprivation of Goods and Services by Staff (for further information, refer to Identifying Neglect policy)
1. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.
2. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident requires but the facility fails to provide them and this has resulted in (or may result in ) physical harm, pain, mental anguish or emotional distress.
3. Neglect includes cases where the facility's indifference to or disregard for resident care, comfort or safety results in (or could have result in) physical harm, pain, mental anguish or emotional distress.
4. Neglect may be a pattern of failures or may be the result of one or more failures involving one resident and one staff person.
b) Resident #13
During a record review on 04/24/24 at 9:00 AM Resident #13's medical records revealed a physician order dated 05/08/23 one-hour checks while the resident was in bed r/t (related to) falls every hour.
Further medical record review revealed the following missing one-hour checks:
-02/17/24 1:00 PM, 2:00 PM, 3:00 PM, 4:00 PM, 5:00 PM, 6:00 PM
-02/21/24 12:00 PM, 1:00 PM, 2:00 PM, 3:00 PM, 4:00 PM, 5:00 PM, 6:00 PM
-02/28/24 4:00 AM, 5:00 AM, 6:00 AM
Further record review revealed an incident note dated 02/27/24 at 2:24 AM (typed as written) CNA Certified Nurse Aide) reported resident found on the floor laying face down on the fall mat. Assessment completed. VS (vital signs) obtained. S/S (signs and symptoms) of pain/ discomfort. Resident yelling out. Skin assessment completed with no injuries noted at this time. Resident unable to describe what happen. Resident stated she hit her head. Assisted CNA with transferring resident back to the bed. CNA provided incontinent care. Contacted on-call physician. Orders received to send resident to ER for further evaluation. Spoke with the local government agency) after hour services regarding the incident. Notified DON(Director of Nursing). Will continue to monitor.
During an interview on 04/24/24 at 1:47 PM the DON acknowledged the one-hour checks were not completed and could have contributed to a resident falling.
b) Resident #90
During a record review on 04/24/24 at 9:15 AM Resident #90's medical records revealed a physician order dated 10/31/22 one-hour checks for fall prevention every hour for Multiple falls.
Further medical record review revealed the following missing one-hour checks:
-03/25/24 3:00 PM, 4:00 PM, 5:00 PM and 6:00 PM
-02/17/24 1:00 PM, 2:00 PM, 3:00 PM, 4:00 PM, 5:00 PM, 6:00 PM
-02/21/24 12:00 PM, 1:00 PM, 2:00 PM, 3:00 PM, 4:00 PM, 5:00 PM, 6:00 PM
-02/28/24 4:00 AM, 5:00 AM, 6:00 AM
Further record review revealed the following incident notes:
-04/07/24 11:15 PM (typed as written)
Resident found in floor with wheelchair flipped backwards; neuros and Orthosis completed per facility protocol; no injuries observed at this time; resident assisted back to wheelchair per residents request; resident with no voiced c/o pain but does state he hit his head when he fell; resident wheeled self down hall post fall; intervention: anti tippers to be placed to wheelchair.
-3/19/2024 at 8:00 AM (typed as written)
Unwitnessed fall- Upon assessment, resident observed to be sitting between his bed and the wall with the bedside table tipped over and halfway under the bed. Pupils equal and reactive. Resident is able to move all 4 (four) extremities without difficulty however is complaining of intermittent lower back pain. PRN (as needed) Tylenol ordered. Resident is currently self-propelling in his wheelchair at baseline. Resident is alert and oriented at baseline with no further complaints. name NP notified. New order received:
1. Thoracic spine 2-3 view x-ray
2. Lumbar spine 2 view x-ray
3. Pelvis 1 view x-ray
RP notified and is agreeable with the current plan of care.
-03/03/2024 at 4:10 PM (typed as written)
Resident yelling out for help. Resident found on the floor laying on his back between his bed and the roommate's bed. Assessment completed. Denies any pain or discomfort. Resident stated he hit his bed on the footboard of the roommate's bed. Skin assessment completed with no injuries noted at the time of the incident. Neuro checks initiated. Orthostatic BP (Blood Pressure) obtained. Resident stated he was trying to put lotion on his thigh and hell back to the floor. Resident was standing inside the doorway at the time of the floor. Wheelchair was not near the resident. Gripper socks on resident properly. Resident transferred to his bed. On-call physician notified with orders received to send to ER (Emergency Room) for further evaluation. Notified nursing manager on duty. Voicemail left for POA (Power of Attorney). Education provided to the resident regarding using wheelchair as directed and asking for staff assistance when needed d/t impaired gait and weakness. BIMS score of 6.0. Dx (Diagnosis) of unsteadiness on feet and muscle weakness. Safety measures in place with call light in reach. Will continue to monitor.
-2/17/2024 11:15 PM (typed as written)
Resident reported a fall from prior shift. Assessment completed. AOx3 with periods of confusion. Denies any pain or discomfort. Skin assessment completed with skin tear noted to right front thigh. Resident stated, I fell this morning and a pretty lady helped me up. Education provided on asking for assistance when needed and reporting a fall when incident occurs. Contacted on-call physician and Guardian. Message left from guardian. Neuro checks initiated. Safety measures in place with call light in reach Will continue to monitor.
During an interview on 04/24/24 at 1:47 PM the DON acknowledged the one-hour checks were not completed and could have contributed to a resident falling.
c ) Resident #100
During a record review on 04/24/24 at 9:45 AM Resident #100's medical records revealed a physician order dated 01/01/24 one-hour checks for fall prevention every hour for Multiple falls.
Further medical record review revealed the following missing one-hour checks:
-01/12/24 3:00 AM, 4:00 AM and 5:00 AM
-01/27/24 5:00 AM and 6:00 AM
Further medical records revealed the following incident note dated 01/26/24 at 10:45AM (typed as written)
CNA reported resident was found on the floor, laying on her left side on the floor mat and her upper body leaning on the bed. Assessment completed. VS obtained. Denies any pain or discomfort. Per resident she denies hitting her head and no s/s noted. Skin assessment completed with no injuries, bruises, or open areas noted at the time. Transferred resident back to her bed. Incontinent care provided. Fall precautions in place. Neuro checks initiated. Phy notified and no orders received. Voicemail left with local state agencies APS caseworker. DON made aware.
During an interview on 04/24/24 at 1:47 PM the DON acknowledged the one-hour checks were not completed and could have contributed to a resident falling.
d) Resident #2
A review of facility records found Resident #2 was placed on 02/13/24 at 1:04 AM after having an altercation with the roommate and stating she was leaving.
On 02/14/24 at 4:05 PM Resident #2 was discovered in the bed with Resident #57 without any pants on per the reportable documentation from the facility.
On 04/23/24 at 5:10 PM, during an interview with the DON the DON confirmed there was an order to start 15-mintue monitoring checks on 02/13/24 at 1:04 AM. The DON also confirmed the 15-minute checks have continued since then with no order or plan in place to end the 15-minute checks as of today.
On 04/24/24 at 12:10 PM the Administrator was asked if the staff were doing the 15-minute monitoring checks how Resident #2 was not checked on before the event with being in the bed with no pants on happened?
Staff statements gathered after the event on 02/14/24 were as follows:
-Nurse Aide (NA) #6 stated on 02/14/24, I was in Parlor assisting other residents and had not been in Residents room for about an hour. The last time I saw either resident was around 3 PM at Valentines Party.
-NA#40 stated, I was passing ice on hallway and hadn't made it to residents' room. It had been about 20 minutes since I saw them.
- Former employee Licensed Practical Nurse (LPN) #114 stated, upon entering room to give patient medication nurse discovered resident and another female resident lying in bed with clothes off from waist down facing each other talking.
A review of the 15- minute monitoring check sheet found all 15-minute time slots had initials in every slot.
The NA statements revealed they had not visually checked Resident #2 for at least 20 minutes to an hour. This was discussed with the DON on 04/29/24 at 9:10 AM.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
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Based on record review and staff interview, the facility failed to ensure an allegation of verbal abuse was reported to all the proper State Authorities. This was true for one (1) resident reviewed ...
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Based on record review and staff interview, the facility failed to ensure an allegation of verbal abuse was reported to all the proper State Authorities. This was true for one (1) resident reviewed in the care area of verbal abuse during a complaint survey. Resident identifier: #10. Facility census: 99.
Findings included:
a) Policy Review
A review of a facility policy titled Abuse Prevention Program with a revision date of 12/16 read as follows:
2. Verbal abuse may be considered to be type of mental abuse. Verbal abuse includes the use of verbal, written or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability.
3. Examples of mental and verbal abuse include, but are not limited to:
a.harassing a resident
b. mocking, insulting, ridiculing
c. yelling or hovering over a resident, with the intent to intimidate;
d. threatening residents, including but not limited to, depriving a resident of care or withholding a resident from contact with family and friends; and
e. isolating a resident from social interaction or activities.
b) Resident #10
A review of the facility grievance and concerns records on 04/24/24 at 9:15 AM revealed a Grievance/Concern form dated 03/26/24.
The form contained the following information typed as written:
Individual initiating concern: Family/Representative
Print name of person with concern and resident concern is regarding Name (daughter) no resident name was provided.
Describe concern in detail using factual support: (typed as written)
Nurse or aid argumentative with patient feels like this evening staff wont assist with keeping mother calm. Daughter heard a discussion while on the phone with mother.
During an interview, on 04/24/24 at 9:28 AM the Director of Nursing (DON), The Administrator and Assistant Director of Nursing (ADON) were all present.
The DON stated, This was (Resident #10's name) I remember this. The Administrator stated, We spoke with the staff, and we felt it was more of a customer service issue of that staff tone of voice.
The ADON stated, I spoke to the family in length about this issue and she was fine with the issue. Yes, I documented that I spoke to her and what was said.
During an interview, on 04/24/24 at 10:39 AM, the DON stated there was no documentation that the ADON spoke to the family representative. The DON acknowledged a reportable form, and an investigation should have been completed and reported to the appropriate agencies. The DON said, I will begin the process at this time.
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 F0675
(Tag F0675)
Could have caused harm · This affected multiple residents
Based on record review and staff interview the facility failed to ensure all residents attain or maintain the highest practicable physical, mental, and psychosocial well-being. This failed practice wa...
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Based on record review and staff interview the facility failed to ensure all residents attain or maintain the highest practicable physical, mental, and psychosocial well-being. This failed practice was true for seven (7) out of seven (7) reviewed for sexual behavior which were ordered 15-minute monitoring checks without a duration or time frame to discontinue the checks. This was depriving the residents of sense of wellbeing for quality of life. Resident identifiers: #57, #2, #95, #99, #62, #37, and #60. Facility censuses 99.
Findings include:
a) Resident #57
A review of facility records found Resident # 57 was placed on 15-minute monitor check on 02/14/24 at 4:05 PM after this Resident was found in bed with another incapacitated resident without any pants on. Both residents reside in the memory unit.
An interview with the Director of Nursing (DON) on 04/23/24 at 5:10 PM. The DON was asked how long the 15-minute monitoring checks were going to continue. The DON responded by saying she and the Administrator were talking about that and she believes they will do them for 90 days. The DON agreed there was no order in place to discontinue these checks. A facility policy for monitoring residents every 15-minutes was requested, however, no policy was provided by the close of this survey.
b) Resident #2
A review of facility records found Resident #2 was placed on 15-minute checks on 02/13/24 at 1:04 AM after having an altercation with the roommate and stating she was leaving.
On 04/23/24 at 5:10 PM, an interview with the DON confirmed there was an order to start 15-minute monitoring checks on 02/13/24 at 1:04 AM. The DON also confirmed the 15-minute checks have continued since then with no order or plan in place to end the 15-minute checks as of today.
c) Resident #95
A review of the facility records revealed Resident # 95 was placed on 15-minute monitoring checks on 03/30/24 at 9:00 PM. After the nursing staff witnessed him kiss another Resident on the mouth at the nurse's station. Resident # 95 has capacity, and it was reported that the resident he kissed did not object to being kissed.
On 04/24/24 at 2:00 PM an interview with the DON and Administrator found that the 15-minutes checks (monitoring residents' movements) are presently still ongoing. The DON was asked how long Resident #95 was going to remain on the 15-minute checks. The DON stated that she and the Administrator were discussing it today and she decided to continue them for 90 days.
d) Resident # 99
While reviewing the facility documents it found Resident # 99 was placed on 15-minute monitoring checks on 03/30/24 at 9:00 PM, for being kissed by another resident, whom she is very close to.
On 04/24/24 at 2:00 PM an interview with the DON and Administrator found that the 15-minutes checks (monitoring residents' movements) are presently still ongoing. The DON was asked how long Resident #99 was going to remain on the 15-minute checks. The DON stated that she and the Administrator were discussing it today and she decided to continue them for 90 days.
e) Resident #62
A review of facility records found Resident # 62 was placed on 15-minute monitor checks on 03/30/24 at 10:49 AM after this resident was found touching and kissing another resident. Both residents reside in the memory unit.
An interview with the DON on 04/23/24 at 5:10 PM. The DON was asked how long this 15-minute monitoring checks were going to continue. The DON responded by saying she and the Administrator were talking about that and she believes they will do them for 90 days. The DON agreed there was no order in place to discontinue these checks. A facility policy for monitoring residents every 15-minutes was requested, no policy was provided by the close of survey.
f) Resident # 37
A review of facility records found Resident # 37 was placed on 15-minute monitor checks on 03/30/24 at 1:47 PM after this resident was found kissing and being touched by another resident. Both residents resided in the memory unit.
An interview with the DON on 04/23/24 at 5:10 PM. The DON was asked how long these 15-minute monitoring checks were going to continue. The DON responded by saying she and the Administrator were talking about that and she believed they would do them for 90 days. The DON agreed there was no order in place to discontinue these checks. A facility policy for monitoring residents every 15-minutes was requested, no policy was provided by the close of survey.
g) Resident #60
A review of facility records found Resident #60 was placed on 15-minute monitor checks on 01/20/24 at 7:00 AM after this resident made an inappropriate sexual comment to another resident in the facility.
An interview with the DON on 04/23/24 at 5:10 PM. The DON was asked how long this 15-minute monitoring checks were going to continue. The DON responded by saying she and the Administrator were talking about that and she believed they would do them for 90 days. The DON agreed there was no order in place to discontinue these checks. A facility policy for monitoring residents every 15-minutes was requested, no policy was provided by the close of survey.
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
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Based on medical record review, and staff interview the facility failed to give medication as ordered by the physician, failed to complete 15-minute monitoring of a resident, failed to complete neu...
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Based on medical record review, and staff interview the facility failed to give medication as ordered by the physician, failed to complete 15-minute monitoring of a resident, failed to complete neuro checks after an unwitnessed fall. These failed practices were true for six (6) out of six (6) residents reviewed for late medications, and seven (7) out of seven (7) residents reviewed for 15-minute monitoring, and one (1) out of one (1) resident reviewed for neuro checks. Resident identifiers: #33, #62, #31, #7, #43, #20, #37, #60, and #90. Facility Census:
Findings included:
a) Resident #33
A review of the facility records titled; Medication Audit Report revealed the following order:
Eliquis (an anticoagulant to prevent blood clots) One (1) tablet twice a day was ordered by the facility attending physician.
On 03/15/24 this medication was scheduled to be administered at 9:00 PM and was not given until 11:06 PM by Licensed Practical Nurse (LPN) #1. There were not any nursing notes to indicate why or that the attending physician was notified.
Resident #33 also had an order for Norvasc (used to treat high blood pressure) One (1) tablet twice a day was ordered by the attending physician.
On 03/15/24 this medication was scheduled to be administered at 9:00 PM and was not given until 11:06 PM by Licensed Practical Nurse (LPN) #1. There were not any nursing notes to indicate why or that the attending physician was notified.
Resident #33 also had an order for Lantus (used to control blood glucose levels) injected 13 units at bedtime was ordered by the facility attending physician.
On 03/23/24 this medication was scheduled to be administered at 9:00 PM and was not given until 11:27 PM by LPN #1. This was 2 hours and 27 minutes late.
Norvasc and Eliquis were scheduled to be administered at 9:00 PM on 03/23/24. These medications were not given until 11:27 PM by LPN #1.
Novolog insulin (used to control glucose levels for type two (2) diabetes) was scheduled to be administered at 9:00 PM on 03/23/24 and was not given until 11:27 PM by LPN #1.
Bactrim DS (this is an antibiotic used for an infection) was ordered to be given every 12 hours. This medication was scheduled for 9:00 PM and was not given until 11:27 PM on 03/23/24 by LPN #1.
On 03/29/24 LPN #1 should have administered Lantus, Novolog, Eliquis, and Norvasc at 9:00 PM. These medications were not given until 11:59 PM. That was nearly three (3) hours late.
On 04/10/24 LPN #4 should have administered Lantus, Novolog, Eliquis, Norvasc at 9:00 PM. These medications were documented as given at 11:32 PM.
On 04/20/24 LPN #1 should have administered Lantus, Novolog, Eliquis, Norvasc at 9:00 PM. These medications were documented as given at 10:46 PM.
On 04/24/24 at 9:20 AM the Director of Nursing and the Assistant Director of Nursing verified and agreed the above medications were given more than an hour late and no nursing notes found the explain why.
b) Resident #31
A review of the facility document called the Medication Admin Audit Report found Resident #31 received the following medication more than an hour after it was scheduled to be given.
On 03/1424 Novolog insulin flex-pen was scheduled for 8:00 PM and to be given before meals and at bedtime. This medication was given at 11:25 PM by LPN # 71.
Additional medications which were administered late were,
--Acidophilus (given for digestive health) and is scheduled three (3) times a day.
--Albuterol Inhalation was to be given four (4) times a day for Chronic Obstructive Pulmonary Disease (COPD),
--Fluticasone-Salmeterol inhaler two (2) times a day for Shortness of breath,
--Eliquis two (2) times a day for ischemic attack,
--Metoprolol to be given two (2) times a day for hypertension.
The above medication was scheduled for 9:00 PM and was given at 10:31 PM.
-- Insulin Detemir Pen-injector two (2) times a day for Diabetes.
The above medication was scheduled for 9:00 PM and was given at 11:25 PM.
On 03/15/24 Novolog insulin flex-pen was scheduled for 8:00 PM and to be given before meals and at bedtime. This medication was given at 10:56 PM by LPN # 71.
Additional medications which were administered late were,
--Acidophilus (given for digestive health) and is scheduled three (3) times a day.
--Albuterol Inhalation was to be given four (4) times a day for Chronic Obstructive Pulmonary Disease (COPD),
--Fluticasone-Salmeterol inhaler two (2) times a day for Shortness of breath,
--Eliquis two (2) times a day for ischemic attack,
--Metoprolol to be given two (2) times a day for hypertension.
The above medication was scheduled for 9:00 PM and was given at 10:47 PM.
--Insulin Detemir Pen-injector two (2) times a day for Diabetes.
The above medication was scheduled for 9:00 PM and given at 10:56 PM.
On 03/16/24 Novolog insulin flex-pen was scheduled for 11:00 AM and to be given before meals and at bedtime. This medication was given at 12:51 PM by LPN # 113.
Additional medication which were administered late were,
--Acidophilus (given for digestive health) and is scheduled three (3) times a day. Albuterol Inhalation was to be given four (4) times a day for Chronic Obstructive Pulmonary Disease (COPD), were scheduled of 11:00 AM was not given until 12:51 PM.
On 03/18/24 Novolog insulin flex-pen was scheduled for 8:00 PM and to be given before meals and at bedtime. This medication was given at 9:55 PM by LPN # 71.
On 03/19/24 Novolog insulin flex-pen was scheduled for 8:00 PM and to be given before meals and at bedtime. This medication was given at 11:38 PM by LPN # 71.
Additional medications which were administered late were,
--Acidophilus (given for digestive health) and is scheduled three (3) times a day.
--Albuterol Inhalation was to be given four (4) times a day for Chronic Obstructive Pulmonary Disease (COPD),
--Fluticasone-Salmeterol inhaler two (2) times a day for Shortness of breath,
--Eliquis two (2) times a day for ischemic attack,
--Metoprolol to be given two (2) times a day for hypertension.
--Insulin Detemir Pen-injector two (2) times a day for Diabetes.
The above medication was scheduled for 9:00 PM and given at 11:38 PM.
On 03/24/24 Novolog insulin flex-pen was scheduled for 8:00 PM and to be given before meals and at bedtime. This medication was given at 10:03 PM by LPN # 71.
On 03/25/24 LPN #113 administered the following medication more than an hour late.
Novolog insulin flex-pen was scheduled for 4:00 PM before meals and was given at 7:16 PM.
Albuterol Inhalation was to be given four (4) times a day for Chronic Obstructive Pulmonary Disease (COPD), This medication was scheduled for 5:00 PM and was given at 7:16 PM.
On 03/28/24 Novolog insulin flex-pen was scheduled for 8:00 PM and to be given before meals and at bedtime. This medication was given at 10:34 PM by LPN # 71.
Additional medications which were administered late were,
--Acidophilus (given for digestive health) and is scheduled three (3) times a day.
--Albuterol Inhalation was to be given four (4) times a day for Chronic Obstructive Pulmonary Disease (COPD),
--Fluticasone-Salmeterol inhaler two (2) times a day for Shortness of breath,
--Eliquis two (2) times a day for ischemic attack,
--Metoprolol to be given two (2) times a day for hypertension.
The above medication was scheduled for 9:00 PM and given at 10:31 PM
--Insulin Detemir Pen-injector two (2) times a day for Diabetes.
The above medication were scheduled for 9:00 PM and given at 11:25 PM.
On 03/30/24 Novolog insulin flex-pen was scheduled for 8:00 PM and to be given before meals and at bedtime. This medication was given at 9:50 PM by LPN # 24.
On 04/01/24 Novolog insulin flex-pen was scheduled for 8:00 PM and to be given before meals and at bedtime. This medication was given at 9:40 PM by LPN # 71.
On 04/02/24 Novolog insulin flex-pen was scheduled for 8:00 PM and to be given before meals and at bedtime. This medication was given at 10:41 PM by LPN # 71.
Additional medications which were administered late were,
--Acidophilus (given for digestive health) and is scheduled three (3) times a day.
--Albuterol Inhalation was to be given four (4) times a day for Chronic Obstructive Pulmonary Disease (COPD),
--Fluticasone-Salmeterol inhaler two (2) times a day for Shortness of breath,
--Eliquis two (2) times a day for ischemic attack,
--Metoprolol to be given two (2) times a day for hypertension.
The above medication were scheduled for 9:00 PM and was given at 10:30 PM.
Insulin Detemir Pen-injector two (2) times a day for Diabetes.
The above medication was scheduled for 9:00 PM and was given at 10:41 PM.
On 04/09/24 Novolog insulin flex-pen was scheduled for 11:00 AM and to be given before meals and at bedtime. This medication was given at 1:01 PM by LPN # 2.
Additional medications which were administered late were,
--Acidophilus (given for digestive health) and is scheduled three (3) times a day.
--Albuterol Inhalation was to be given four (4) times a day for Chronic Obstructive Pulmonary Disease (COPD), were scheduled of 11:00 AM was not given until 1:01 PM.
On 04/1424 LPN # 2 administered the following medication more than an hour late:
--Acidophilus (given for digestive health) and is scheduled three (3) times a day. Albuterol Inhalation was to be given four (4) times a day for Chronic Obstructive Pulmonary Disease (COPD), were scheduled of 11:00 AM was not given until 1:34 PM.
On 04/21/24 Novolog insulin flex-pen was scheduled for 8:00 PM and to be given before meals and at bedtime. This medication was given at 10:10 PM by LPN # 71.
The above medication was scheduled for 9:00 PM and given at 11:25 PM.
On 04/24/24 at 9:20 AM the Director of Nursing and the Assistant Director of Nursing verified and agreed the above medications were given more than an hour late and no nursing notes found the explain why.
c) Resident #7
During a review of the facility form title, Medication Admin Audit Report, the following medications were found to be administered past the one (1) hour of standard of care practice:
NovoLOG FlexPen Subcutaneous Solution Pen-injector (insulin used to control type two (2) diabetes), inject 15 units subcutaneously before meals. This medication was due on 03/16/24 at 11:00 AM and was given at 12:55 PM by Licensed Practical Nurse (LPN) #113.
Symbicort Inhalation Aerosol (used for chronic obstructive pulmonary disease, unspecified) 80-4.5 MCG/ACT, give two (2) puffs inhale orally two times a day. The medication was due on 03/21/24 at 9:00 AM and was not given until 10:34 AM by Licensed Practical Nurse (LPN) #113.
Lactulose Oral Solution (used for elevated ammonia level related to alcohol cirrhosis of liver without ascites, give 30 ml by mouth three (3) times a day. The medication was due on 03/21/24 at 9:00 AM and was given at 10:34 AM by LPN #113.
Lactulose Oral Solution, give 30 ml by mouth three (3) times a day. Was due on 03/21/24 at 3:00 PM and was given at 4:57 PM by LPN #113.
NovoLOG FlexPen Subcutaneous Solution Pen-injector (insulin used to control type two (2) diabetes), inject 15 units subcutaneously before meals. This medication was due on 03/25/24 at 4:00 PM and was given at 7:18 PM by Licensed Practical Nurse (LPN) #113.
Lactulose Oral Solution (used for elevated ammonia level related to alcohol cirrhosis of liver without ascites), give 30 ml by mouth three (3) times a day. The medication was due on 03/29/24 at 3:00 PM and was given at 4:49 PM by LPN #2.
NovoLOG FlexPen Subcutaneous Solution Pen-injector (insulin used to control type two (2) diabetes), inject seven (7) units subcutaneously before meals. This medication was due on 03/30/24 at 11:00 AM and was given at 1:39 PM by Licensed Practical Nurse (LPN) #113.
NovoLOG FlexPen Subcutaneous Solution Pen-injector (insulin used to control type 2 diabetes), inject seven (7) units subcutaneously before meals. This medication was due on 03/31/24 at 11:00 AM and was given at 12:42 PM by Licensed Practical Nurse (LPN) #113.
Lactulose Oral Solution (used for elevated ammonia level related to alcohol cirrhosis of liver without ascites), give 30 ml by mouth three (3) times a day. The medication was due on 04/08/24 at 3:00 PM and was given at 4:31 PM by LPN #2.
NovoLOG FlexPen Subcutaneous Solution Pen-injector (insulin used to control type two (2) diabetes), inject seven (7) units subcutaneously before meals. This medication was due on 04/10/24 at 4:00 PM and was given at 5:36 PM by Licensed Practical Nurse (LPN) #2.
Lactulose Oral Solution (used for elevated ammonia level related to alcohol cirrhosis of liver without ascites), give 30 ml by mouth three (3) times a day. The medication was due on 04/13/24 at 3:00 PM and was given at 4:47 PM by LPN #2.
Lactulose Oral Solution (used for elevated ammonia level related to alcohol cirrhosis of liver without ascites), give 30 ml by mouth three (3) times a day. The medication was due on 04/18/24 at 3:00 PM and was given at 5:00 PM by LPN #2.
Lactulose Oral Solution (used for elevated ammonia level related to alcohol cirrhosis of liver without ascites), give 30 ml by mouth three (3) times a day. The medication was due on 04/19/24 at 3:00 PM and was given at 5:12 PM by LPN #2.
On 04/24/24 at 9:20 AM the Director of Nursing and the Assistant Director of Nursing verified and agreed the above medications were given more than an hour late and no nursing notes were found to explain why.
d) Resident #43
During a review of the facility form titled, Medication Admin Audit Report, the following medications were administered past the one (1) hour of standard of care practice:
Fluticasone-Salmeterol Inhalation Aerosol Powder Breath Activated 100-50 MCG/ACT (for acute chronic respiratory failure), give one (1) puff inhale orally two times a day. The medication was due on 03/15/24 at 9:00 PM and was given at 10:46 PM by LPN #71.
LevETIRAcetam Oral Tablet 500 mg, give one (1) tablet by mouth two times per day for seizures. The medication was due on 03/15/24 at 9:00 PM and was given at 10:46 PM by LPN #71.
Ativan Oral Tablet 0.5 mg, give one (1) tablet by mouth every 6 (six) hours for anxiety, agitation. The medication was due on 04/13/24 at 12:00 PM and was given at 1:40 PM by LPN #2.
On 04/24/24 at 9:20 AM Director of Nursing and the Assistant Director of Nursing verified and agreed the above medications were given more than an hour late and no nursing notes found the explain why.
e) Resident #20
During a review of the facility form titled, Medication Admin Audit Report, the following medications were administered past the one (1) hour of standard of care practice:
Gabapentin Oral Tablet 800mg (for diabetes mellitus neuropathy), give one (1) tablet by mouth three (3) times a day. The medication was due on 03/21/24 at 1:00 PM and was given at 2:45 PM by LPN # 113.
A finger stick (to monitor blood glucose), take before meals and at bedtime was due on 03/21/24 at 8:00 PM and was taken at 9:59 PM by LPN #24.
Nateglinide Oral Tablet 120 mg, give one (1) tablet by mouth before meals for diabetes mellitus. The medication was due on 03/25/24 at 4:00 PM and was given at 7:16 PM by LPN #113.
A finger stick (to monitor blood glucose), take before meals and at bedtime was due on 03/25/24 at 4:00 PM and was taken at 7:19 PM by LPN #113.
Gabapentin Oral Tablet 800mg (for diabetes mellitus neuropathy), give one (1) tablet by mouth three (3) times a day. The medication was due on 03/26/24 at 1:00 PM and was given at 2:48 PM by RN #9.
A finger stick (to monitor blood glucose), take before meals and at bedtime was due on 03/30/24 at 8:00 PM and was taken at 10:23 PM by LPN #24.
A finger stick (to monitor blood glucose), take before meals and at bedtime was due on 03/31/24 at 11:00 AM and was taken at 12:38 PM by LPN #113.
Ranolazine ER Oral Tablet Extended Release 12-hour 500mg, give one (1) tablet by mouth two (2) times a day for chest pain. The medication was due on 04/02/24 at 9:00 PM and was given at 10:32 PM by LPN #71.
Gabapentin Oral Tablet 800mg (for diabetes mellitus neuropathy), give one (1) tablet by mouth three (3) times a day. The medication was due on 04/03/24 at 1:00 PM and was given at 5:04 PM by LPN #2.
A finger stick (to monitor blood glucose), take before meals and at bedtime was due on 03/31/24 at 8: 00 PM and was taken at 9:42 PM by ADON.
On 04/24/24 at 9:20 AM Director of Nursing and the Assistant Director of Nursing verified and agreed the above medications were given more than an hour late and no nursing notes found the explain why.
f) Resident #62
Review of 15-minute monitoring sheets with the DON on 04/23/24 at 5:14 PM, confirmed many pages were missing location and/or nurse signature as well as multiple blank spaces. The following sheets had blank spaces/missing data for the following times:
04/02/24 no data from 7:15 PM to 11:45 PM.
04/04/24 no data from 12:00 AM to 1:45 PM.
04/05/24 no data from 12:00 AM to 6:30 AM.
04/12/24 no data from 6:30 AM to 11:45 PM.
04/23/24 no data from 2:00 PM to 11:45 PM.
g) Resident # 37
Review of 15 minute monitoring sheets with DON on 04/23/24 at 5:14 PM, DON agreed that many pages were missing location and/or nurse signature as well as multiple blank spaces. The following sheets had blank spaces/missing data for the following times:
04/13/24 no data at 6:45 AM
04/14/24 no data at 6:45 AM.
04/15/24 no data at 7:00 AM
h) Resident #60
Review of 15-minute monitoring sheets with DON on 04/23/24 at 5:14 PM, DON agreed that many pages were missing location and/or nurse signature as well as multiple blank spaces. The following sheets had blank spaces/missing data for the following times:
03/08/24 no data from 2:45 PM to 6:30 PM.
03/10/24 no data from 7:15 PM to 10:30 PM.
04/18/24 no data at 10:15 AM
i) Resident #90
During a medical record review on 04/24/24 at 1:30 PM Resident #90's medical record revealed a physician order dated 03/19/24 at 9:34 AM for Neuro checks every shift for post fall 03/19 for three days.
Further record review revealed a neuro check record was void the following documentation on 03/19/24:
-8:00AM
-8:15 AM
-8:30 AM
-8:45 AM
-9:45 AM
-10:45 AM
-11:45 AM
-12:45 PM
-4:45 PM
During an interview on 04/24/24 at 11:19 AM the DON acknowledged the neuro checks were not completed according to the physician orders.
By the end of the survey no facility neuro check policy was provided.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 and remained as free of accident hazards as was possible. This was a random ...
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Based on observation and staff interview the facility failed to ensure the resident environment over which it had control and remained as free of accident hazards as was possible. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents who reside at the facility. Facility census: 99.
Findings included:
a) Medication room
On 04/24/24 at 1:04 PM the medication room door was observed propped open and unattended. This was witnessed by Licensed Practical Nurse (LPN) #56. LPN #56 stated the Pharmacy tech was the person that did it.
On 04/24/24 at 1:09 PM the Pharmacy Tech returned to the medication room from a room beside the Medication room and closed the door.
b) Electrical box
On 04/24/24 at 1:10 PM at the west nurse's station there was an electrical box on the wall that had a padlock on the door, but the padlock was unlocked. This was pointed out to LPN #56. LPN #56 locked the padlock.
The above observations were reported to the Administrator at 1:15 PM. No comments were made.
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
Staffing Information
(Tag F0732)
Could have caused harm · This affected multiple residents
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Based on facility documents and staff interviews the facility failed to meet the requirements of the staff posting by failing to reflect the actual number of staff who worked and the actual number o...
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Based on facility documents and staff interviews the facility failed to meet the requirements of the staff posting by failing to reflect the actual number of staff who worked and the actual number of hours they worked. This failed practice had the potential to affect a limited number of residents. Facility census: 99.
Findings included:
a) Staff Posting
On 04/22/24 at 3:23 PM, the Administrator provided the staff postings for the last two (2) weeks. A review of these documents revealed the posting sheets were not a working sheet to reflect a call-out. The Administrator was asked if the facility had any callouts in that time frame.
After a review of the direct care staff time punch card for the last two (2) weeks it was found the facility had 13 callouts in that time frame.
On 04/24/24 at 9:10 AM the Administrator agreed the staff postings had not been corrected and/or updated the reflection of the actual number of staff that worked.
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
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
Based on observation and staff interview the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents. This was a random opportunity for discovery and had the...
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Based on observation and staff interview the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents. This was a random opportunity for discovery and had the potential to affect a limited number of residents who reside at the facility. Facility census: 99.
Findings included:
a) Low temperature
On 04/24/24 at 12:45 PM an observation of the residents sitting at the nurses with a blanket on. The area felt very cool. Called for Maintenance Assistant #6 to please check the temperature at chair level with an ambient thermometer.
On 04/24/24 at 12:49 PM Maintenance Assistant #6 had an ambient thermometer and the temperature at chair level was 61 degrees and the wall thermometer was set on 69. Maintenance Assistant #6 changed it to 74 degrees. Maintenance Assistant #6 went on to say he had to change the thermostat back up all the time.
Feb 2024
2 deficiencies
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
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Based on observation and staff interview the facility failed to ensure they maintained a clean and sanitary environment for all residents. Observations were made of torn pillows and a room with an f...
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Based on observation and staff interview the facility failed to ensure they maintained a clean and sanitary environment for all residents. Observations were made of torn pillows and a room with an foul odor. These were random opportunities for discovery. Resident identifiers: #67 and #75. Census: 94.
Findings included:
a) Resident #67
On 02/14/24 at 1:00 PM an observation of Resident #67's yellow pillow revealed it was torn in several places. On 02/15/24 at 9:30 AM an observation revealed Resident #75's yellow pillow was torn in several places. Resident #75's pillow was shown to Social Worker #79 on 02/15/24 at 9:40 AM. On 02/15/24 at 12:45 PM the director of nurses (DoN) said she saw the pillow and replaced it after the surveyor observed it on 02/14/24.
b) Resident #75
An observation of Resident #75's room, on 02/14/24 at 11:00 AM, revealed a strong odor coming from the room. A half full urinal was observed sitting in the window seal. Nurse Aide #32 said the odor was from Resident #75. Nurse Aide #32 said the resident was a heavy wetter and the mattress was where the odor was coming from. The mattress which was blue had discolored circular areas on it. Nurse Aide #32 said he would have Housekeeper #115 spray the mattress and pillows down. At 3:45 PM another observation of the room revealed the odor was still present. Nurse Aide #32 said he had not put sheets on the bed yet because it was still wet from where Housekeeper #115 had sprayed it. NA #32 said the resident did not like to wear briefs but instead liked to wear pull ups. The resident also had a yellow pillow with rips and tears.
On 02/15/24 at 11:30 AM Licensed Practical Nurse (LPN) #65 said Resident #75 would dump his urinal in the heat/ac unit. On 02/15/24 at 1:15 PM the Senior Executive Director said she knew Resident #65's room had a foul urine odor but the facility did not really know what else to do about it. She said was known to pour his urinal down into the heat/air condition unit.
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 F0676
(Tag F0676)
Could have caused harm · This affected multiple residents
Based on observation, record review and staff interview the facility failed to ensure three (3) residents who were random opportunities of discovery had Activities of Daily living (ADL) provided for t...
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Based on observation, record review and staff interview the facility failed to ensure three (3) residents who were random opportunities of discovery had Activities of Daily living (ADL) provided for them in the form of grooming (nail care). Resident identifiers: #29, #41, and #76. Facility census: 94.
Findings included:
a) Resident #29
An observation of Resident #29's finger nails on 02/14/24 at 12:50 PM revealed the resident's nails were long and jagged with debris underneath them. Resident #29 said he would not mind to have his nails trimmed. The resident's care plan revealed he was dependent for ADLs.
b) Resident #41
An observation of Resident #41's hands on 02/14/24 at 11:00 AM revealed the resident had long jagged fingernails. Resident #41 said she he would let a facility staff member trim/cut his finger nails. Care plan review revealed the resident was dependent for ADLs.
c) Resident #76
An observation of Resident #76's hands on 02/15/24 at 11:30 AM revealed the resident had long fingernails with debris underneath them.
The care plan review revealed the resident was dependent for activities of daily living (ADLs).
On 02/15/24 at 10:00 AM Nurse Aide #28 said residents get nail care done on shower/bath days.
During an interview with Licensed Practical Nurse (LPN) #58, on 02/15/24 at 1:15 PM, she said she was the LPN working on the hall where these three (3) residents reside and she agreed they would be dependent upon staff for nail care.
Dec 2023
26 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected multiple residents
Based on observation and staff interview the facility failed to ensure the residents environment over which it had control was free from accident hazards. There was an unlocked medication room that co...
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Based on observation and staff interview the facility failed to ensure the residents environment over which it had control was free from accident hazards. There was an unlocked medication room that contained medicaitons on the dementia care unit. This was a random opportunity for discovery. The deficient practice put all 23 residents currently residing on the dementia care unit at risk for serious injury, serious harm, serious impairment, or death. Resident identifiers: #56, #88, #59, #67 #33, #87, #43, #37, #13, #66, #68, #14, #86, #70, #8, #81, #54, #78, #19, #48, #1, #52, and #6. Facility Census: 91.
Findings included:
a) Record review of the facility's policy titled, Storage of Medications, with revision date November 2020, showed:
-Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity control. Only persons authorized to prepare and administer medications have access to locked medications.
- The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.
-Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended.
-Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses ' station or other secured location.
An observation on 12/04/23 from 10:32 AM to 10:44AM found the Alzheimer's unit medication room unsecure and unattended and allowing access to medication by residents, unauthorized staff, or visitors. The medication room remained unlocked until the surveyor's intervention. At 10:44 am the certified nursing assistant was asked to find the unit manager. Once Unit Manager #91 arrived and realized the door to the medication room was unlocked and the door latch was loose with the screws backing out, she went and got Licensed Practical Nurse (LPN) # 46. When the LPN arrived at the medication room the following items were found in the room and were accessible to all residents currently residing on the dementia care unit:
In the Refrigerator:
-Trulicity
-Novolog
-Basaglar
-Tuberculin
-Prevar
In an unlocked cabinet:
- Cigarettes
-Amiodarone hcL
-ELIQUIS
-Promethazine
-Allopurinol
-Ondansetron
-Bethanechol
-Methocarbamol
-Warfarin
-Trazodone
-Escitalopram
-Isosorbide Mononitrate
-Carvedilol
-Atorvastatin
-Ezetimibe
-Clorindione
-Ropinirole
-Furosemide
-Clopidogrel
Many over the counter medication was located on an open shelf.
The facility was notified of the immediate jeopardy (IJ) at 1:33 PM on 12/04/23. The facility submitted their first abatement plan of correction (POC) at 3:57 PM on 12/04/23. The state agency requested changes and the second abatement POC was submitted at 4:18 PM on 12/04/23. The abatement POC was accepted by the state agency at 4:26 PM on 12/04/23. After observation of the implementation of the abatement POC, the IJ was abated at 10:30 AM on 12/05/22. The IJ started on 12/04/23 and ended on 12/05/23.
The facility's approved abatement POC consisted of the following:
-The door to the Life Enrichment Unit (LEU) medication room was immediately locked.
-This affected all Residents in the LEU but did not affect any of the unit as the unit is not accessible to other residents.
-Change door lock to a self-locking doorknob. This will be completed today by the maintenance staff.
-All staff in the facility at this time will be educated related to ensuring that all required doors are always locked, by the Staff Development Nurse. All staff will be educated before working in order to ensure all doors remain locked at all times, staff will be educated by the Staff Development Nurse or designee.
-All doors required to be locked will be checked twice a shift by the Charge Nurse on that Hallway. Doors will be checked twice a day for 14 days then once a day for 30 days, will reassess the need for monitoring at that time. Any doors found unlocked will be immediately locked and staff present will be educated related to locking the doors. Documentation of the door checks will be reviewed each morning in clinical meetings to ensure that checks are being completed as planned.
DISCLAIMER: The preliminary findings and subsequent abatement plan are not an admission of wrongdoing, but an acknowledgement of the surveyor's preliminary findings.
During an interview, on 12/04/23 10:58 AM, Unit Manager #91 and Licensed Practical Nurse (LPN) #46, verified the medication room should have been locked when unattended.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
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Based on record review, staff interview, and resident interview the facility failed to protect Resident #34 from sexual abuse resulting in actual psychosocial harm. The facility failed to ensure Res...
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Based on record review, staff interview, and resident interview the facility failed to protect Resident #34 from sexual abuse resulting in actual psychosocial harm. The facility failed to ensure Resident #34 was safe and not exposed to continued sexual abuse from Resident #10. This was a random opportunity of discovery. Resident identifier: #34, #10. Facility Census: 91.
Findings included:
a) Resident #34
A review of the facility reportables on 12/04/23 at 10:30 AM revealed the following Adult Protective Services (APS) Mandatory Reporting Form dated 11/23/23. The form contained the following information:
The Alleged Victim Resident #34
The Alleged Perpetrator Resident #10
The date of incident: 11/23/23
Time of Incident: 7:25 PM
Where Incident occurred: Facility Lobby
Describe incident: Perpetrator accused of sexual misconduct of victim.
How long has the abuse existed? one episode today and previous episodes exist.
A review of the following Statement/Interview Documentation Forms revealed the following information pertaining to this incident:
-- Form dated 11/23/23 Nurse Aide (NA) #54 reported she was leaving the building and spotted Resident #34 sitting in her chair in front of the fireplace in the lobby. Resident #10 was standing in front of her with his penis in her mouth. His pants were down around his thighs. NA #54 redirected both residents to their rooms and notified the nurse on duty.
-- Form dated 11/23/23 Resident #34 stated He was trying to get close to me and I didn't want him to. He stated that he wanted me to suck him out and another words he wants to (F***) me, and I don't want to (F***) him. He tried to put his penis in my mouth, but he couldn't do it.
-- Form dated 11/23/23 Resident #10 stated, I'm not incriminating myself.
-- Form dated 11/24/23 Staff # 54 stated I, (First and Last name of NA #54), was working on Thursday November 23, 2023. I had clocked out at 7:32 PM and was walking toward the front of the building. That's when I saw resident, #10, standing up in front of the fireplace with his pants down. While another Resident #34 giving him a blow job (the act of stimulating a man's penis with the mouth for sexual pleasure). I had redirected them. Then I went back to west hall to report it to (Licensed Practical Nurse LPN #4's name)
A review of Resident #34's medical records on 12/04/23 at 2:13 PM found the following progress notes:
Resident #34 had a diagnosis of mild intellectual disability.
-11/24/23 at 2:00 PM typed as written SW (Social Worker) met with the resident, (Resident #34 name). She discussed with SW the incident that happened with a male resident. (Resident #34 name) related feeling safe and not afraid. During the course of the conversation, (Resident #34 name) started talking about her childhood and some of the abuse that she sustained at a young age.
-A Comprehensive Encounter on 12/01/23 at 5:00 PM typed as written Per nursing, noticed a change in resident's behavior and does not seem to be herself. The patient states that she is feeling not good and her mood is up and down
-11/27/23 at 2:00 PM typed as written Patient has experienced crime related events: Sexual Assault- rape, attempted rape, made to perform sexual acts against consent .
Patient has experienced environmental events:
None of the above
Trauma Responses:
Upsetting thoughts or memories about any of the above mentioned come into your mind against your will? Yes.
A follow up interview with the Social Worker on 12/07/23 at 8:47 AM, confirmed that during her interview with Resident #34 on 11/24/23 at 2:00 pm, Resident #34 disclosed to her she had been sexually abused previously by her family at a young age.
During a record review on 12/04/23 at 12:56 PM of Resident #10's medical records the following notes were found:
-09/06/23 at 11:12 AM Resident to Resident encounter of verbal sexual abuse to Resident #57.
-11/09/23 at 11:00 AM Resident to Resident encounter of verbal sexual abuse to Resident #34.
-11/09/23 at 3:55 PM Resident to Resident encounter of verbal sexual abuse to Resident #34.
-11/12/23 at 11:39 AM Resident to Resident encounter of verbal sexual abuse to Resident #34.
-11/23/23 at 11:04 AM Resident to resident encounter of sexual nature with Resident #37.
During the review of the facility's APS Mandatory Reporting Forms on 12/04/23 at 10:30 AM revealed a form dated 06/22/23. The Alleged Victim was Resident #72, and the Alleged Perpetrator was Resident #10.
Describe incident: (First and last name of Resident #10) told (First and Last name of Resident #72) if she would suck his (d***) he would give her a cigarette.
Describe action taken to prevent further abuse/neglect: (First and last name of Resident #10) has been told to not go into resident's room.
Between 09/06/23 and 11/23/23 at the time of the sexual abuse of Resident #34 Resident #10 had six (6) instances of inappropriate sexual behavior. The facility failed to identify his pattern of behavior and take steps to ensure the safety of Resident #34.
During an interview on 12/05/23 at 8:25 AM the Administrator stated, (Resident #10's name) has had sexual behaviors. We have tried several things, like 15-minute checks, room changes, medication changes and alternative placement. I know the medical records were void of any evidence of the placement attempts by the previous Social Worker. The situation is unfortunate. He has a lot of street smarts and knows how to answer questions to keep himself out of trouble.
During an interview on 12/06/23 at 2:36 PM the Administrator stated some of the incidents involving (Resident #10's name) I was not aware of. Then we looked at everything, if it was not hands on it did not get reported. I am not saying it is ok but if it was not an actual physical situation it was not reported.
The Administrator was asked when resident #10 fondled Resident #37's breast, why did you not report it? The Administrator stated it was just an attempt to fondle the breasts, he did not touch them. I felt the staff did not report an attempt because they stopped it before it happened. I am not saying that this was handled appropriately. We have a need for education on reporting.
The Administrator was asked Was the incident on 11/23/23 involving Resident #34 reported to the police? The administrator stated yes but it was reported but no documentation was done because they never returned my phone calls.
The Administrator was asked why was (Resident #10 name) on 1:1 prior to 11/23/23 incident to ensure the safety of Resident #34?
The Administrator stated, I am not sure, I would have to look at the timeline.
No evidence of documentation of a timeline was ever presented to the Survey team prior to the exit.
The Administrator stated there was a misconception of what was and was not abuse. I do not read notes daily and nursing must have not caught that information.
b) Facility's abuse policy
A review of the facility policy titled Freedom from Abuse and Neglect Policy found the following:
Training:
.3. Staff members will identify and assess suspected or alleged reports of abuse and neglect. Types of abuse may include:
.C. Rape or other sexual
1. Sexual harassment
2. Sexual assault
3. Sexual coercion
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 staff interview, the facility failed to treat each resident with dignity and respect. This was true for one (1) of one (1) resident reviewed for the dignity care area and on...
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Based on observation and staff interview, the facility failed to treat each resident with dignity and respect. This was true for one (1) of one (1) resident reviewed for the dignity care area and one (1) random opportunity for discovery . Resident Identifiers: #66, #74. Facility Census: 93.
Findings included:
a) Resident #66
On 12/6/23 at approximately 12:27 PM, during a tour of the facility, Resident #66 was observed sitting up in their bed while Nurse Aide (NA) #42 stood over top of them while feeding the resident their noon time meal.
On 12/6/23 at approximately 12:27 PM, NA #42 stated in an interview they knew they were supposed to be sitting down, next to Resident #66 while providing feeding assistance and they were sorry. NA# 42 then stated, Resident #66 is finished eating anyway.
b) Resident #74
A review of the facility policy titled Dignity with a revision date on 02/21 read as follows.
Policy Interpretation and Implementation
.11. Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.
During an observation on 12/06/23 at 10:02 AM, This surveyor knocked on Resident # 74's door, the sitter was sitting in the room. This surveyor asked to enter the room, Resident #74, and the sitter both stated Yes. As the surveyor was walking in Resident # 74's room, a resident was sitting in his wheelchair with a t-shirt on, Resident #74 was standing up from his wheelchair. He was standing in front of the window beside his bed, Resident # 74 had no pants on, and his penis was visible.
Resident #74 was asked Are you getting dressed? The Nurse Aide/sitter(NA) #11 stated yes.
NA was asked why the privacy curtain and the blinds are not closed?
NA #11 stated The curtain was closed but he opened it. The NA was asked what about the blinds why are they not closed. No information was provided. NA #11 proceeded to close the blinds and curtains upon surveyor intervention.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
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Based on resident and staff interview, the facility failed to provide services in the facility with reasonable accommodation of resident needs and preferences, by failing to ensure residents were pr...
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Based on resident and staff interview, the facility failed to provide services in the facility with reasonable accommodation of resident needs and preferences, by failing to ensure residents were provided with the proper sized undergarments. This was true for one (1) of one (1) resident reviewed for the accommodation of needs care area. Resident identifiers: 43. Facility Census: 93.
Findings Include:
a) On 12/5/2023 at approximately 12:54 PM, during an interview, Resident #22 stated the facility will frequently run out of bariatric incontinence supplies and the Nurse Aides will have to put them in a smaller size, which cuts into their sides.
On 12/11/23 at approximately 10:30 AM, during an interview with Central Supply Clerk (CSC) #2 the employee said the facility did run out of bariatric incontinence supplies and the staff would have to put smaller sizes on the residents until they received a shipment of new ones, or they can borrow some from another facility.
On 12/11/23 at approximately 11:02 AM, an interview was conducted with Nurse Aide (NA) # 82. NA #82 stated, The only supplies we ever have problems with are bariatric ones. NA #82 stated staff will have to put smaller sizes on residents when they are out of bariatric incontinence supplies until they get more.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, resident interview, and staff interview, the facility failed to provide a safe, clean, comfortable, and h...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, resident interview, and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike This has the potential to affect more than a limited number of residents . Resident identifiers: #45, #48, #86, and #92. Room numbers: #117, #126, #129, #130, #131, #133, #201, #302, #304, #312, #311, #31, and #303. Facility Census: 91.
Findings Include:
a) Hallways
On 12/04/23 at approximately 10:34 AM, Excessive debris in the floor in front of the storage closet on the East Front hallway was observed.
On 12/04/23 at approximately 10:39 AM, observation of the floors in the East Back hallway found excessive debris in the floor, in front of resident rooms, and thick layers of dirt and debris in the corners of the hallway.
On 12/04/23 at approximately 10:44 AM, Environmental Services Manager (EVSM) #118, witnessed the condition of the hallways.
b) room [ROOM NUMBER]
On 12/04/23 at approximately 10:35 AM, popcorn and excessive debris was observed on the floor in room [ROOM NUMBER]. EVSM #118 witnessed the condition of the floor in the room and stated that it probably should be cleaned again.
c) room [ROOM NUMBER]
On 12/04/23 at approximately 11:13 AM, room [ROOM NUMBER] was observed to have excessive amounts of trash on the floor along with a sticky brown substance in multiple places throughout the room. The condition of the room was witnessed by Human Resources Partner (HRP) #65.
d) Main Dining Room
On 12/04/23 at approximately 10:59 AM, the main dining room was observed tohave food on the floors underneath the tables. There was excessive debris throughout the entire dining room. Thick layers of dust, excessive debris, and food were observed under the ice and vending machines in the dining room. Food was observed on the floor in front of the kitchen door. EVSM #118 witnessed the condition of the dining room and, concerning the condition of the floors underneath the vending and ice machines, stated Honestly, it probably hasn't ' ever been touched under those things.
On 12/04/23 at approximately 3:25 PM, an observation was conducted in the main dining room and revealed there was still food and debris under tables, the piano, and next to the vending machines.
d) Dining Room on dementia care unit
On 12/04/23 at approximately 11:37 AM, food, excessive debris, and a thick brown ball was observed on the floor of the dining room in the dementia unit. Nursing Aide (NA) #54, stated the dining room is supposed to be cleaned after every meal but it was not cleaned after breakfast this morning. NA #54 stated It ' s hard to get anyone to clean in here.
On 12/04/23 at approximately 11:42 AM, EVSM #118 was made aware of the condition of the dining room in the dementia unit. EVSM #118 stated, it is hard to clean the dining room because residents are always in there and stated You have to use common sense and know you cannot clean if residents are in the dining room. EVSM #118 then picked up the thick brown ball out of the floor without gloves and did not perform hand hygiene.
e) Resident #65
During the initial tour of the facility on 12/05/23 at 1:21 PM Resident #65's over the bed table was identified as having the following issues, the lament was peeling and the chipboard was exposed and deteriorating.
During an interview on 12/07/23 at 10:48 AM the Maintenance Area Supervisor #120 acknowledged the chipboard on the over the bed table was exposed and the table needed to be replaced.
f) Dementia Care Unit
During tour of the Dementia Care Unit throughout the Long-term care survey process, room [ROOM NUMBER], #304, #312, #315, #311, and #303 were not homelike. These rooms did not have pictures, calendars, or personal items. Also, many rooms did not have clocks or curtains.
During an interview on 12/12/23 at 8:46 AM the Life Engagement Coordinator confirmed the residents' families decorate the rooms that have personal items. She continued to say the facility only decorates the common areas. She verified if residents don't have family or friends to bring items to make their stay more home like, the facility does not provide items.
During the interview and tour with Maintenance Director #12O on 12/12/23 at 9:43 AM, he verified room [ROOM NUMBER], #304, #312, #315, #311, and #303 were not homelike.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
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Based on record review and staff interviews the facility failed to provide the resident and/or representative with the bed hold policy at the time of discharge. This was true for one (1) of two (2) ...
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Based on record review and staff interviews the facility failed to provide the resident and/or representative with the bed hold policy at the time of discharge. This was true for one (1) of two (2) residents reviewed for the care area of hospitalizations during the long term care survey process. Resident Identifiers: #46. Facility Census: 93.
Findings Included:
a) Resident #46
On 12/11/23 at 11:00 AM, during a record review of Resident #46 for hospitalizations, one (1) of four (4) bedhold notifications was not available. During an interview on 12/11/23 at 11:30 AM, Staff # 68 was unable to provide the requested behold notification dated 6/23/23. Staff #75 followed up on 12/11/23 at 2:40 PM to confirm the behold document was not found. Staff #75 stated they could not speak to why but they would do better next time.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
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Based on medical record review and staff interview the facility failed to ensure a new Pre admission Screening and Resident Review (PASARR) was completed to reflect the residents new diagnosis bipol...
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Based on medical record review and staff interview the facility failed to ensure a new Pre admission Screening and Resident Review (PASARR) was completed to reflect the residents new diagnosis bipolar disorder and major depression. This was true for one (1) of two (2) residents reviewed in the PASARR care area. Resident Identifiers: Resident #45. Facility Census: 93.
Findings Included:
a) Resident #45
During a record review on 12/06/23 09:42 AM, Resident # 45's PASARR dated 09/07/21 was void of the diagnosis of affective bipolar disorder and Major depression. Further record review revealed the following diagnosis included:
-Schizoaffective Disorder 06/04/21
-Affective Bipolar Disorder 06/04/21
-Major Depression 03/15/23
During an interview on 12/07/23 at 8:43, AM the Social Worker (SW) stated I was unaware we needed to do a new PASARR with a new diagnosis. I have worked in long term care for years, and never knew that. The SW acknowledged a new PASARR should have been completed.
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 the resident's Pre-admission Screening (PAS) reflec...
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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 the resident's Pre-admission Screening (PAS) reflected pre-admission diagnoses for one (1) of one (1) resident reviewed for the category of PASARR, during the long-term care survey. Resident identifier #40. Census 93.
Findings Included:
a) Resident #40
On 12/07/23, a record review of the resident's electronic medical record (EMR), the resident's most recent PAS, dated 08/11/22, indicated no level II was needed. Section lll #30 MI/MR Assessment indicated No current diagnosis.
The record also revealed indicated the resident had a psych diagnosis of Major Depression on admission [DATE] but did not receive a new PAS to address whether or not specialized services were needed.
On 12/07/23 at 2:23 PM the Director of Nursing verified, Resident #40's PAS did not reveal his diagnosis of Major Depression. She confirmed a new PAS was not completed.
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 medical record review and staff interview the facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives for Resident #47 and Resident #40...
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Based on medical record review and staff interview the facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives for Resident #47 and Resident #40. This was true for two (2) of 20 residents sampled during the Long-Term Care Survey Process (LTCSP). Resident Identifiers: Resident #47 and Resident #40. Facility Census: 93.
Findings included:
a) Resident #47
During a record review on 12/07/23 at 9:30 AM, Resident # 47's medical record revealed a care plan with an initiated date of 10/11/23 was void any focus, goals, and interventions for the resident-to-resident sexual encounter of nature.
During an interview on 12/11/23 at 10:03 AM, the Director of Nursing (DON) acknowledged the care plans did not reflect any plans for the resident-to-resident sexual encounter of nature.
b) Resident #40
On 12/05/23 at 12:05 PM during an interview Resident #40 stated that all he does is lay in bed or watch tv. He stated that there is nothing to do.
A review of the current care plan with the initiated date of 08/01/22 showed there was no care plan addressing Activities or Resident #40's preferences, with interventions and goals. This showed it was not updated to reflect Resident #40's current status.
During an interview, on 12/11/23 at 3:55 PM, the Director of Nursing (DON) confirmed there was no Activities care plan for Resident #40 The DON stated she will have the care plan updated to reflect his activity preferences.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
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Based on observation, family interview, staff interview and medical record review the facility failed to ensure Resident #66 maintained acceptable parameters of hydration status. This was true for o...
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Based on observation, family interview, staff interview and medical record review the facility failed to ensure Resident #66 maintained acceptable parameters of hydration status. This was true for one (1) of one (1) resident reviewed for the Nutrition/Hydration Status area of care. Resident Identifiers: 66. Facility Census: 93.
Findings Include:
a) Resident #66
On 12/05/23 at approximately 12:34 PM, during a tour of the facility, it was observed that no water was placed within reach of Resident #66. Upon further observation, it was discovered there was no water in Resident #66's room.
On 12/06/23 at approximately 2:20 PM, a family interview was conducted in Resident #66's room. The family member stated Resident #66 is not able to reach for or hold things up well enough to eat or drink. The family member stated Resident #66 is often thirsty when I visit and I am worried [they] are not getting enough to drink. A full glass of thickened water was observed sitting out of reach of Resident #66 on the nightstand, during the family interview.
On 12/06/23 at approximately 2:23 PM, an interview was conducted with Nurse Aide (NA) #82 regarding Resident #66's hydration. NA #82 stated staff is supposed to offer drinks to Resident #66 every hour, due to them not being able to reach for and hold items on their own. NA #82 stated they were not caring for Resident #66 today.
On 12/06/23 at approximately 2:25 PM, an interview was conducted with Nurse Aide (NA) #30, who was Resident #66's NA. NA #30 was asked how often drinks are offered to Resident #66, they stated, This isn't usually my assignment, but I will offer them drinks at breakfast, lunch, and dinner. NA #30 was unable to recall whether they had offered Resident #66 a drink today.
On 12/06/2023 at approximately 3:05 PM, during a tour of the facility, it was observed a full glass of thickened water remained on the nightstand next to Resident #66's bed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0745
(Tag F0745)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to ensure medically-related social services were maintained to ensure the highest practicable well-being of one (1) of 20 residents revi...
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Based on record review and staff interview, the facility failed to ensure medically-related social services were maintained to ensure the highest practicable well-being of one (1) of 20 residents reviewed during the Long-term Care Survey Process (LTCSP). Resident #44 was identified as having grief and there was lack of evidence the resident was monitored and or interventions implemented during the grief process. Resident identifier: Resident #44. Census: 93.
Findings included:
a) Resident #44
A record review on 12/7/23, showed a progress note, dated 10/31/23, in which Resident #44 was informed of the death of a sister. It was also noted that the resident agreed to have grief counseling.
An assessment was conducted on 11/16/23 noting the assessor documented areas were not assessed due to a language barrier. For example, past history was unknown due to language barrier, suicidal ideation's, homicidal ideations and notes indicated unable to score to language barriers. However, the resident was assessed as having grief with recommendations to encourage resident to participate in activities such as massage and aromatherapy and psychotherapy as indicated. Follow up within 3-6 months or sooner as indicated, address concerns and questions.
An interview with Nurse Practitioner (NP) #119, on 12/07/23 at 08:25 AM, verified the assessment conducted on 11/16/23, did show areas of the exam not completed due to a language barrier and stated further, it was unsure why that was a factor. It was also stated by NP #119, the facility was able to reach the agency that had conducted the exam 24 hours a day, seven (7) days a week for any questions or issues.
There was lack of evidence, in the electronic health record, that staff had questioned the assessment not being completed in depth due to the resident's language barrier.
An interview with Social Worker #74, on 12/11/23 at 10:10 AM, revealed there was lack of evidence social service monitoring was conducted from 10/31/23 through 12/10/23, or the assessment was reviewed to determine reason for areas not able to be assessed.
During the interview, on 12/11/23 at 10:10 AM, Social Worker #74, confirmed the resident was able to be understood and understood when spoken to directly but did wear a hearing aide.
Social Worker #74 revealed during the interview, it was not certain the resident had the hearing aide in place for the assessment. Social Worker #74 stated, There were times when the resident was visited but no record of the visit or results of the visit in relation to grief could be found. No additional information was provided at the time of exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation and staff interview, the facility failed to ensure drugs and biologicals, used in the facility, were stor...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation and staff interview, the facility failed to ensure drugs and biologicals, used in the facility, were stored, and labeled in accordance with current accepted professional practices. This was true for medications stored in one (1) of two (2) medication carts inspected. The facility failed to ensure medications were dated when opened and put in to use or was found to be expired and still being stored for use. This practice had the potential to effect more than a limited number of residents. Resident identifiers: Resident #7, and Resident #50. Facility census: 93
Findings included:
a) An observation of the East Front Medication Cart, on [DATE] at 10:17 AM, revealed a vial of Levimir insulin for Resident #50, that was opened but had no date of when the vial of insulin was opened for use. Licensed Practical Nurse (LPN) #4 was questioned about the undated opened vial of insulin during this time. LPN #4 verified the vial of Levimir insulin was opened and being used for Resident #50, but did not contain a date of when the insulin was opened.
b) An observation of the East Front Medication Cart, on [DATE] at 10:30 AM, revealed an insulin quick pen containing Lantus, for Resident #7. The date opened was labeled [DATE]. LPN #4 verified the pen was labeled as opened and put in to use on [DATE] and was still being used.
A review of the Manufacturer and pharmacy recommendations for Lantus insulin was the medication should be discarded after 28 days of use. The Lantus quick pen was not discarded after 28 days of opening the insulin as confirmed by LPN #4 during the medication cart inspection on [DATE] at 10:30 AM.
An interview, with the Director of Staff Development, on [DATE] at 10:44 AM, verified staff were to be labeling the insulin when opened and put into use, as well as, replacing insulin every 25-28 days to ensure the facility was following the manufacturers instruction. The Director of Staff Development further stated, staff were in need of some education because if the insulin was not discarded correctly staff would continue to administer what was on the medication cart.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview the facility failed to provide a COVID-19 booster vaccination for one (1) of five (5) residents reviewed for compliance with Covid -19 vaccinations. ...
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Based on medical record review and staff interview the facility failed to provide a COVID-19 booster vaccination for one (1) of five (5) residents reviewed for compliance with Covid -19 vaccinations. Resident identifier: #72. Facility Census: 93.
Findings included:
a) Resident #72
Medical record review, on 12/12/23, for Resident #72 revealed he did not receive a Covid-19 vaccination booster. Continued review found Resident #72's could have received the Covid-19 booster on 03/27/22.
On 12/12/23 at 10:28 AM during an Interview, the Infection Preventionist verified Resident #72 did not receive the Covid-19 booster when eligible and the facility did not follow up on the missed dose.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected multiple residents
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Based on medical record review, policy review and staff interview the facility failed to notify the physician and/or resident representative in a timely manner when a resident had a change in condit...
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Based on medical record review, policy review and staff interview the facility failed to notify the physician and/or resident representative in a timely manner when a resident had a change in condition. Resident #73 perpetrated sexual abuse on Resident #47, #60, and #17 on several occasions. The facility staff failed to notify the physician and/or responsible parties of these incidents. Resident identifiers: #74, #47, #60 and #17. Facility Census: 93
Findings included:
A review of the facility policy titled Freedom from Abuse and Neglect Policy read as follows.
.Investigation:
.3. Investigations will be prompt, comprehensive and responsive to the situation and contain founded conclusions. The investigation will include, but is not limited to the following:
a. Notification of physician and representative; .
a) Resident #74
During a review of the facility mandatory reportable forms on 12/04/23 at 2:00 PM, A resident to resident encounter of sexual nature which occurred on 11/23/23 and 09/06/23 by Resident #74.
During a record review on 12/05/23 at 8:49 AM, Resident # 74's medical record revealed the following sexual encounters:
-On 11/23/23 an sexual encounter of nature
-On 11/12/23 an encounter of verbal sexual abuse
-On 11/09/23 an encounter of verbal sexual abuse
-On 11/09/23 an encounter of verbal sexual abuse
-On 09/06/23 an encounter of verbal sexual abuse
During a medical record review on 12/06/23 at 8:57 AM, Resident #74's medical records were void of any notification of the incident to the physician and/or resident's representative.
During an interview on 12/06/23 at 1:43 PM, the Director of Nursing (DON) acknowledged the physician and/or resident's representative was not notified of these resident-to-resident occurrences involving Resident#74.
B) Resident #47
During a record review on 12/05/23 at 2:53 PM, medical records revealed the following resident to resident verbal sexual abuse:
-On 11/12/23 an encounter of verbal sexual abuse.
-On 11/09/23 an encounter of verbal sexual abuse.
-On 11/09/23 an encounter of verbal sexual abuse.
During a medical record review on 12/06/23 at 9:04 AM, Resident #47's medical records were void of any notification of the incident to the physician and/or resident's representative.
During an interview on 12/06/23 at 1:43 PM, the DON acknowledged the physician and/or resident's representative was notified of the resident-to-resident occurrence.
c) Resident #60
During a review medical record on 12/06/23 at 8:59 AM, A resident to resident encounter of sexual nature which occurred 11/23/23 with Resident #60 was found.
During a medical record review on 12/06/23 at 9:11 AM, Resident #60's medical records were void of any notification of the incident to the physician and/or resident's representative.
During an interview on 12/06/23 at 1:43 PM the DON acknowledged the physician and/or resident's representative was not notified of the resident-to-resident occurrence.
d) Resident #17
During a review of the facility mandatory reportable forms on 12/06/23 at 8:59 AM, found a resident-to-resident encounter of sexual nature which occurred 09/06/23 with Resident #17.
During a medical record review on 12/06/23 at 9:02 AM, Resident #17 medical records were void of any notification of the incident to the physician and/or resident's representative.
During an interview on 12/06/23 at 1:43 PM, the DON acknowledged the physician and/or resident's representative was not notified of the resident-to-resident occurrence.
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
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, resident interview, and staff interview, the facility failed to make information on how to file a grieva...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, resident interview, and staff interview, the facility failed to make information on how to file a grievance or complaint available to the resident, and to establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights . This has the potential to affect more than a limited number of residents . Resident Identifiers: Resident Council, 22, 28. Room numbers: #117, #126, #129, #130, #131, #133, #201. Facility Census: 91.
Findings included:
a) Resident #22
On 12/05/23 at approximately 12:54 PM, Resident #22 reported they were missing 15 pairs of socks, 2 gowns, and a shirt. Resident #22 stated they had reported the missing items to housekeeping, CNAs, and Nurses. Resident #22 reported they were never given a grievance form to fill out and the facility never followed up on the missing items, nor had they been found.
On 12/5/23 at approximately 3:26 PM, an interview with Senior Executive Director (SED) #50 confirmed they were aware Resident #22 had missing items but no grievance forms were filled out pertaining to the missing property.
b) Resident Council
On 12/05/23 at approximately 2:30 PM, during the Resident Council meeting, residents in attendance revealed they were not aware of the grievance process, nor did they know where to find the grievance forms at the facility. Resident #85 was the only resident in attendance who knew the grievance process. Resident #85 stated they had to ask for a grievance form and were only aware of the grievance process because they worked as a nurse in many facilities in the past.
On 12/05/23 at approximately 3:30 PM, a tour of the facility was conducted and found no grievance forms were accessible to residents throughout the facility.
On 12/05/23 at approximately 3:54 PM, an interview was conducted with Licensed Social Worker (LSW) #74. LSW #74 confirmed there were no grievance forms accessible to the residents at the facility. LSW #74 stated they would make copies of the grievance form and put them next to the front office.
Review of the facility's policy titled, grievance /concern, showed:
-Upon receipt of the grievance/concern, the grievance/concern form will be initiated by staff member receiving the concern.
-Upon receipt of the grievance /concern form, the Administrator or designee will document the grievance/concern on the grievance/concern log.
- Immediate action will be taken to prevent further potential violations of any patient's right while the alleged violation is being investigated.
-Notify the person filing the grievance of resolution in a timely manner.
c) Resident #28
During a complaint investigation on 12/04/23 a record review of the grievances log revealed, Resident #28 filed a grievance/concern form on 10/26/23 requesting not to have a male Nurse Aide taking care of her.
A continued record review found the findings and conclusions were, staff to be educated the Resident prefers female caregivers. Also, the Care Plan would be updated to reflect Resident #28's preference.
During an interview with Resident #28 on 12/04/23 at 2:38 PM, she confirmed she prefered female caregivers only.
Review of Resident #28's Care Plan and [NAME] on 12/05/23 at 12:45PM, showed they did not contain her preference for female caregivers.
On 12/05/23 at 1:29 PM during an Interview the Director of Nursing, she stated she was aware of the concern but did not know it was not followed upon. She stated she would educate the staff and update the care plan to reflect Resident #28's preferences.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected multiple residents
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Based on record review and staff interview the facility failed to implement their abuse prohibition policy regarding reporting of allegations of sexual abuse. This failed practice had the potential ...
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Based on record review and staff interview the facility failed to implement their abuse prohibition policy regarding reporting of allegations of sexual abuse. This failed practice had the potential to affect more than a limited number of residents currently residing in the facility. Resident identifiers: Resident #47 and #60 . Facility Census: 93.
Findings Included:
During a review of the facility policy titled Freedom from Abuse and Neglect Policy not dated read as follows.
.Identification:
1. Staff will immediately report any suspicious event or injury that may constitute abuse, neglect, exploitation, or misappropriation to the Executive Director.
.3. The facility will report the allegation to the State Agency in accordance with state law.
a) Resident #47
During a record review on 12/04/23 at 12:56 PM, Resident #10's medical records revealed the following notes:
-11/09/23 at 11:00 AM, Resident to Resident encounter of verbal sexual abuse to Resident #47.
-11/09/23 at 3:55 PM, Resident to Resident encounter verbal sexual abuse to Resident #47.
-11/12/23 at 11:39 AM, Resident to Resident encounter of verbal sexual abuse to Resident #47.
b) Resident #60
During a record review on 12/04/23 at 12:56 PM, Resident #74's medical records revealed a note dated on 11/23/23 at 11:04 AM Resident to resident encounter of sexual nature with Resident #60.
During an interview on 12/05/23 at 8:25 AM, the Administrator stated, (Resident #74's name) has had sexual behaviors. We have tried several things, like 15-minute checks, room changes, medication changes and alternative placement. I know the medical records were void of any evidence of the placement attempts by the previous Social Worker. The situation is unfortunate. He has a lot of street smarts and knows how to answer the questions to keep himself out of trouble.
During an interview on 12/06/23 at 2:36 PM, the Administrator stated, Some of the incidents involving (Resident #74's name) I was not aware of. Then we looked at everything, if it was not hands on it did not get reported. I am not saying it is ok but if it was not an actual physical situation it was not reported.
The Administrator was asked, When Resident #74 fondled Resident #60's breast, why did you not report it? The Administrator stated, It was just an attempt to fondle the breasts, he did not touch them. I felt the staff did not report an attempt because they stopped it before it happened. I am not saying that this was handled appropriately. We have a need for education on reporting.
The Administrator stated there was a misconception of what was and was not abuse. The administrator said, I do not read notes daily and nursing must have not caught that information.
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
Based on record review and staff interview, the facility failed to ensure an allegation of abuse was reported to all the proper State Authorities. This was true for two (2) of three (3) resident revie...
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Based on record review and staff interview, the facility failed to ensure an allegation of abuse was reported to all the proper State Authorities. This was true for two (2) of three (3) resident reviewed in the care area of Abuse during the Long Term Care Survey Process . Resident identifier: Resident #47, and Resident #60. Facility Census: 93.
Findings Included:
a) Resident #47
During a record review on 12/04/23 at 12:56 PM, Resident #74's medical record found the following notes:
-11/09/23 at 11:00 AM Resident to Resident encounter of verbal sexual abuse to Resident #47.
-11/09/23 at 3:55 PM Resident to Resident encounter of verbal sexual abuse to Resident #47.
-11/12/23 at 11:39 AM Resident to Resident encounter of verbal sexual abuse to Resident #47.
b) Resident #60
During a record review on 12/04/23 at 12:56 PM, Resident #74's medical records revealed a note dated on 11/23/23 at 11:04 AM pertaining to a resident to resident encounter of sexual nature with Resident #60.
During an interview on 12/05/23 at 8:25 AM, the Administrator stated, (Resident #74's name) has had sexual behaviors. We have tried several things, like 15 minute checks, room changes, medication changes and alternative placement. I know the medical records were void of any evidence of the placement attempts by the previous Social Worker. The situation is unfortunate. He has a lot of street smarts and knows how to answer the questions to keep himself out of trouble.
During an interview on 12/06/23 at 2:36 PM, the Administrator stated some of the incidents involving (Resident #74's name) I was not aware of. Then we looked at everything, if it was not hands on it did not get reported. I am not saying it is ok but if it was not an actual physical situation it was not reported.
The Administrator was asked when Resident #74 fondled Resident #60's breast, why did you not report it? The Administrator stated it was just an attempt to fondle the breasts, he did not touch them. I felt the staff did not report an attempt because they stopped it before it happened. I am not saying that this was handled appropriately. We have a need for education on reporting.
The Administrator stated there was a misconception of what was and was not abuse. I do not read notes daily and nursing must have not caught that information.
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 #46
On 12/05/23 at 02:16 PM, a review of Resident #46's progress notes indicated Resident #46 refuses to use his Bi-...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b) Resident #46
On 12/05/23 at 02:16 PM, a review of Resident #46's progress notes indicated Resident #46 refuses to use his Bi-pap. A review of the care plan for Resident #46 did not include the residents refusals of using his Bi-pap. On 12/11/23 at 11:21 AM, the Director of Nursing Staff #10 acknowledged the care plan does not include the residents refusal for use of bipap and interventions for the refusals as it should.
b) Resident #26
During a complaint investigation on 12/04/23 a record review of the grievances log revealed, Resident #26 filed a grievance / concern form on 10/26/23 requesting she did not want a male Nurse Aide taking care of her.
A continued record review found the findings and conclusions were, staff to be educated that Resident #26 prefers female caregivers. Also, the Care Plan would be updated to reflect Resident #26s preference.
During an interview with Resident #26 on 12/04/23 at 2:38 PM, she confirmed she prefers female caregivers only.
Review of Resident #26's Care Plan and [NAME] on 12/05/23 at 12:45PM, showed they did not contain her preference for female caregivers.
On 12/05/23 at 1:29 PM during an Interview the Director of Nursing stated she was aware of the concern but did not know it was not followed upon. She stated that she would educate the staff and update the care plan to reflect Resident #26's preferences.
Based on record review and staff interview the facility failed to revise the person-centered care plan, after a change in the resident's care or preference for care, for three (3) of 20 residents reviewed during the Long-term Care Survey Process (LTSP). Resident identifiers: Resident # 44, #26, and #46. Census: 93.
Findings included:
a) Resident #44
A record review, on 12/7/23, showed a progress note, dated 10/31/23 , indicating Resident #44 experienced the death of a sister. It was also noted the resident was in agreement to grief counseling.
An assessment was conducted on 11/16/23, which assessed the resident as having grief. Recommendations were made to encourage resident to participate in activities such as massage and aromatherapy and psychotherapy as indicated. Follow up within 3-6 months or sooner as indicated, address concerns and questions.
A review of the current care plan , updated 11/28/23 failed to contain a focus area of grief or bereavement , when the resident had consented to grief counseling after the loss of a family member.
An interview, with Social Worker #74, on 12/11/23 at 10:20 AM , confirmed grief should have been identified and addressed on the care plan, with goals and modalities to assist the resident through the grief process, when the care plan was reviewed and revised on 11/28/23. Social Worker #74, verified during the interview, that no revision had been made to Resident #44's care plan for the grief process.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
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Based on record review, resident interviews and staff interviews the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the phy...
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Based on record review, resident interviews and staff interviews the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of the Residents. This was true for four (4) of five (5) Residents reviewed in care area of Activities during the Long-Term Care Survey Process (LTCSP). Resident Identifiers: Resident #74, Resident #65, Resident #35 and Resident #82. Facility Census: 93.
Findings Included:
a) Resident #74
During a record review on 12/06/23 at 10:51 AM, Resident # 74's medical record revealed monthly activity participation record. The participation records were void documentation of any involvement in group or individual activities.
During a record review on 12/06/23 08:05 PM, Resident # 74's daily activity participation record revealed the following days void of any activity participation:
-11/01/23 to 11/05/23
-11/07/23 to 11/12/23
-11/14/23 to 11/17/23
-11/22/23 to 11/30/23
-12/01/23
-12/03/23
-12/05/23
-12/06/23
During an interview on 12/07/23 at 10:01 AM the Activity Director(AD) #24 stated, I am the only one working, I have no help, I am doing the best I can. I have had no assistant since September, its just Me. I was off a few weeks and no activities were held because its only Me. The AD acknowledged the activity participation records were incomplete and activities were not held.
b) Resident # 65
During a record review on 12/07/23 at 9:47 AM, Resident # 65's daily activity participation record revealed the following days void of any activity participation:
-11/01/23 to 11/05/23
-11/07/23 to 11/12/23
-11/14/23 to 11/17/23
-11/22/23 to 11/30/23
-12/01/23
-12/02/23
-12/03/23
-12/05/23
-12/06/23
During an interview on 12/07/23 at 10:01 AM, the AD #24 stated I am the only one working, I have no help, I am doing the best I can. I have had no assistant since September, it's just Me. I was off a few weeks and no activities were held because its only Me. The AD acknowledged the activity participation records were incomplete and activities were not held on most of the days.
c) Resident #35
During an interview on 12/05/23 at 11:27 AM, Resident #35 stated he does not enjoy the activities offered. Stated he is an adult and likes to do adult activities like fishing and stuff not coloring pictures. Resident #35 stated he does not want books or magazines from activities as this resident prefers to do it and not read about it. On 12/11/23 at 11:30 AM, A review of Resident #35's activities assessment found Resident #35 to be self directed in activities and one on one visits.
During a record review on 12/11/23 at 11:32 AM Resident #35's daily activity participation record revealed the following days void of any activity participation:
-11/01/23 to 11/05/23
-11/07/23 to 11/12/23
-11/14/23 to 11/17/23
-11/22/23 to 11/30/23
-12/01/23 to 12/03/23
-12/10/23
The Activity Director(AD) #24 acknowledged the activity participation records were incomplete and activities were not held during an interview on 12/11/23 at 12:00PM.
d) On 12/5/23 at approximately 2:02 PM, an interview was conducted with Resident # 82, in which the resident voice concerns about there not being enough activities taking place in the building. Resident #82 stated the activities they have, when they have them, are not stimulating enough. Resident #82 also stated there is not enough of a variety of activities taking place throughout the building and activities rarely happen in the evening.
On 12/7/23 at approximately 10:01 AM, an interview was conducted with Activities Director (AD) #24. AD #24 stated I am the only one working, I have no help, I am doing the best I can. I have had no assistant since September, it ' s just me. I was off for a few weeks and no activities were held because it ' s only me. AD #24 acknowledged the activity participation records were incomplete and activities were not held.
During a record review on 12/11/2023 at approximately 10:00 AM, the activity participation record for Resident #82 revealed the following days void of any activity participation:
-10/01/2023
-10/04/2023
-10/06/2023
-10/11/2023
-10/15/2023
-10/22/2023 to 10/26/2023
-10/28/2023
-10/31/2023
-11/01/2023 to 11/05/2023
-11/07/2023 to 11/12/2023
-11/14/2023 to 11/17/2023
-11/22/2023 to 12/04/2023
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
Based on record review, and staff interview the facility failed to follow Physician orders for Resident #46. Resident #46 was not getting his morning time medications as ordered by the physician on da...
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Based on record review, and staff interview the facility failed to follow Physician orders for Resident #46. Resident #46 was not getting his morning time medications as ordered by the physician on days he went to dialysis. Resident #46 also was not served food in the correct form to meet his needs and as ordered by the physician. This was true for one (1) of 20 sampled residents. Resident Identifier: #46. Facility Census: 93.
Findings Include:
a-1) Resident #46's meal service
On 12/11/23 at 10:58 AM, a review of Resident #46's medical record found a physician order for a Dysphagia Advanced diet, with thin liquids. and a peanut butter and jelly sandwich with each meal.
An observation of the noontime meal on 12/11/23 beginning at 12:10 PM, revealed Certified Nursing Assistant (NA) #13 delivered Resident #46 his roommates tray. When Nurse Aide #82 entered the room with Resident #46's tray NA #13 was overheard saying, I screwed up. Upon entering the room, NA #82 delivered Resident #46's tray to his roommate since Resident #46 all ready had the roommates tray on his over the bed table and was eating from it. Resident #46's
roommate then pointed out to NA #82 he was not supposed to have the pot pie but should have received the alternate which was a beef patty. NA #82 stated, I know she gave your tray to your roommate so this is his tray. Resident #46's roommate indicated he wanted NA #82 to get him a new tray with the beef patty because he did not like chicken pot pie.
The certified dietary manager at 12:25 PM entered Resident#46's room. When asked if the beef patty was prepared to meet the needs of Dysphagia Advance diet he stated, No it should have been chopped up. He stated, I'll go get him another tray. The CDM then asked Resident # 46 if he wanted the beef or the Pot Pie. The resident indicated he wanted the pot pie because that sounded better than what he got served.
Further review of the medical record found Resident #46 had been on a dysphagia advanced diet since his admission. He was on the diet as a result of diverticultitis not because of swallowing difficulties.
a-2) Resident #46
A review of Resident #46's medication administration record (MAR) on 12/06/23 at 02:30 PM identified the following dates when Resident #46's morning medications were not administered as ordered by the physician; 11/08/23, 11/13/23, 11/15/23, 11/17/23, 11/27/23, 11/29/23, and 12/4/23. The medical record further identified Resident #46 had dialysis on referenced dates but there were no physician orders or care plan to address Resident #46's medication administration while at dialysis.
During an interview on 12/06/23 at 03:06 PM with the Director of Nursing (DON) Staff #10 she stated the medication should be given prior to leaving or upon return from dialysis. Staff #10 reviewed the coding on the above referenced dates and acknowledged Resident #46 was not getting the medication Resident #46 should be getting and she will get with the doctor to correct it.
CONCERN
(E)
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 ensure performance reviews of Nurse Aide (NA) at least once every 12 months. This was true for two (2) of five (5) employee files re...
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Based on record review and staff interview the facility failed to ensure performance reviews of Nurse Aide (NA) at least once every 12 months. This was true for two (2) of five (5) employee files reviewed for the Sufficient Nurse Staff care area. This had the potential to affect more than a limited number of residents currently residing in the facility. Employee identifiers: #23, and #46. Facility census: 93.
Findings included:
a) Nurse Aide #23
During the staff record review, on 12/11/23 at 10:00 AM, personnel files were reviewed to ensure the performance reviews were completed at least once every 12 months.
During the review of NA #23's file it was revealed the NA was hired on 02/01/22. The personnel file was void of the performance reviews needed every 12 months.
During an interview, on 12/11/23 at 12:56 PM, the Director of Nursing (DON) acknowledged there were no performance reviews completed for NA #23.
b) Nurse Aide #46
During the staff record review, on 12/11/23 at 10:00 AM, personnel files were reviewed to ensure the performance reviews were completed at least once every 12 months.
During review of NA #46's personnel file it was noted the NA was hired on 02/01/22. The personnel file was void of the performance reviews every 12 months.
During an interview on 12/11/23 at 12:56 PM, the Director of Nursing (DON) acknowledged there were no performance reviews completed for NA #46.
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
.
Based on record review, and staff interview, the facility failed to have a pharmacist review each resident's medication regimen monthly to identify irregularities and maintain record of the identifi...
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.
Based on record review, and staff interview, the facility failed to have a pharmacist review each resident's medication regimen monthly to identify irregularities and maintain record of the identified irregularities. This was true for three (3) of five (5) residents reviewed for unnecessary medications. Resident identifiers: #70, #66 and #46. Facility census: 93.
Findings included:
a) Resident #70
A review for Unnecessary Medication for Resident #70 on 12/06/23 found the record did not contain medication regimen reviews or gradual dose reductions for December 2022, January 2023, February 2023, March 2023, April 2023, May 2023, June 2023, or July 2023.
During an interview on 12/07/23 at 8:35 AM the Director of Nursing (DON) verified the facility was unable to find documentation that pharmacy reviews were completed.
b) Resident #66
On 12/06/23 at approximately 3:00 PM, a review of Resident #66's electronic record was conducted. During this record review, there was no indication of any Medication Regimen Review (MRR) or Gradual Dose Reduction (GDR) documentation for Resident #66.
On 12/07/2023 at approximately 8:35 AM, the Director of Nursing (DON) #10 confirmed the MRR and GDR documentation was incomplete for most of the year. DON #10 was only able to provide documentation related to MRR and GDR from August 2023 to November 2023.
c) Resident #46
During a medical record review for unnecessary medication on 12/7/23 at 2:30 PM for Resident #46, the Drug Regimen reviews were not available. During an interview with Director of Nursing (DON) Staff #10 on 12/07/23 at 8:35 AM the Drug Regimen Reviews was provided for August 2023 through November 2023. The DON acknowledge that the Drug Regimen Reviews had not been completed for the entire year and was missing prior to 08/2023.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
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Based on observation and staff interview the facility failed to keep the nourishment room on the dementia unit clean and sanitary. This failed practice had the potential to affect more than isolated...
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Based on observation and staff interview the facility failed to keep the nourishment room on the dementia unit clean and sanitary. This failed practice had the potential to affect more than isolated number of residents. Facility Census: 93.
Findings included:
a) Nourishment Room
Tour of the dementia care unit on the morning of 12/05/23 found the refrigerator in the activities room were the resident food was stored was rusted on the outside and the inside had a build up of debris and needed cleaned.
The dementia care unit also had a small nourishment room which contained a microwave and a coffee pot. The coffee pot was observed to be dirty and was covered with dry brown stains. In the cabinets in the nourishment room was spilt coffee and other crumbs. In one cabinet was a tub of peanut butter which had a use by date of 09/14/23. The certified dietary manager was present during these observations and confirmed the findings. He stated, I didn't even know this nourishment room was here. Licensed Practical Nurse (LPN) #46 was interviewed at the conclusion of the tour. She was asked if Residents were served coffee from the coffee pot in the Nourishment room. She indicated they were.
CONCERN
(E)
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 ensure three (3) of 20 residents reviewed during the long-term care survey process had a Physician Orders for Scope of Treatment (POS...
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Based on record review and staff interview, the facility failed to ensure three (3) of 20 residents reviewed during the long-term care survey process had a Physician Orders for Scope of Treatment (POST) form completed per direction and one (1) of 20 residents Physician 0rders were accurate. Resident identifiers: #72, #40, #74 and #99. Facility census: 93.
Findings Included:
a) Resident #72
Record review on 12/06/23 at 9:43 AM found, a POST form on Resident #72's chart was unsigned by the Resident or Medical Power of Attorney (MPOA). The POST form was dated 06/09/22.
During an interview on 12/06/23 at 2:04 PM with the Director of Nursing, she confirmed Resident #72's POST form was incomplete without a Resident or MPOA signature.
b) Resident #40
Record review on 12/05/23 at 2:30 PM found, a POST form on Resident #40's chart was unsigned by the Resident or MPOA. The POST form was dated 06/27/22.
During an interview on 12/06/23 at 2:04 PM with the Director of Nursing, she confirmed Resident #40's POST form was incomplete without a Resident or MPOA signature.
c) Resident #74
During a record review on 12/06/23 at 10:37 AM, Resident #74's medical record revealed a Physician Orders for Scope of Treatment (POST) form signed and dated by the physician on 11/29/23 was void the Professional assisting health care provider with the form completion name, date and title.
The 2021 POST form guidance titled, Using the POST Form: Guidance for Health Care Professionals, 2021 edition, available on-line, stated, The person preparing the form also signs in this section. A form lacking the signature of the person preparing the form is invalid.
During an interview on 12/06/23 at 1:06 PM, the Social Worker (SW) stated oh no I did not look at the POST form when we received it back to see if it was completely filled out. The SW acknowledged Resident #74's POST form was not completed accurately.
During an interview on 12/06/23 at 1:10 PM, the Administrator acknowledged the POST was not completed accurately.
d) Resident #99
A review of Resident #99's medical record on 12/12/23 at 10:00 am found an order for Ativan injection solution 2 milligram (MG) per milliliter (ML) give .25 mg by mouth every four (4) hours as needed.
At 10:30 am on 12/12/23 the Director of Nursing (DON) was asked why they were giving injectiable ativan orally. She stated she would have to look into it. She later reported they received the oral solution from the pharmacy and the oral solution is what they gave. She indicated it was a transcription error on the order. She showed the surveyor the bottle of oral solution ativan which was sent for Resident #99.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected most or all residents
Based on record review and staff interview the facility failed to have Quality Assurance Assessment (QAA) Committee meetings that consist of the Infection Preventionist (IP) attendance. This had the p...
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Based on record review and staff interview the facility failed to have Quality Assurance Assessment (QAA) Committee meetings that consist of the Infection Preventionist (IP) attendance. This had the potential to affect all residents currently residing in the facility. Facility Census: 93.
Findings included:
a) QAA meeting
During a review of the facility QAA meeting sign in sheet on 12/11/23 at 3:30 PM, revealed the QAA meetings were held monthly with no IP attending within the third quarter of the QA meetings.
During an interview 12/12/23 at 8:17 AM, the Administrator acknowledged the IP was not in attendance for any of the third quarter QA meetings.
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 observations and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment...
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Based on observations and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections with regards to the laundry room and water management. This practice had the potential to affect all residents that resided in the facility. Facility census: 93.
Findings included:
a) Laundry Room
During a tour of the laundry room on 12/05/23 at 3:45 PM with the Maintenance Director #120 found:
--The door closure was removed to keep the door open, that maintained a separation between the clean and soiled area of the laundry room to prevent contamination of airflow.
--The ventilation was not on/ working to pull air from the clean to the soiled area.
--There was a black substance on the walls at the side and behind the washer.
-- There was dirt and debris around the washer area.
-- The hand sink was not hooked up in the laundry room. Staff had to go across the hall, for hand hygiene.
-- There were holes in the walls, and the mopboard / floor molding was removed exposing chipped and holes in the dry wall.
During the tour the Maintenance Director #120 verified the issues and stated all areas would be fixed.
b) Water Management
A facility record review related to water management revealed no documentation was maintained to prevent growth of water borne pathogens including description of the building water system or testing protocols.
On 12/06/23 at 9:20 AM the Maintenance Director #120 verified the facility did not maintain the water management. He stated that it would be corrected, and a water test would be sent out today.
Sept 2023
7 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
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 a baseline care plan was developed within 48 hours of a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure a baseline care plan was developed within 48 hours of admission for one (1) of three (3) residents reviewed for the care area of falls. Resident identifier: #97. Facility census: 96.
Findings include:
a) Resident #97
The resident was admitted to the facility from the hospital with a diagnosis of closed fracture of the right pelvis on 11/03/22. The Resident was discharged to home on [DATE].
A nurses note dated 11/03/22:
.She has been admitted to us with a fractured pelvis, history of falls, shoulder pain, knee pain, inability to walk .
The Resident's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/08/22 found the resident was coded as having falls prior to being admitted to the nursing home.
Review of the Residents care plan for falls found the following focus:
Is at risk for falls r/t (related to) new environment, psychotropic medication use, history of falls, Deconditioning and Gait/balance problems. Initiated on 11/22/22.
The goal associated with the focus:
Will not sustain serious injury through the review date.
Date Initiated: 11/22/2022
Interventions to accomplish the goal included:
Anticipate and meet Residents needs.
Date Initiated: 11/22/2022
Be sure the call light is within reach and encourage her to use it for assistance as needed. She needs prompt response to all requests for assistance.
Date Initiated: 11/22/2022
Ensure that Resident is wearing appropriate footwear.
Date Initiated: 11/22/2022
Follow facility fall protocol.
Date Initiated: 11/22/2022
Monitor for latent injuries.
Date Initiated: 11/27/2022
Ortho b/p (blood pressure) and neuro (neurological) checks s/p (after) fall per order.
Date Initiated: 11/27/2022
Resident requires close supervision while ambulating with walker
Date Initiated: 11/30/2022
At 2:00 PM on 09/18/23, the Director of Nursing (DON) confirmed the Resident's care plan for falls was not developed within 48 hours of admission. The care plan addressing falls was developed on 11/22/22, which was 19 days after her admission to the facility. The DON further confirmed the facility was aware the resident had falls prior to being admitted to the nursing home.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview the facility failed to implement the care plan for two (2) of three (3) ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview the facility failed to implement the care plan for two (2) of three (3) residents reviewed for the care area of falls. Resident identifiers: # 58 and #3.
Facility census:
Facility census: 96.
Findings included:
a) Resident #58
Record review found the Resident had four (4) falls since 05/03/23.
Review of the current care plan found the following focus:
At risk of falls related to deconditioning, gait/balance problems, muscle atrophy, incontinence and history of falls. revised on 05/22/23
The goal associated with the focus:
Will not sustain serious injury through the review date. Resident will not attempt to pick up objects off the floor and will request staff assistance. Revised on 08/28/23.
Interventions included:
Non skid strips to foot of bed initiated on 10/25/22.
Observation of the Resident at 3:40 PM on 09/18/23, found the resident was sleeping in his bed. The non skid strips were not present at the foot of the bed. At 3:40 PM on 09/18/23, the Licensed Practical Nurse (LPN) #91 and nurse aide (NA) #95 also observed and confirmed there were no non skid strips at the foot of the Resident's bed.
At 4:13 PM on 09/18/23, the Director of Nursing (DON) said the floor in the Resident's room had been recently cleaned and waxed. She thought the housekeeping staff must have removed the strips. She stated the strips have been replaced.
b) Resident #3
Record review found the Resident fell on [DATE] while in his room. He stated he was trying to put on his underwear when he lost his balance and fell backwards.
The Residents most recent Minimum Data Set (MDS), a quarterly with an assessment reference date (ARD) on 06/22/23 noted the Resident requires the extensive assistance of one staff member for dressing.
Review of the current care plan found a focus:
Resident is at risk for falls r/t (related to): History of falls, Confusion, Deconditioning, Gait/balance problems, Psychoactive drug use. Date Initiated: 03/28/2023 Revision on: 03/28/2023
The goal associated with the focus:
Resident will not sustain serious injury through the review date. Date Initiated: 03/28/2023 Revision on: 03/28/2023 Target Date: 09/13/2023
Interventions included:
Be sure call light is within reach and encourage Resident to use it for assistance as needed. Resident needs prompt response to all requests for assistance. Date Initiated: 03/28/2023 Revision on: 03/28/2023
Observation of the Resident at 3:25 PM on 09/18/23 found the Resident was in bed sleeping. The call light was in the floor behind the head board of his bed.
A second observation at 4:30 PM on 09/18/23 found the call light had not been moved.
At 4:30 PM on 09/18/23, Licensed Practical Nurse (LPN) #25 confirmed the call light was not within reach of the Resident. She retrieved the call light and clipped it to the Resident's bed beside the Resident's right arm.
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
Based on record review and interview the facility failed to provide pharmaceutical services , including procedures that assure the accurate dispensing and administering of all drugs. This was found fo...
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Based on record review and interview the facility failed to provide pharmaceutical services , including procedures that assure the accurate dispensing and administering of all drugs. This was found for
five (5) of five (5) resident records reviewed. Resident Identifiers: Resident #25, #38, #44, #52 and #85. Facility Census 96.
Findings Include:
a) Medication administration - interviews
On 09/18/23 at 1:00 PM, the surveyor spoke with Assistant Director of Nursing (ADON) regarding reconciliation of narcotics. He said he runs a daily report and compares what was removed from the Pixis (automated drug dispenser), compared to the Medication Administration Record (MAR). He said there are often minor discrepancies and he gets the nurse that dispensed the medication to fix it on the MAR. He said it is usually just a matter of changing the date or the time.
On 09/19/23 at 11:00 AM, the ADON who said he had gotten yesterdays medication discrepancies corrected; all but one. As of this morning he has six (6) awaiting correction.
09/19/23 at 12:00, the ADON said reconciliation of medication is an ongoing problem and it takes up a considerable amount of his time to have to daily reconcile the medication sheets and the Pixis. He said he would call the LPN's to come fix their mistakes or have them fix them on their next shift. He agreed he needed to get this issue fixed immediately.
A record review of medical records with the ADON found the following issues:
Resident #25 had Tramadol HCL Tablet 50 milligram (mg) which was removed from Pixis on 09/15/23 at 8:17 PM, by Licensed Practical Nurse (LPN) #96. According to ADON and the electronic MAR the medication was not documented at the correct time given. The ADON said he had to get the LPN to come in and fix her times.
Resident #38 had a Hydroco/APAP 5-325 mg tablet removed from the Pixis on 09/15/23 at 9:31 PM, By LPN#51. This medication was not charted when given but according to the ADON, the nurse came in and fixed it yesterday (09/19/23).
Resident #44 had Tramadol HCL Tablet 50 milligram (MG) which was removed from Pixis on 09/15/23 at 8:17 PM, by Licensed Practical Nurse (LPN) #96. According to ADON and the electronic MAR the medication was pulled at the incorrect time and no corrective documentation was available.
Resident #52 had a Hydroco/APAP 5-325 mg tablet removed from the Pixis on 09/15/23 at 7:40 PM by LPN #96. This medication was not charted on the MAR on the day it was dispensed. The ADON said he had LPN #96 come in and sign for the missing dose. On 09/16/23 at 7:47 AM, a Hydroco/APAP 5-325 mg tablet was removed from the Pixis for this resident by LPN #51. Review of MAR and according to the ADON this medication has yet to be charted as administered.
Resident #85 had a Hydroco/APAP 5-325 mg tablet removed from the Pixis on 09/16/23 at 4:25 PM by LPN #24. The ADON said it was not charted at time is was given and it is being charted now.
Review of Resident #52 effectiveness of medication (Hydroco/APAP 5-325 mg tablet) was dated as 09/19/23 at 11:53 AM, this medication was documented as given on 09/17/23 at 8:47 AM and marked effective at 10:48 AM of same date but it was actually documented according to electronic MAR as being given on 09/18/23 at 12:47 PM. The effectiveness of the medication was documented on 09/18/23 at 12:48 PM by LPN #51. This same process for the same resident the same medication and the same LPN was repeated on 09/16/23. Medication was given at 8:00 AM and documented effective at 10:00 AM. The electronic MAR had this medication given at 09/19/23 at 11:43 AM and effectiveness documented on 09/19/23 at 11:46 AM.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and interview the facility failed to serve food within professional standards for food safety. This failed practice had the potential to affect more than a limited number of resid...
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Based on observation and interview the facility failed to serve food within professional standards for food safety. This failed practice had the potential to affect more than a limited number of residents and was a random opportunity for discovery. Facility census: 96.
Findings include:
a) Kitchen observations
On 09/18/23 at 10:00 AM, a tour of the kitchen was conducted with the Dietary Account Manager (DAM). The panty door was propped open with a can of food. When asked why, the DAM said the magnet was broken and that was the only way to keep the door open. Behind the door revealed a hole in the wall where the wall part of the magnetic closure was caved in and would not make contact. The floor behind the door was dirty and had a dead insect in the dust.
When the DAM pulled out several of the metal shelves, all had dust, dirt and debris behind and under them.
The dishwashing room also had dirt and debris behind and under the tables.
The Prep table had dirt and debris under it as well.
The ovens had a hard build up of dried food on the bottom of the oven.
The trash can, beside the hand washing sink, foot opener, and surrounding area was visibly soiled.
All the above observations were witnessed and discussed with the Dietary Account Manager. He said they have a company that comes in once a month to do a deep cleaning of the kitchen.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Record review and staff interview the facility failed to ensure all medical records were accurate. This was a random op...
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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 all medical records were accurate. This was a random opportunity for discovery and the potential to affect a limited number of residents. Resident identifiers: #37, #24, and #83. Facility census 96.
Findings included:
a) Research of licenser
While investigating an allegation that stated a Licensed Practical Nurse (LPN) #35 was portraying themselves as a Registered Nurse (RN) #35, the Assistant Director of Nursing (ADON) #35 was asked when he became a RN. ADON #35 said a couple of months ago.
License research found that ADON #35 received a temporary RN license on [DATE] and this license expired on [DATE]. After [DATE], RN #35 was a LPN until he passed the testing for a RN on [DATE].
b) Record review findings
While reviewing medical records it was discovered that on [DATE] and [DATE] the current ADON #35 signed a nursing note on Resident #37, that stated his position was an RN. However, from [DATE] until [DATE] the current RN #35 was a LPN not an RN. This occurred multiple times listed below are examples:
For Resident #24 on [DATE], [DATE], and [DATE] these nursing notes were signed by LPN #35 as having the position of RN.
For Resident #49 on [DATE], [DATE], [DATE], [DATE] the nursing notes were signed by LPN #35 as an RN.
For Resident #83 on [DATE] a nursing note signed by then LPN #35 as an RN.
On [DATE] at 12:03 PM the Administrator was asked about the above findings. The administrator stated she was not aware that was happening. She went on to say she assumed that after he did not pass his broads his title would have been changed when his pay was changed. The Administrator also agreed it should have not continued for seven (7) months. The administrator said the title/position of all of the employees is auto populated when they sign in the computer.
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
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
c) 300 hall observations
During a tour of the facility, observation found on hall 300 there were water rings on the ceiling and places where a layer of the ceiling covering had peeled away from the ce...
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c) 300 hall observations
During a tour of the facility, observation found on hall 300 there were water rings on the ceiling and places where a layer of the ceiling covering had peeled away from the ceiling. It was noted there was a large amount of a black substance on and around the vents where the water rings were and holes from the missing ceiling covering.
On 09/18/23 at 12:23 PM, a tour and interview with Maintenance Supervisor (MS) #90 found MS #90 said the local company had just come to the facility last week because of the condensation from the air conditioner. He said that would be the reason for the water marks on the ceiling. MS #90 agreed there was a black substance on and around the vents.
Based on observation and staff interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents. Window curtains were not present or did not close properly to allow for privacy. Vents in the ceiling were covered with dust and the ceiling on 300 hallway was in need of repair. This was a random opportunity for discovery and had the potential to affect more than a limited number of Residents at the facility. Facility census: 96.
a) Observations of curtains
At 10:15 AM on 09/18/23, a tour of the facility with the housekeeping supervisor #88 found the following rooms had no window curtains and no blinds allowing resident care to be visible from outside the facility. Rooms 214, 216, 313, 301, 113, 133, 105, and 106.
For rooms 105, 107, 109, 106, 110, 112, 115, 112, 125, 124, 126, and 128, the hooks for the curtains were missing on both the left and right sides of each pair of curtains where the curtains meet in the middle of the window. This would also allow for care to be observed from outside the facility.
The Housekeeping Supervisor said several months ago, the facility had a bed bug outbreak. All the curtains were taken down to be washed. Several curtains just shredded. We are trying to get them replaced but they are on backorder. When asked about why the hooks were missing, he stated, We don't know how to get them back up in that center piece.
b) Vents in the dining room
At 10:25 PM on 09/19/23, observation of the return air vents in the dining room with Maintenance Supervisor #90 found a large build up of lint and debris. The surveyor touched the vent in the ceiling with a piece of paper and lint and debris rained down onto the floor. MS #90 said we pay a company to come in and clean those every month.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to establish and maintain an infection prevention and control progr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This failed practice of staff failing to properly don Personal Protection Equipment (PPE) when indicated by signage on door and had the potential to affect all residents who currently reside at the facility. Facility census 96.
Findings included:
The Facility was in a COVID outbreak with positive staff
a) room [ROOM NUMBER]
On 09/18/23 at 9:51 AM, it was observed that Housekeeper (HK) #105 was in room [ROOM NUMBER] cleaning. There was a sign on the door bright yellow and orange in color the stated this room is in Contact Precaution. The sign said, STOP you must wear mask, gown, and gloves before entering the room.
HK #105 did not have a gown or gloves, and her mask was under her chin. HK #105 was asked about wearing the PPE as required by the sign on the door. HK #105 pulled her shoulders upward and said I do not know.
b) room [ROOM NUMBER]
On 09/18/23 at 10:00 AM, Nurse Aide (NA)#9 was observed going into room [ROOM NUMBER] that had sign on the door indicating this room was in Contact Precautions. NA #9 walked directly out of room [ROOM NUMBER] into 124 and went behind the privacy curtain and began assisting the resident in bed A. When NA #9 came out she was asked why she did not follow the instructions on the sign. NA #9 stated that she only had to do that if she was doing things like changing a brief or bathing the resident. NA #9 was asked if the sign said Enhance Barrier or Contact Precautions. NA #9 said Contact Precautions, but she was told that she only had to gown up if she was providing direct care.
c) room [ROOM NUMBER]
On 09/19/23 at 10:15 AM, it was observed room [ROOM NUMBER] had a sign on the door that said Enhanced Barrier. Observation of room [ROOM NUMBER] found the Resident and NA #26 were in the room. NA #26 was helping the resident get dressed and was not wearing any PPE. When NA #9 came out of the room she was asked about the PPE. She stated she did not have to because it was no longer needed. She was asked about the sign on door, NA #9 and said she did not even see the sign.
d) Interviews
On 09/18/23 at 11:10 AM, the Infection Preventionist (IP) was informed of the observations. He stated that he was told by the facility Nurse Practitioner (NP) it was ok to only use PPE if providing direct care. He was reminded that the staff observed were providing direct care, with Contact Precautions signage and Enhanced Barrier Precaution posted on the door to the room and that staff should use PPE to go into the room. The IP agreed that was what the sign instructed.
On 09/19/23 at 11:28 AM the Director of Nursing was informed of the above and stated the staff are being educated about the use of PPE.
Nov 2022
23 deficiencies
3 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0697
(Tag F0697)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, resident interview, and staff interview, the facility failed to treat pain to the extent possible in a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, resident interview, and staff interview, the facility failed to treat pain to the extent possible in accordance with professional standards of practice. This caused harm to the resident by causing uncontrolled pain and an emergency room visit for this uncontrolled pain. This was true for one (1) of two (2) residents reviewed for the care area of pain. Resident identifier: #22. Facility census: 90.
Findings included:
a) Resident #22
During an initial interview on 11/14/22 at 3:33 PM, Resident #22 reported pain from a fractured pelvis. She stated she received Tramadol for pain, which lessened but did not totally eliminate her pain.
Review of Resident #22's medical records showed the resident was admitted [DATE] at 7:15 PM. Resident #22's diagnoses included fibromyalgia, pain in the shoulder, pain in the knee, osteoarthritis, and fracture of the pelvis with routine healing. She also had diabetic foot ulcers to both feet.
A progress note written on 11/03/22 at 10:30 PM stated, Resident arrived at 1915 by [ambulance service]. [Ambulance service] stated that the patient had already been crying about her pain level and needed pain medication. Transferred patient from the stretcher to the bed and took her V/S [vital signs] which were BP [blood pressure]163/79, hr [heart rate] 98, resp [respiratory] 20, o2 [oxygen] 93, and temp [temperature] 98.0. Resident had 2 diabetic ulcers, one on each foot. Pain level was at a 10 she stated. Started crying and yelling. I called to get a prn [as needed] Tylenol order but that wasn't good enough to help with the pain she stated and then she wanted to be sent back to the hospital. Nursing supervisor is aware, and patient has capacitated. Resident was sent to the hospital for more observation. Will continue to monitor. (Typed as written.)
Resident #22 returned to the facility on [DATE] at 10:55 PM. A progress note written at that time stated, Resident was sent out to [hospital] at 2200 for uncontrollable pain. She stated that her pain level was at a 10. She has capacity. [Hospital] call at 2230 and stated that they were sending her back. I asked if they helped with her pain. They stated that, she will tell you no that they didn't, but they gave her a tramadol. I asked if I could call them back to make sure we could still take her with her pain level that high. The nurse stated, Well she is already on her way and should be coming through the doors as we speak. The resident was transferred x2 from stretcher to bed. She has been admitted to us with a fracture pelvis, history of falls, shoulder pain, knee pain, inability to walk, x2 foot ulcers due to secondary DM [diabetes mellitus], Diabetes and Hip pain-swelling. Her pain comes from her hip and feet she stated. At this time, she is in bed in the lowest position with her eyes open, with call light within reach. NP [nurse practitioner] and [doctor] has been paged and supervisors are aware. Will continue to monitor. (Typed as written.)
Review of Resident #22's medical records showed a pain evaluation assessment was started upon Resident #22's admission [DATE] at 7:15 PM. The pain assessment was signed on 11/04/22 at 4:59 AM. The assessment stated the resident's pain level was currently rated as a 10 on a scale from 1-10, with 10 being the worst pain imaginable. The pain locations were listed as the right heel, left heel, coccyx, and right trochanter (hip). According to the assessment form, For each site listed, describe type of pain (stabbing, burning, sharp, dull, throbbing), duration, and frequency and whether it is continuous or intermittent in the description box. The descriptions of the pain were ulcer for the right heel, ulcer for the left heel, moisture for the coccyx, and pelvic fracture for the right trochanter (hip).
The pain assessment recorded Resident #22 stated pain was improved by pain medication and worsened by movement. The resident also reported the pain affected sleep and rest, social activities, appetite, physical activity and mobility, emotions, and intimacy. A comment on the pain assessment stated, Resident arrived at 1915 and was crying out in pain. She was sent back out for uncontrolled pain, and they gave her a tramadol and sent her right back. Resident was still in pain at a 10 she stated. There was no indication in the medical records that Resident #22's continued pain level of 10 when she returned from the hospital was addressed.
Further review of Resident #22's medical records showed on 11/04/22 an order was written for acetaminophen (Tylenol) 325 milligrams (mg), two (2) tablets every six (6) hours as needed for mild to moderate pain in the shoulder and knee. Review of Resident #22's Medication Administration Record (MAR) showed the resident did not receive any Tylenol until 11/08/22.
The following order was written on 11/04/22, Non-pharmacological techniques attempted to alleviate pain. 1. Offer snack or drink. 2. Offer diversion activity- reframing guided imagery. 3. Determine if toileting would be beneficial. 4. Determine if sleep or relaxation techniques would be beneficial. 5. Reposition affected area. 6. Offer cold or heat application. 7. Massage, pressure or vibration techniques. 8. Offer exercise or task to distract thoughts of pain. Every shift for pain, document all non-pharmacological interventions listed (numerical intervention) above. The resident's MAR showed check marks to indicate the order had been completed, but the specific non-pharmacological interventions attempted were not documented on the MAR. A nursing note written on 11/4/2022 at 2:47 PM stated, Resident continues to be monitored related to new admission; resident intermittently c/o [complaints of] pain in legs and hips, turning and repositioning effective. This was the only nursing note written regarding non-pharmacological interventions for Resident #22's pain.
Resident #22 also had an order written on 11/04/22 to Observe resident for signs and symptoms of pain every shift. No pain=0, mild pain 1-4, moderate pain 5-7, and severe pain 8-10. On night shift on 11/04/22, the resident's pain was reported as 0.
On 11/04/22, the resident was prescribed pregabalin (Lyrica), 300 mg, twice a pain for fibromyalgia. The medication was not available from the pharmacy until 11/05/22 at 9:00 AM.
Resident #22 also had an order written on 11/04/22 for aspirin, 81 milligrams (mg), one (1) capsule by mouth one time a day for moderate pain. This low dose of aspirin is usually prescribed to prevent heart attack and strokes for people with risk factors for these conditions. Resident #22 had diagnoses of atherosclerosis and hypertension. The resident also had a previous history of a heart attack. The order was discontinued on 11/07/22. The MAR showed the resident received aspirin daily from 11/04/22 through 10/07/22. The resident's pain level was recorded on the MAR before aspirin administration and was recorded as 0 for 11/04/22.
The following note was written on 11/4/2022 at 11:55 PM, Resident asked to be transferred out to the hospital for uncontrolled pain. Stated she has capacity. I asked what hospital she would like to go to, and she said it's her right not to tell me because she plans on not coming back. She signed the bed hold refusal and transfer forms. Will continue to monitor.
The following note was written on 11/05/22 at 1:30 AM, Resident Returned from [hospital] at 1330. Report was called in by [nurse's name]. Resident received Tramadol 50mg for pain. Resident stated she wanted to come back to Glasgow Health and Rehab. [Doctor] is aware of her going out to the hospital for uncontrolled pain and that she came back with a new order for Tramadol 50 mg every 12 hours as needed for pain. Will continue to monitor.
Following her return from the hospital on [DATE], Resident #22 received Tramadol twice a day for reported pain levels of 4-10. The resident's MAR reported the medication was effective at relieving her pain. On 11/09/22, the Tramadol's frequency was changed to every six (6) hours as needed for pain. Resident #22 continued to receive Tramadol two (2) to four (4) times a day for reported pain levels of 4-10. The resident's MAR reported the medication was effective at relieving her pain.
On 11/16/22 at 1:12 PM, Resident #22 was interviewed regarding her transfer to the hospital on [DATE] for pain control. The resident stated she had been having pain all day. She thought the facility was giving her Tramadol for pain before her emergency room evaluation on 11/04/22 but stated that she went to the emergency room because she wanted a stronger pain medication.
During an interview on 11/16/22 at 1:43 PM, the Director of Nursing (DON) stated Resident #22 was not prescribed pain medication after her emergency room visit on 11/03/22 because the emergency room physician did not order any medication. The DON acknowledged the facility's doctor could have prescribed pain medication. The DON stated Resident #22 was prescribed Tramadol after her emergency room visit on 11/04/22 because the emergency room physician ordered the medication. The DON also stated the resident's order for aspirin for moderate pain was incorrect, and this dosage of aspirin was not used to treat pain.
No further information was provided through the completion of the survey process.
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SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0740
(Tag F0740)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on resident interview, resident observation, record review and staff interview the facility failed to provide the necess...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on resident interview, resident observation, record review and staff interview the facility failed to provide the necessary behavioral health care and services to assist the resident in attaining or maintaining the highest practicable physical, mental, and psychosocial well-being for Resident #85 following the death of his son. Observations of the resident found him to be very tearful and suffering from mental anguish. The facility had provided no grief counseling or any mental health services to help Resident #85 deal with the passing of his his son. This failure resulted in actual psychosocial harm for Resident #85 who was suffering grief on his own without any assistance from facility staff to help lessen the effects of his grief. Resident Identifier: #85 Facility Census: 90
Findings included:
a) Resident #85
On [DATE] at 3:04 PM during the initial interview process Resident #85 was very tearful, depressed and emotional. He was lying in the bed in the dark. He stated his son had recently died. He explained the history of the residents ex-wife passing away when his son was just nine (9) years old and he had raised the boy alone. He was all he had and they were very close.
On [DATE] at 1:10 PM this surveyor went back to speak with the Resident again and he was flipping through pictures on his cell phone. When asked if he was OK, he stated he was just looking at pictures of his son on his cell phone. Again he was tearful and very emotional. I asked him if he was able to go to the funeral, he stated he was. He further explained another relative found his son dead in the bed in their trailer that the Resident and son shared before he came to the facility. I asked the Resident if he would like to speak to someone concerning his loss. He stated he really thinks he needs to, he had been in Vietnam and this was even worse than what he saw there. He indicated no one at the facility had spoken with him about the loss of his son or his feelings about it. He further stated they had not offered to set up any counseling for him.
A review of the residents care plan found no interventions related to helping the resident deal with the grief of losing his son. The care plan goal stated, .his son recently passed away and (First Name of Resident # 85) is very upset. Revision date [DATE]. However the care plan was void of any interventions to help the resident with his grief.
A nurses note dated [DATE] at 1:51 Pm written by the Assistant Director or Nursing (ADON) read as follows, Resident reviewed in IdT. weight loss continues. Res no eating well according to staff. Res did have a son that passed away this week and has affected him a great deal.
Facility staff was aware the resident was very upset about his son's passing and noted it was, affecting him a great deal, but failed to intervene in any form or fashion to help the resident process his grief to begin the healing process. Resulting in lasting mental anguish and psychosocial harm for Resident #85.
The above was confirmed with the Administrator on [DATE] at 10:00 AM and no further information was provided.
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SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Dental Services
(Tag F0791)
A resident was harmed · This affected 1 resident
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Based on observation, resident interview, staff interview and record review, the facility failed to ensure Resident #54 received the necessary dental services to ensure he was pain free and able to ...
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Based on observation, resident interview, staff interview and record review, the facility failed to ensure Resident #54 received the necessary dental services to ensure he was pain free and able to attain his highest practicable physical well-being. Resident #54 was to have teeth extracted the facility has failed to make the arrangements for Resident #54 to have his teeth extracted. This failure has resulted in actual harm for Resident #54 because he has continued pain from the teeth which are in poor condition. This was true for one (1) of two (2) residents reviewed for the care area of dental status. Resident identifier: #54. Facility census: 90.
Findings included:
a) Resident #54
On 11/14/22 at 3:00 PM an observation and Interview, found Resident #54 had missing teeth. He stated that his teeth hurt, and he needs a dental appointment. Resident #54 stated that the facility was supposed to make him an appointment, but never has. He indicated his teeth are painful and he really needs them extracted.
A care plan review found:
Focus:
-- Resident has the potential for oral health problems d/t he is edentulous and requires staff assistance with oral care.
Goal:
-- Resident will comply with mouth care at least daily through review date.
Interventions included:
-- Coordinate arrangements for dental care, transportation as needed/as ordered.
-- Observe/document/report any signs or symptoms of oral/dental problems needing attention: Pain (gums, toothache, palate), Abscess, Debris in mouth, Lips cracked or bleeding, Teeth missing, loose, broken, eroded, decayed, Tongue (black, coated, inflamed, white, smooth), Ulcers in mouth, Lesions.
A medical record review for Resident #54 revealed, a 360-care dental summary report completed 05/26/21 with the doctors note: Resident #54 has three (3) teeth that need extracted. Referral left with facility.
A continued medical record review revealed, Resident #54s oral health assessment completed 07/16/21, noted broken, loose or carious teeth. No other dental assessments completed.
11/16/22 9:04 AM the Director of Nursing (DON) verified Resident #54s dental assessments should have been completed but, they were missed.
Subsequent Medical record review found, consent for dental surgery signed on 02/17/22. The Physician clearance for dental treatment completed and signed on 02/16/22. A second oral surgery referral from 360 Care was made again on 07/12/22 for (5) teeth.
On 11/16/22 at 11:00AM the Director of Nursing (DON) confirmed Resident #54s dental extraction appointments were canceled and never rescheduled.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
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Based on observation, resident interview, and record review the facility failed to ensure Resident #18's call light was always within reach. This was a random opportunity for discovery. Resident ide...
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Based on observation, resident interview, and record review the facility failed to ensure Resident #18's call light was always within reach. This was a random opportunity for discovery. Resident identifier: #18. Facility census: 90.
Findings included:
Observation on 11/14/22 at 12:01 PM found Resident #18's call light was not within reach. The call light was hanging on the back of the privacy curtain against wall. Nurse Aide (NA) #28 verified the call light was not in reach for the resident, and stated Well where is it? NA #28 then traced the cord from the wall and found the light was above the residents reach clipped into the folds of the privacy curtain. The Resident stated, I don't see well, do I have a call light? NA #28 then provided the call light to the Resident and instructed her how to use it.
Record review of Resident #18's care plan showed the Resident is risk for falls related to being legally blind, non-ambulatory, seizures, psychotropic medication use and has dementia. Intervention stated to be sure Resident's call light is within reach and encourage Resident #18 to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Date Initiated: 08/22/2022 Revision on: 11/01/2022.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
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Based on resident interview, resident observation, record review and staff interview the facility failed to allow the resident the right to choose his preference in relation to his personal care. Th...
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Based on resident interview, resident observation, record review and staff interview the facility failed to allow the resident the right to choose his preference in relation to his personal care. This was true for one (1) of two (2) residents reviewed for the care area of choices. Resident #77. Facility Census: 90
Findings Included:
a) Resident #77
On 11/14/22 at 1:06 PM Resident #77's appearance was disheveled. He needed to be shaved, his hair was long and unkept and his finger nails were visibly dirty. He stated he is not getting his showers as he should be. He expressed his desire to take showers rather than bed baths and he hasn't had a shower in over a week. He would like a hair cut and shaved. This was confirmed on 11/14/22 at 1:15 PM with Licensed Practical Nurse # 89.
Record review shows Resident #77 is scheduled for a shower twice a week on Wednesday and Saturday 7:00 AM - 7:00 PM shift. According to documentation in Point Click Care (PCC) for the last 30 days, he received a shower on 11/02/22. Since 10/19/22 he received one (1) shower, 10 bed baths and four (4) days were documented not applicable.
According to his current care plan he is to receive a sponge bath when a full bath or shower cannot be tolerated. He states he has no problems tolerating a shower if staff gets him out of bed. He is dependent on one (1) staff member to provide his shower.
An interview with the Director of Nursing at 2:20 pm on 11/15/22 confirmed Resident #77 did not receive his showers as scheduled and had only received on shower since 10/19/22.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview the facility failed to ensure a notice of the behold policy was given to each resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview the facility failed to ensure a notice of the behold policy was given to each resident and/or representative upon discharge from the facility. This was true for two (2) of three (3) residents reviewed for the care area of hospitalizations during the Long-Term Care Survey Process (LTCSP). Resident Identifiers: Residents #342 and #42. Census: 90.
Findings included:
a) Resident #342
A record review, for Resident #342, showed the resident had been transferred to the emergency department, on 11/04/22, because of a change of condition. Further review of the record, showed no evidence a written notice of the transfer, including readmission rights and the policy of the bed hold period was provided to the resident or resident's representative.
An interview, with the facility Administrator, on 11/15/22 at 1:28 PM, verified the facilty failed to send the required written information of the bed hold policy or re-admission rights when Resident
#342 was transferred to the hospital.
b) Resident #42
Review of Resident #42's medical records showed Resident #42 went to her scheduled dialysis appointment on 09/06/22. At the dialysis facility, the resident developed mental status changes and shortness of breath. Resident #42 was sent to the hospital from the dialysis facility and was diagnosed with sepsis. The resident remained in the hospital until 09/14/22 and returned to the long-term care facility upon discharge from the hospital.
During an interview on 11/15/22 at 2:11 PM, the facility administrator stated Resident #42's representative was not sent a bed hold notice when the resident was hospitalized on [DATE]. The administrator stated bed hold notices are not sent when residents are admitted to the hospital from an appointment. The administrator stated Resident #42 was entitled to a bed hold, but stated the facility is never too full to re-admit a resident.
No further information was provided through the completion of the survey.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, observation and staff interview the facility failed to ensure three (3) of 27 residents Minimum Data S...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, observation and staff interview the facility failed to ensure three (3) of 27 residents Minimum Data Set (MDS) assessments were coded to accurately reflect the resident's status. Resident identifiers: #18, #35, and #22. Facility census: 90.
a) Resident #18
Record review of the Resident's MDS with and ARD target date of 10/22/22 indicated seven (7) days of antibiotic use. Review of the Resident's orders and Medication Administration Record showed no record of antibiotics being ordered or administered in the month of October 2022.
During an interview on 11/15/22 at 2:30 PM the Director of Nursing (DON) stated, I have looked everywhere and asked all the departments, we can't find where she got any antibiotics in October, so it must be coded wrong.
b) Resident #35
During an interview on 11/14/22 at 12:20 PM Resident #35 stated, I can't chew the meat, it's too tough I don't have any teeth. I look at the tray and if I don't think I can eat it I ask for something else.
Record review of the Resident's admission MDS dated [DATE] showed section L0200, question F difficulty with chewing to be answered No.
Record review of the Resident's Quarterly MDS dated [DATE] showed section L0200, question F difficulty with chewing to be answered No.
Review of the Resident's care plan showed the Resident has the potential for oral/dental health problems r/t missing teeth and requires staff assistance with hygiene. Coordinate arrangements for dental care, transportation as needed/as ordered. Date Initiated: 05/03/2022.
During an interview on 11/16/22 at 8:13 AM, the Director of Nursing (DON) verified the MDS assessments to be incorrect and stated, Yea after talking to him [Resident #35], its clear we missed that he didn't have all his teeth and was having trouble chewing.
c) Resident #22
Review of Resident #22's admission Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 11/08/22 showed the resident had taken an anticoagulant medication four (4) days during the seven (7) day look back period.
Review of Resident #22's Medication Administration Record (MAR) showed the resident had not taken a medication classified as an anticoagulant during the seven (7) day look back period for the admission MDS. The resident had taken the medication Ticagrelor (Brilinta) for atherosclerotic heart disease of native coronary artery without angina pectoris. Ticagrelor's mechanism of action is to inhibit platelet aggregation and is not classified as an anticoagulant medication according to the Resident Assessment Instrument manual that gives instructions for coding MDS assessment.
During an interview on 11/15/22 at 3:01 PM, the Director of Nursing stated she understood Ticagrelor inhibits platelet aggregation and is not classified as an anticoagulant on MDS assessments.
No further information was provided through the completion of the survey.
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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
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Based on record review, staff interview and resident interview the facility failed to provide Resident #4 with advance notice of care planning conferences to enable resident's participation. This wa...
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Based on record review, staff interview and resident interview the facility failed to provide Resident #4 with advance notice of care planning conferences to enable resident's participation. This was true for one (1) of 27 Residents reviewed in the sample. Resident identifier #4. Facility census: 90.
Findings included:
During an interview on 11/14/22 at 2:00 PM, Resident #4 stated, I just wish they would they [facility staff] would let me know about my transfer. Resident was asked if she was given the opportunity to attend her care plan meetings to discuss discharge planning and she stated she did not know what that was? The Resident further stated [Ombudsman's first and last name] came and met with her in her room recently but that was it.
A record review showed no progress notes or recent care plan meeting notes within the medical record.
During an interview on 11/16/22 at 12:15 PM the facility's Licensed Social Worker (LSW) stated she does not take care of the care plan meeting or invites. The LSW stated she just started working there in October 2022 and [Registered Nurse #90's first and last name] does the care plan stuff. The LSW verified Resident #4 does have capacity and is able to make her own medical decisions, with a Brief Interview for Mental Status (BIMS) score of 15.
On 11/16/22 at 12:53 PM, Registered Nurse (RN) #90 (designated in house care plan meeting director) was asked when the Resident's last care plan meeting was? RN #90 said she would have to go look, she keeps a list but does not document in the medical record. RN #90 further stated, We have a schedule and if no resident or family members comes to care plan meeting, we just review the care plan and call it good. RN #90 stated she sends letters out at the end of the month to everyone we have care plan meeting for that coming month but does not keep copies of the letters or put documentation of the notification in the Resident's medical record.
During an interview on 11/16/22 at 2:12 PM, the Administrator stated, We [facility staff] do not keep a copy of the letters sent to Residents for care plan meetings, that is on us we dropped that ball. We have not done it since June when the other social worker quit. We went without a licensed social worker for a while. The administrator further said the care plan conferences and scheduling was just kinda dumped on RN #90 and she doing the best she could.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to develop a discharge summary which included a recapitulation...
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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 develop a discharge summary which included a recapitulation of the resident's stay, a final summary of the resident's status, and reconciliations of all pre- and post - discharge medications. Also, the facility failed to ensure the discharge instructions were signed by the staff member completing the discharge and by the resident or the resident's representative. This was true for one (1) of one (1) residents reviewed for the care area of discharge. Resident identifier: #90. Facility census: 90.
Findings included:
a) Resident #90
Review of Resident #90's medical records showed the resident was discharged to home on [DATE].
Review of Resident #90's Discharge Instruction Form showed the section for discharge medications was blank. The section contained areas to list medication names, medication actions, dosages, and how and when to take the medications. None of these areas had been completed. The form also contained an area to indicate if an attachment regarding medications had been given to the resident, but this area had not been checked. The Discharge Instruction Form stated prescriptions had been sent to the resident's pharmacy.
Additionally, the signature section of the form had not been completed. The section contained areas for staff signature and date and family signature and date.
During an interview on 11/16/22 at 11:59 AM, the Director of Nursing (DON) confirmed signatures had not been obtained on the Discharge Instruction Form. The DON also confirmed the medication section had not been completed. The DON stated residents are given a list of their discharge medications, but a copy of the list is not maintained for the records. Additionally, the DON stated the physician did not complete a recapitulation of Resident #90's stay.
No further information was provided through the completion of the survey.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, resident interview, and record review the facility failed to ensure that residents who are dependent for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, resident interview, and record review the facility failed to ensure that residents who are dependent for Activities of Daily Living (ADL) care receives necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This was true for two (2) of three (3) residents reviewed for the care area of ADL care. Resident Identifiers: #77 and #89. Facility Census: 90.
Findings Included:
a) Resident #77
On 11/14/22 at 1:06 PM Resident #77's appearance was disheveled. He needed shaved, his hair was long and unkept and his finger nails were visibly dirty. He stated he is not getting his showers as he should be. He expressed his desire to take showers rather than bed baths and reported he had not had a shower in over a week. He also indicated he would like a hair cut and shave. This was confirmed on 11/14/22 at 1:15 PM with Licensed Practical Nurse # 89.
A Record review found Resident #77 is scheduled for a shower twice a week on Wednesday and Saturday 7:00 AM - 7:00 PM shift. According to documentation in Point Click Care (PCC) for the last 30 days, he received a shower on 11/02/22. Since 10/19/22 he received one (1) shower, 10 bed baths and four (4) days were documented not applicable.
According to his current care plan he is to receive a sponge bath when a full bath or shower cannot be tolerated. He states he has no problems tolerating a shower if staff gets him out of bed. He is dependent on one (1) staff member to provide his shower.
An interview with the Director of Nursing (DON) on 11/15/22 at 2:20 pm confirmed the resident had only received one shower in the last 30 days.
b) Resident #89
During an observation on 11/14/22 at 3:41 PM, Resident #89 was noted to be lying in bed. The resident's upper and lower dentures were lying on his TV stand. Resident #89 stated he had placed his dentures there because he did not have a denture cup. The resident stated he would like to have a denture cup to store his dentures.
On 11/14/22 at 3:45 PM, Licensed Practical Nurse (LPN) #70 was informed Resident #89 would like a denture cup for his dentures. LPN #70 looked in Resident #89's room for a denture cup but was unable to locate one. LPN #70 stated a denture cup would be obtained for Resident #89.
Review of Resident #89's medical records showed the resident was admitted to the facility on [DATE]. Review of Resident #89's [NAME], which gives instructions to the nurse aides, showed no indication the resident had dentures and needed denture care.
On 11/15/22 at 11:26 AM, the Director of Nursing (DON) confirmed Resident 89's [NAME] did not contain instructions for denture care. The DON stated she would make sure denture care instructions were added to the resident's [NAME].
No further information was provided through the completion of the survey.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
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Based on observation, resident interview, medical record review and staff interview the facility failed to follow the Physician's orders as written. This was true for two (2) of twenty-seven (27) sa...
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Based on observation, resident interview, medical record review and staff interview the facility failed to follow the Physician's orders as written. This was true for two (2) of twenty-seven (27) sampled residents. Resident Identifier: #55 and #85. Facility Census: 90
Findings Included:
a) Resident #55
On 11/14/22 at 1:51 PM it was observed that Resident #55 had an oxygen concentrator at bedside. He was not wearing oxygen at this time. He stated he is suppose to have it on, but since he was moved to his current room on 10/17/22, the staff has not set it up nor put it on him. It was confirmed with Licensed Practical Nurse #89 on 11/14/22 at 2:04 PM that Resident #55 had been without his oxygen for twenty-eight (28) days.
A review of the medical record found a current order dated 9/04/22 for two (2) Liters of oxygen via nasal cannula. According to the current care plan he is to have Oxygen (02) via nasal canula @ 2 Liters per order for shortness of breath.
b) Resident #85
1) Computed Tomography Scan
On 11/14/22 at 12:30 PM, Resident #85 complained of having kidney stones. A review of the medical record found a Computed Tomography (CT) scan was ordered on 9/22/22 at 10:38 AM related to kidney stone protocol. Further review of the medical record found no evidence this CT scan was ever completed.
An interview with the Director of Nursing (DON) on 11/15/22 at 1:10 pm confirmed the CT Scan was never obtained as ordered.
2) Rewieght Order
A review of Reisdent #85's weights in the medical record found Resident #85 has had some weight losses and/or gains. However, upon further review and discussion with the Director of Nursing (DON) she states staff is to re-weigh the resident if there is a five (5) pound loss or gain from the last weight.
The following weights were documented in the medical record:
11/10/2022 09:56 am
254.1 Lbs
(Manual)
11/4/2022 12:17 pm
248.6 Lbs
(Manual)
10/27/2022 12:27pm
262.8 Lbs
(Manual)
10/6/2022 2:30 pm
263.1 Lbs
Mechanical Lift
9/29/2022 10:44am
265.6 Lbs
(Manual)
9/23/2022 10:38 am
268.2 Lbs
Mechanical Lift
9/17/2022 3:18 pm
285.7 Lbs
Wheelchair
There should have been re-weights completed on:
9/23/22 when there was a 17.5 weight loss documented.
11/04/22 when there was a 14.2 weight loss documented.
11/10/22 when there was a 5.5 weight gain documented.
This was confirmed with the DON on 11/16/22 at 12:22 PM.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
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Based on observation, record review, and staff interview, the facility failed to ensure an indwelling urinary catheter was maintained within professional standards of practice. The facility failed t...
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Based on observation, record review, and staff interview, the facility failed to ensure an indwelling urinary catheter was maintained within professional standards of practice. The facility failed to ensure the catheter was anchored. The facility also failed to clarify and initiate bladder training ordered by the physician. The facility also failed to provide appropriate catheter care. This was true for one (1) of two (2) residents reviewed for catheter care. Resident identifier: #22. Facility census: 90.
Findings included:
a) Resident #22
Review of Resident #84's medical records showed the resident had an indwelling urinary catheter inserted on 11/04/22 when the resident was unable to urinate.
On 11/15/22 at 9:19 AM, observation of Resident #84's catheter care was made. The catheter did not have an anchor to secure the catheter to the resident's thigh to prevent excessive tension on the catheter, which can lead to discomfort, urethral tears or dislodging of the catheter. Nurse Aid (NA) #84, who was performing the catheter care, confirmed the catheter was not anchored.
Licensed Practical Nurse (LPN) #66 was informed Resident #84's catheter was not anchored. LPN #66 stated a catheter anchor would be obtained for the resident.
Review of Resident #84's physician orders showed an order written on 11/07/22 for bladder training every shift. Bladder training involves clamping the catheter for periods of time to help the resident to regain urinary continence and allow the removal of the catheter. Review of Resident #84's Medication Administration Record (MAR) showed a check mark for this order twice a day to indicate bladder training had been performed.
During an interview on 11/16/22 at 11:04 AM, the Administrator stated there was no facility policy or procedure for bladder training for residents with indwelling urinary catheters. The Administrator stated the physician would write specific orders for catheter clamping and unclamping times. The Administrator confirmed Resident #84's bladder training order needed clarified and revised.
During an interview on 11/16/22 at 11:20 AM, Licensed Practical Nurse #66 stated he would not know how to perform Resident #84's bladder training based on the order written.
During an interview on 11/16/22 at 11:27 AM, LPN #72 stated she was unsure what the check marks on Resident #84's MAR for bladder training indicated. LPN #72 stated she would not know how to perform bladder training based on the order written. LPN #72 stated the order needs to specify catheter clamping and unclamping times.
No further information was provided through the completion of the survey.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
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Based on medical record review and staff interview, the facility failed to monitor meal intakes for a resident with significant weight loss. This was true for one (1) of three (3) residents reviewed...
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Based on medical record review and staff interview, the facility failed to monitor meal intakes for a resident with significant weight loss. This was true for one (1) of three (3) residents reviewed for the care area of nutrition. Resident identifier: #75. Facility census: 90.
Findings included:
a) Resident #75
Review of Resident #75's medical records showed on 05/12/22, the resident weighed 195 lbs. On 11/10/22, the resident weighed 171 pounds, which was a 12% loss in 6 months.
Review of Resident #75's meal intake documentation for the last 30 days showed on eight (8) days the percentage of the meal eaten had not been recorded for every meal.
- On 10/22/22, only one (1) meal intake had been recorded.
- On 10/29/22, only two (2) meal intakes had been recorded.
- On 10/30/22, only two (2) meal intakes had been recorded.
- On 11/02/22, only two (2) meal intakes had been recorded.
- On 11/03/22, only two (2) meal intakes had been recorded.
- On 11/04/22, only two (2) meal intakes had been recorded.
- On 11/06/22, only two (2) meal intakes had been recorded.
- On 11/07/22, only two (2) meal intakes had been recorded.
During an interview on 11/15/22 at 12:56 PM, the Director of Nursing confirmed Resident #75's meal percentage intakes had not been performed for every meal.
No further information was provided through the completion of the survey.
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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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation and staff interview, the facility failed to ensure medications were stored in accordance with currently a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation and staff interview, the facility failed to ensure medications were stored in accordance with currently accepted professional principles. A multi-use medication vial stored in the medication preparation room had not been discarded in the time frame recommended by the manufacturer after opening . Additionally, two (2) bags of intravenous fluids were past the manufacturer's expiration date. These were discoveries made during the facility task of medication storage. Facility census: 90.
Findings included:
a) East medication preparation room
During investigation of the medication preparation room on [DATE] at 10:25 AM, a multi-dose vial of Mantoux tuberculin purified protein derivative (PPD) stored in the room refrigerator was noted to have an opening date of [DATE]. (Tuberculin purified protein derivative is given by injection to aid in the diagnosis of tuberculosis.) The vial's box stated the medication was supposed to be discarded 30 days after opening.
Additionally, two (2) bags of .45% normal saline solution for intravenous infusion were noted to have expiration dates of [DATE].
Licensed Practical Nurse (LPN) #66 confirmed the tuberculin PPD vial and the two (2) saline bags were expired. LPN #66 stated these items would be discarded.
No further information would be provided through the completion of the survey.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility to ensure the residents care plan contained descriptions of care and services provided by hospice. This was true for one (1) of one (1) resid...
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Based on record review and staff interview, the facility to ensure the residents care plan contained descriptions of care and services provided by hospice. This was true for one (1) of one (1) residents reviewed for the care area of hospice services. Resident identifier: 13. Facility census: 90.
Findings included:
a) Resident #13
Review of Resident #13's medical record on 11/15/22, showed a physician order: Hospice care services as of 08/10/22. Continued review found the care plan did not contain the required descriptions of care and services provided by hospice.
On 11/16/22 at 11:50 AM the Director of Nursing (DON) confirmed neither the order, nor the care plan contained specific Hospice care information.
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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 interview the facility failed to ensure the Resident's environment was clean, safe, sanitary, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observations and staff interview the facility failed to ensure the Resident's environment was clean, safe, sanitary, and homelike. A privacy curtain in Resident room [ROOM NUMBER] was visibly soiled. Resident room [ROOM NUMBER] and 303 had doors which were in poor repair, and the wardrobe door was broken off lying in the floor of resident room [ROOM NUMBER]. These findings were random opportunities for discovery. Resident identifier: R #35. Room Numbers: 108, 302, 303, and 305. Facility census: 90.
Finding included:
a) room [ROOM NUMBER] soiled privacy curtain
An observation on 11/14/22 at 12:14 PM showed the privacy curtain in room [ROOM NUMBER] between beds to be visibly soiled with large amounts of pink substance running down the curtain. This finding was verified by Licensed Practical Nurse (LPN) #66. LPN #66 stated, Yea that needs changed, I'm not sure what that [pink substance] is. Resident #35 stated he liked to keep that curtain pulled so it would block out the light coming in from the outside window.
b) room [ROOM NUMBER] and 303
An observation, on 11/16/22 at 9:40 AM, of rooms [ROOM NUMBERS] found, the doors in disrepair, with the paint peeling off.
An interview, on 11/16/22 at 9:58 AM, the Director of Nursing confirmed doors were in disrepair with the paint peeling off. She stated that the managers were going to paint each Resident room door, but they haven't got to it yet.
c) room [ROOM NUMBER]
An observation, on 11/16/22 11:02 AM, of rooms 305 found, the drawer on the wardrobe broke and laying on the floor.
During an interview on 11/16/22 at 11:02 AM Resident #54 stated that the drawer has been broke for a long time.
During an interview on 11/17/22 at 8:14 AM the Life Engagement Coordinator #66 stated that she would get the wardrobe fixed right away.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
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Based on record review and staff interview, the facility failed to ensure a representative from the Office of the State Long-Term Care Ombudsman was notified of transfers and/or discharges as requir...
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Based on record review and staff interview, the facility failed to ensure a representative from the Office of the State Long-Term Care Ombudsman was notified of transfers and/or discharges as required. This was true for two (2) of three (3) residents reviewed for the care area of hospitalizations and true for one (1) of two (2) residents reviewed for discharge during the long term care survey process (LTCSP). Resident Identifiers: Residents #442, #342 and #42. Census: 90.
Findings included:
a) Resident #442
A record review showed Resident #442 had been transferred to the hospital after a fall on 04/22/22. Further review of the record showed no evidence the State Ombudsman had been notified of the transfer as required.
An interview, with the facility's Administrator, on 11/15/22 at 3:31 PM, verified the facility had failed to notify the State Ombudsman of Resident #442's transfer to the hospital, occurring on 04/22/22.
b) Resident #342
A record review showed Resident #342 had been discharged on 9/15/22 with a return not anticipated. Further review of the medical record showed no evidence the State Ombudsman had been notified of Resident #342's discharge from the facility as required.
An interview, with the facility's Administrator, on 11/15/22 at 3:31 PM, verified the facility had failed to notify the State Ombudsman of Resident #342's discharge from the facilty, occurring 09/15/22.
c) Resident #42
Review of Resident #42's medical records showed Resident #42 went to her scheduled dialysis appointment on 09/06/22. At the dialysis facility, the resident developed mental status changes and shortness of breath. Resident #42 was sent to the hospital from the dialysis facility and was diagnosed with sepsis. The resident remained in the hospital until 09/14/22 and returned to the long-term care facility upon discharge from the hospital.
During an interview on 11/15/22 at 2:11 PM, the facility Administrator stated she had no documentation the ombudsman was notified of Resident #42's hospitalization on 09/06/22. The Administrator stated she sent discharge notices to the ombudsman at the end of September 2022. However, she did not keep a list of the discharge notices that were sent. The Administrator acknowledged Resident #42 did not receive a notice of discharge because she had been admitted to the hospital from a dialysis appointment. The Administrator stated she did not know if the ombudsman was notified regarding Resident #42's hospitalization because there was not a discharge notice to send to the ombudsman.
No further information was provided through the completion of the survey.
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CONCERN
(E)
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 as free of accident hazards as possible. These were random opportunities...
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Based on observation and staff interview the facility failed to ensure the resident environment over which it had control was as free of accident hazards as possible. These were random opportunities for discovery and had the potential to affect more than an isolated number of residents. Facility census: 90.
Findings Included:
a) Unlocked Nourishment Room
During the initial tour on 11/14/22 at 11:50 AM an observation found the nourishment room door was unlocked on the Life Engagement Alzheimer's Unit (ACU). The nourishment room contained a coffee maker with a hot pot of coffee on the counter, accessible to residents living on the ACU.
On 11/14/22 at 11:50 AM the Director of Nursing (DON) verified the door was sticking and not closing all the way and there was a coffee maker with a hot pot of coffee in reach of residents. She stated the nourishment room should always be locked. The DON called maintenance to get the door fixed at this time.
b) The ACU kitchen.
On 11/14/22 at 12:02 PM an observation the Life Engagement Alzheimer's Unit (ACU) of the Resident Kitchen found three (3) cleaning spray bottles with blue unidentified liquid, one (1) cleaning spray bottle with yellow unidentified liquid, and one (1) cleaning spray bottle with clear unidentified liquid, in unlocked and unsecured cabinets, accessible to residents living on the ACU.
On 11/14/22 at 12:20 PM during an interview the Life Engagement Coordinator #66, confirmed there were five (5) spray bottles of unidentified liquids in the Residents kitchen cabinets accessible to ACU Residents. She stated that all chemicals should be locked up.
c) [NAME] Hall Fire Doors in Facility
On 11/15/22 at 9:23 AM it was observed that the fire doors on west hall were broken causing an accident hazard. Both fire doors on the west hall had push bars across the doors which were broken. The end caps on the push bars was missing. The inside of the push bars was sharp metal and was accessible to residents because the end caps was missing.
This was confirmed with the Director of Nursing (DON) and Administrator on 11/15/22 at 9:25 AM. According to the Administrator they have ordered the doors but have not received them. She can not provide documentation of the doors being ordered.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0800
(Tag F0800)
Could have caused harm · This affected multiple residents
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Based on observation and staff interview, the facility failed to ensure food was held prior to food service at appropriate temperatures, cold food should be held at 41 degrees or below. This failed ...
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Based on observation and staff interview, the facility failed to ensure food was held prior to food service at appropriate temperatures, cold food should be held at 41 degrees or below. This failed practice had the potential to affect more than an isolated number of residents. Facility census: 90
Findings included:
a) Kitchen Tour
Observation on 11/14/22 at 11:14 AM during the kitchen tour found, the chopped tossed garden salad in the steam table.
During an Interview and temperature check on 11/14/22 at 11:20 AM with Dietary aide #48 revealed the chopped tossed salad was being held at 94 degrees.
On 11/14/22 at 11:40 AM the dietary Manager in training verified cold food should be held at 41 degrees on below and the chopped tossed garden salad was not.
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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 observations, staff interview, and record review, the facility failed to provide each resident food and / or drink that was palatable, attractive, and at a safe and appetizing temperature. ...
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Based on observations, staff interview, and record review, the facility failed to provide each resident food and / or drink that was palatable, attractive, and at a safe and appetizing temperature. This has the ability to affect all Residents that get their nutrition from the kitchen. Facility Census: 90
Findings Included:
a) Dining Observation
On 11/15/22 at 12:06 PM an observation of tray pass on the 100-hall found, the holding tray cart open on both sides throughout the tray pass.
On 11/15/22 at 12:19 PM the Dietary Manager in Training took temperatures of the last resident tray on the 100-hall cart the following temperatures were obtained:
--Ham - 95 degrees Fahrenheit (F)
--Glazed Carrots -107 degrees F.
--Egg Noodles - 96 degrees F.
--Spiced Peaches -54 degrees F.
On 11/15/22 at 12:22 AM during an Interview the Dietary Manager in Training verified the lunch trays were not being served at a palatable safe and appetizing temperature.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
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Based on observation, policy review and staff interview the facility failed to complete labeling and date stored food items in the refrigerator and freezer on the Life Engagement Alzheimer's Unit (A...
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Based on observation, policy review and staff interview the facility failed to complete labeling and date stored food items in the refrigerator and freezer on the Life Engagement Alzheimer's Unit (ACU) resident kitchen. The facility also failed to the monitor the temperature of Resident #85's personal refrigerator in his resident room. This has the ability to affect more than a limited number of residents that reside on the ACU. In addition to Resident #85 who was a random opportunity for discovery. Resident Identifiers: #85. Facility Census: 90.
Findings Included:
a) ACU Resident Kitchen
A review of the facility's policy titled Food Receiving and Storage, with revised date October 2017, revealed the following:
Food items and snacks kept on the nursing units be maintained as indicated below.
--All food items to be kept below 41 degrees, must be placed in the refrigerator and labeled with use by date.
Observation during the ACU kitchen tour on 11/16/22 11:59 AM found:
-- Refrigerator -two (2) packs of open cheese with no labeling or dates.
-- Freezer- One (1) open gallon of vanilla ice-cream with no labeling or dates.
-- cabinet - one (1) open bag of potato chips and four (4) boxes of snack crackers which were not labeled nor dated.
During an interview on 11/16/22 at 12:20 PM, the Dietary Manager in Training verified, there was no labeling or dates on the items mentioned.
b) Resident #85
On 11/14/22 at 11:15 AM it was noted Resident #85's personal refrigerator at bedside still had the September Temperature Sheet hanging on the refrigerator. It was completed through 9/15/22 AM. This was confirmed with Licensed Practical Nurse #89 on 11/14/22 at 11:30 AM. October and November temperature log sheets were located and provided by the Director of Nursing on 11/14/22 at 2:40 PM.
There were fifteen (15) days from 9/16/22 through 9/30/22 with no temperature checks. According to the Refrigerators and Freezers Policy revision date December 2014, refrigerator temperatures are to be checked twice a day.
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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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview the facility failed to ensure each medical record was complete and accurate this wa...
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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 each medical record was complete and accurate this was true for 12 of 27 sampled residents during the Long Term Care Survey Process. Resident Identifiers: #62, #33, #56, #84, #89, #22, #91, #35, #342, # 55, #66, and #54. Facility Census: 90.
Findings Included:
a) Resident #33
A review of Resident #33's shower/bed bath documentation from the point of care system in the medical record indicated Resident #33 received the following showers and/or bed baths.
-- [DATE] - Bed Bath at 6:59 pm.
-- [DATE] - a shower at 5:58 pm.
-- [DATE] - a shower at 9:03 am.
-- [DATE] - a bed bath at 6:59 pm.
Further review of the shower sheets provided by the facility found the following conflicts in regards to the documentation in the Point of Care System:
-- [DATE] the shower sheet indicated Resident #33 received a bed bath. This was not documented in POC in the medical record.
-- [DATE] the shower sheet indicated Resident #33 received a shower. This was not documented in POC in the medical record.
-- [DATE] the shower sheet indicated Resident #33 received a shower. This was not documented in POC in the medical record.
-- [DATE] the shower sheet indicated Resident #33 received a shower. This was not documented in POC in the medical record.
-- [DATE] the shower sheet indicated Resident #33 received a shower. This was not documented in POC in the medical record.
-- [DATE] the shower sheet indicated Resident #33 received a shower. This was not documented in POC in the medical record.
-- [DATE] the shower sheet indicated Resident #33 received a shower. This was not documented in POC in the medical record.
An interview with the Director of Nursing (DON) at 9:10 am on [DATE] confirmed the Shower Sheets are not part of the medical record. She agreed the documentation on the shower sheets did not match the documentation in the medical record and should have.
b) Resident #56
A review of Resident #56's shower/bed bath documentation from the point of care system indicated Resident #56 received the following showers and/or bed baths.
-- [DATE] - Bed Bath at 2:59 pm.
-- [DATE] - Bed Bath documented at 6:59 pm.
-- [DATE] - Bed Bath at 6:08 pm.
-- [DATE]- Shower at 2:59 pm.
Further review of the shower sheets provided by the facility found the following conflicts in regards to the documentation in the Point of Care System:
-- [DATE] the shower sheet indicated Resident #56 had a bed bath. This was not documented in POC in the medical record.
-- [DATE] the shower sheet indicated Resident #56 received a shower. This was not documented in POC in the medical record.
-- [DATE] the shower sheet indicated Resident #56 received a bed bath. This was not documented in POC in the medical record.
-- [DATE] the shower sheet indicated Resident #56 received a shower. This was not documented in POC in the medical record.
-- [DATE] the shower sheet indicated Resident #56 received a bed bath. This was not documented in POC in the medical record.
-- [DATE] the shower sheet indicated Resident #56 received a bed bath. This was not documented in POC in the medial record.
-- [DATE] the shower sheet indicated Resident #56 received a bed bath. This was not documented in POC in the medial record.
-- [DATE] the shower sheet indicated Resident #56 received a bed bath. This was not documented in POC in the medial record.
-- [DATE] the shower sheet indicated Resident #56 received a bed bath. This was not documented in POC in the medial record.
An interview with the Director of Nursing (DON) at 9:10 am on [DATE] confirmed the Shower Sheets are not part of the medical record. She agreed the documentation on the shower sheets did not match the documentation in the medical record and should have.
c) Resident #62
A review of Resident #62's shower/bed bath documentation from the point of care system indicated Resident #62 received the following showers and/or bed baths.
-- [DATE] - Bed Bath at 6:59 pm.
-- [DATE] - a shower and a bed bath both documented at 6:59 pm.
-- [DATE] - a shower at 1:07 pm.
-- [DATE] - a shower at 8:43 am, a bed bath at 6:10 pm, and 11:36 pm.
-- [DATE] - a shower at 6:59 pm.
-- [DATE] - a bed bath at 8:49 am.
-- [DATE]- a refusal of bathing at 1:17 pm.
Further review of the shower sheets provided by the facility found the following conflicts in regards to the documentation in the Point of Care System:
-- [DATE] the shower sheet indicated Resident #62 refused bathing. This was not documented in POC in the medical record.
-- [DATE] the shower sheet indicated Resident #62 received a shower. The documentation in POC in the medical record indicated Resident #62 received a shower and a bed bath both at the same time.
-- [DATE] the shower sheet indicated Resident #62 received a bed bath. The documentation in POC in the medical record indicated Resident #62 received a shower instead of a bed bath.
-- [DATE] the shower sheet indicated Resident #62 received a bed bath. This was not documented in POC in the medical record of Resident #62.
-- [DATE] the shower sheet indicated Resident #62 received a bed bath but the POC documentation in the medical record indicated he received a shower.
-- [DATE] the shower sheet indicated Resident #62 refused bathing but the POC documentation in the medical record indicated he received a bed bath.
An interview with the Director of Nursing (DON) at 9:10 am on [DATE] confirmed the Shower Sheets are not part of the medical record. She agreed the documentation on the shower sheets did not match the documentation in the medical record and should have.
d) Resident #84
A review of Resident #84's shower/bed bath documentation from the point of care system indicated Resident #84 received the following showers and/or bed baths.
-- [DATE] - Bed Bath at 6:59 pm.
-- [DATE] - Shower Documented at 6:00 pm.
-- [DATE] - Shower documented at 8:53 am.
-- [DATE]- Shower at 9:24 am.
-- [DATE] - Bed Bath at 9:43 am
-- [DATE] - Shower at 11:16 am.
-- [DATE] - Bed Bath at 6:59 pm
-- [DATE] - Bed Bath at 9:38 am.
Further review of the shower sheets provided by the facility found the following conflicts in regards to the documentation in the Point of Care System:
-- [DATE] the shower sheet indicated Resident #84 refused bathing. This was not documented in POC in the medial record.
-- [DATE] the shower sheet indicated Resident #84 refused bathing. This was not documented in POC in the medical record.
An interview with the Director of Nursing (DON) at 9:10 am on [DATE] confirmed the Shower Sheets are not part of the medical record. She agreed the documentation on the shower sheets did not match the documentation in the medical record and should have.
E) Resident #89
A review of Resident #89's shower/bed bath documentation from the point of care system indicated Resident #89 received the following showers and/or bed baths.
-- [DATE] - Shower documented at 3:37 pm.
-- [DATE] - Bed Bath documented at 10:06 am.
-- [DATE] - Bed Bath at 11:26 am.
-- [DATE]- Bed Bath at 6:59 pm.
-- [DATE] - Bed Bath at 9:52 am.
Further review of the shower sheets provided by the facility found the following conflicts in regards to the documentation in the Point of Care System:
-- [DATE] the shower sheet indicated Resident #89 received a shower. This was not documented in POC in the medial record.
-- [DATE] the shower sheet indicated Resident #89 received a shower. This was not documented in POC in the medial record.
An interview with the Director of Nursing (DON) at 9:10 am on [DATE] confirmed the Shower Sheets are not part of the medical record. She agreed the documentation on the shower sheets did not match the documentation in the medical record and should have.
f) Resident #22
Review of Resident #22's physician's orders showed an order written on [DATE] for aspirin, 81 milligrams (mg), one (1) capsule by mouth one time a day for moderate pain. This low dose of aspirin is usually prescribed to prevent heart attack and strokes for people with risk factors for these conditions. Resident #22 had diagnoses of atherosclerosis and hypertension. The resident also had a previous history of a heart attack. The aspirin order was discontinued on [DATE].
During an interview on [DATE] at 1:27 PM, the Director of Nursing (DON) confirmed this order was incorrect. The DON stated aspirin was not prescribed for moderate pain.
No further information was provided throughout the completion of the survey.
g) Resident #91
Review of Resident #91's medical records showed the resident was admitted from a hospital to the facility on [DATE]. Upon admission to the facility on [DATE], a 'Do Not Resuscitate' (DNR) order was written, meaning cardiopulmonary resuscitation (CPR) and other life saving measures would not be attempted in the event of a cardiac or respiratory arrest. Review of the records from Resident #91's hospitalization showed the resident did not have capacity to make medical decisions. There was no documentation in the hospital records of DNR status for the resident.
Further review of Resident #91's medical records showed a CPR form dated [DATE]. On this form the resident's Medical Power of Attorney (MPOA) gave verbal instructions for the resident to have CPR in the event of cardiac or respiratory arrest. The instructions were witnessed by two (2) staff members and signed by the physician. On [DATE], an order was written for Resident #91 to be full code, meaning the resident was to have cardiopulmonary resuscitation (CPR) and other life saving measures.
During an interview on [DATE] at 11:54 AM, the Director of Nursing (DON) was asked why Resident #91 initially had a DNR order upon admission to the facility. The DON stated Resident #91's DNR order on [DATE] was written in error. The DON stated another resident with a name similar to Resident #91's had been admitted the same day. This other resident had a do not resuscitate status and mistaking the two (2) residents led to an error in Resident #91's orders. Resident #91's code status orders were corrected when the facility realized a mistake had been made.
No further information was provided through the completion of the survey.
h) Resident #35
During an interview on [DATE] at 12:20 PM Resident #35 stated, I can't chew the meat, it's too tough I don't have any teeth. I look at the tray and if I don't think I can eat it I ask for something else.
Record review of the Resident's admission Minimum Data Set (MDS) dated [DATE] showed section L0200, question F difficulty with chewing to be answered No.
Record review of the Resident's Quarterly MDS dated [DATE] showed section L0200, question F difficulty with chewing to be answered No.
Record review of Resident #35's admission assessment dated [DATE] showed section D (Oral/Nutritional) question 12 Teeth/Dentures to be blank.
Record review of Resident #35's Oral Health Evaluation dated [DATE] indicated Resident #35 had full natural teeth and no oral health issues identified.
On [DATE] at 8:09 AM, Resident #35 was interview by the Director of Nursing in the presence of surveyor. The DON asked the Resident if he had any teeth at all, and the Resident stated, Only 2 on the bottom back. The Resident was asked if he wanted new dentures and resident declined and said he was done with that they won't fit right, it hits on the bottom back teeth and flops sideways. Resident #35 stated he was making do and to keep the soft sandwiches coming. The DON stated they should be doing a dental assessment quarterly and the dental thing was new to them. The DON agreed the Resident's oral health assessment was not completed accurately for his dental status and did accurately reflect his difficulty chewing or his missing teeth.
I) Resident #342
A record review for Resident #342 showed the resident was admitted to the facility on [DATE]. The resident was discharged from the facility on [DATE] with a return not expected. On [DATE], Resident #342 was again admitted to the facility.
A review of the Profile sheet , dated [DATE], containing pertinent contact and billing information showed Resident #342 was responsible for herself and for the billing statement. The profile information for the [DATE] admission showed the resident's spouse was listed as the guarantor and was the emergency contact for the resident.
A review of the [NAME] Virginia POST Form, completed on [DATE], noted the resident's spouse listed as the emergency contact.
Resident #342 had been assessed by facility staff to have a Brief Interview for Mental Status (BIMS) of 15 which indicated the resident was cognitively intact. On [DATE] the resident was re-assessed to have a BIMS score of 14 which indicated the resident remained cognitively intact.
An interview, with Resident #342, on [DATE] at 11:31 AM, revealed the resident's spouse was deceased and had been deceased prior to the first admission of [DATE].
An interview with the Social Services Director, on [DATE] at 12:44 PM, revealed she was unaware the resident's spouse had passed away, however, the information on the profile sheet and the POST form should have been corrected to reflect the current contact information.
An interview, with the Business Office Director, on [DATE] at 01:12 PM, revealed she was unsure who would update the medical records profile information to ensure the information was correct and current.
An interview with the facility administrator, on [DATE] at 01:32 PM, confirmed the profile sheet and POST form was not correctly documented and provided a Policy: Change in a Resident's Condition or Status, with a revision date of February 2021. This policy noted, under Item 10: the business office manager or designee would verify the address and telephone number of the resident's family or representative on a quarterly basis. and any changes were to be reported to the director of nursing to ensure the information would be changed in the medical record.
j) Resident #55
1) Post Form
On [DATE] at 2:17 PM upon review of Resident #55's [NAME] Virginia Physician Orders for Scope of Treatment (POST) form signed and dated [DATE] by the Nurse Practioner (NP), the form is missing a license/certification number for the NP. This is required in order for the form to be considered completed in it's entirety. This was confirmed with the Director of Nursing on [DATE] at 2:40 PM.
2) Capacity Statement
On [DATE] at 2:20 PM upon review of Resident #55's Physician Determination of Capacity form, it was identified that the Physician failed to date the form. This is required in order for the form to considered completed in it's entirety. This was confirmed with the Director of Nursing on [DATE] at 2:40 PM.
k) Resident #66
1) POST Form
On [DATE] at 2:15 PM upon review of Resident #66's [NAME] Virginia Physician Orders for Scope of Treatment (POST) form signed and dated [DATE] by the Nurse Practioner (NP), the form is missing a license/certification number for the NP. This is required in order for the form to be considered completed in it's entirety. This was confirmed with the Director of Nursing on [DATE] at 2:40 PM.
2) Capacity Statement
On [DATE] at 2:13 PM upon review of Resident #66's Physician Determination of Capacity form, it was identified that the Physician failed to date the form. This is required in order for the form to considered completed in it's entirety. This was confirmed with the Director of Nursing on [DATE] at 2:40 PM.
L) Resident #54
1) Dementia Diagnosis
On [DATE] at 3:00 PM an observation and Interview with Resident #54 on the Life Engagement Alzheimer's Unit (ACU). Resident #54 stated that he was over in another part of the building, when he was admitted to the facility.
A medical record review of revealed, Resident #54s did not have an active diagnosis of Alzheimer's disease or related dementia required to reside on a locked Alzheimer's Unit.
During an interview on [DATE] at 8:17 AM the Director of Nursing (DON) stated that she was sure he had a diagnosis of dementia.
During an interview on [DATE] at 11:09 AM the Director of Nursing (DON) provided a copy of a physician / nurse practitioner diagnosis of dementia dated [DATE]. The DON Verified the diagnosis was never added to Resident #54's medical record.
2) Resident #54's dental assessments.
On [DATE] at 3:00 PM an observation and Interview, Resident #54 has missing teeth. He stated that his teeth hurt, and he needs a dental appointment. Resident #54 stated that the facility was supposed to make him an appointment, but never has.
A medical record review of revealed, Resident #54s oral health assessment completed [DATE], noted broken, loose or carious teeth. No other dental assessments completed.
[DATE] 9:04 AM the Director of Nursing (DON) verified Resident #54s dental assessments should have been completed but, they were missed.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to ensure documentation in the residents medical record of the...
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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 documentation in the residents medical record of the information/education provided regarding the benefits and risks of immunizations and the administration or the refusal of /or medical contraindications to the vaccines. This was true for three (3) of five (5) residents reviewed for immunizations during the Long- Term Care Survey Process (LTCSP). This failed practice had the potential to affect all residents residing in the facility eligible for immunizations. Resident identifiers: Residents #47, #33 and #44. Census: 90
Findings included:
a.) Policy Review
A review of the Policy, titled: Vaccination of Residents, dated with a revision date of October 2019, showed prior to receiving vaccinations, the resident or legal representative [NAME] be provided information and education regarding the benefits and potential side effects of the vaccinations and this education would be documented in the resident's medical record. If vaccinations were refused, the refusal would be documented in the medical record.
A review of the Policy, titled: Pneumococcal Vaccine, revision date of March 2022, showed before a resident received a pneumococcal vaccine, the resident of legal representative would receive information regarding benefits and potential benefits and potential side effects of the vaccination. Provision of such education would be documented in the resident's medical record. Additionally, if the vaccination was refused, the appropriate information would be documented in the resident's medical record to include the date of the refusal of the pneumococcal vaccination.
b) Resident #47
A record review, for Resident #47, showed the resident was eligible for a pneumococcal vaccine. A notation on the vaccination status showed the consent was refused. Upon further review, there was no evidence the resident or legal representative had been provided education on the vaccination with potential benefits and side effects and the date the information was provided documented in the medical record. Additionally, there was no evidence of the date the pneumococcal vaccination was refused.
An interview, with the Infection Preventionist, on 11/16/22 at 10:54 AM, revealed the family had been contacted and the immunization had been refused, however, the information had not been documented in the resident's medical record.
c) Resident #33
A record review, for Resident #33, showed the resident was eligible for a pneumococcal vaccination. Further review of the medical record showed no evidence the resident had been provided education on the pnemococcal vaccines available with risks verses benefits as well as potential side effects of the vaccine with acceptance or refusal of the vaccine documented in the resident's medical record.
An interview, with the Infection Preventionist (IP), on 11/16/22 at 10:51 AM, revealed the resident had capacity, therefore, the IP stated the resident was asked if they wanted the pneumococcal vaccine and the resident refused. At this time, the IP confirmed there was no documentation in the resident's medical record of any education of the risks verses benefits of the immunization, or the potential side effects of receiving the vaccine. Additionally, the IP verified there was no documentation in the medical record of the signed refusal of the vaccination, with the date noted of the refusal.
An interview, with the facility Administrator, on 11/16/22 at 11:20 AM , confirmed that the facility policy required all vaccination information to be part of the resident's medical record.
d) Resident #44
A record review revealed Resident #44 was admitted to the facilty on 10/13/22. There was no evidence, in the medical record, the resident or legal representative had been provided education and had been offered for Resident #44 to receive an Influenza vaccination.
An interview, with the IP, on 11/16/22 at 10: 49 AM, revealed the facility had attempted to contact the family to discuss the influenza vaccination, however, there was no documentation made in the resident's medical record of the date(s) and the attempt(s) to reach the family.
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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
- "What changes have you made since the serious inspection findings?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 1 life-threatening violation(s), 4 harm violation(s), $72,444 in fines. Review inspection reports carefully.
- • 91 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $72,444 in fines. Extremely high, among the most fined facilities in West Virginia. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Glasgow Hills Of Journey's CMS Rating?
CMS assigns GLASGOW HILLS OF JOURNEY 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 Glasgow Hills Of Journey Staffed?
CMS rates GLASGOW HILLS OF JOURNEY's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes.
What Have Inspectors Found at Glasgow Hills Of Journey?
State health inspectors documented 91 deficiencies at GLASGOW HILLS OF JOURNEY during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 4 that caused actual resident harm, and 86 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Glasgow Hills Of Journey?
GLASGOW HILLS OF JOURNEY 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 JOURNEY HEALTHCARE, a chain that manages multiple nursing homes. With 112 certified beds and approximately 103 residents (about 92% occupancy), it is a mid-sized facility located in GLASGOW, West Virginia.
How Does Glasgow Hills Of Journey Compare to Other West Virginia Nursing Homes?
Compared to the 100 nursing homes in West Virginia, GLASGOW HILLS OF JOURNEY's overall rating (1 stars) is below the state average of 2.7 and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Glasgow Hills Of Journey?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, and the below-average staffing rating.
Is Glasgow Hills Of Journey Safe?
Based on CMS inspection data, GLASGOW HILLS OF JOURNEY has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in West Virginia. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Glasgow Hills Of Journey Stick Around?
GLASGOW HILLS OF JOURNEY has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.
Was Glasgow Hills Of Journey Ever Fined?
GLASGOW HILLS OF JOURNEY has been fined $72,444 across 1 penalty action. This is above the West Virginia average of $33,803. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Glasgow Hills Of Journey on Any Federal Watch List?
GLASGOW HILLS OF JOURNEY 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.