MORGANTOWN HEIGHTS OF JOURNEY
For profit - Limited Liability company
100 Beds
JOURNEY HEALTHCARE
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
0/100
#106 of 122 in WV
Photo by Morgantown Heights
Photo by Morgantown Heights
Photo by CERISE Roberts
1 / 5 photos
Last Inspection: March 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Morgantown Heights of Journey has received a Trust Grade of F, indicating poor performance with significant concerns about care quality. It ranks #106 out of 122 facilities in West Virginia, placing it in the bottom half, and it is the lowest-ranked facility in Monongalia County. Although the facility shows signs of improvement, decreasing from 34 issues in 2024 to 6 in 2025, the overall situation remains concerning, with $148,460 in fines, which is higher than 95% of similar facilities in the state. Staffing is a mixed bag; while the turnover rate is 0%, which is excellent, the facility provides less RN coverage than 94% of state facilities, potentially impacting resident care. Specific incidents of concern include a resident being left on the floor after a fall when proper lifting procedures were not followed, and failures in pain management for two residents, resulting in actual harm.
- Trust Score
- F
- In West Virginia
- #106/122
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- Turnover data not reported for this facility.
- Penalties ✓ Good
- $148,460 in fines. Lower than most West Virginia facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 18 minutes of Registered Nurse (RN) attention daily — below average for West Virginia. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 80 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 14%
Review needed
34 → 6 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 34 issues
2025: 6 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below West Virginia average (2.7)
Significant quality concerns identified by CMS
Federal Fines: $148,460
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: JOURNEY HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 80 deficiencies on record
2 life-threatening 1 actual harm
Sept 2025
1 deficiency
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 interview and record review, the facility failed to perform a thorough investigation after an instance of resident-to-resident abuse. This was a random opportunity for discovery. Resident Ide...
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Based on interview and record review, the facility failed to perform a thorough investigation after an instance of resident-to-resident abuse. This was a random opportunity for discovery. Resident Identifiers: Resident #46. Facility Census: 72.Findings Include:a) Resident #46On September 9, 2025, during an interview conducted at approximately 1:08 PM, Resident #5 expressed concern about the behavior of Resident #46 towards other residents in the dining room. Resident #5 reported that Resident #46, who is known for his temper, threw a cup at another male resident, narrowly missing him. Additionally, about a month ago, Resident #46 became irritated with Resident #74 when she approached and began touching items on his table. In that instance, Resident #46 reportedly hit Resident #74 and told her, Go sit down! Sit down, or I will put you down, and you will be down for the rest of the day. Resident #5 also mentioned that Resident #46 called Resident #74 a bitch. It's worth noting that staff members were present during both incidents.Record review revealed that Resident #46 has a Brief Interview for Mental Status (BIMS) score of 15. When questioned about the incident on 09/08/25 at 1:20 PM, while the resident was coloring a picture mounted on the wall, the resident ignored the question. Resident #74 had a BIMS score of 00.A record request on 09/09/25 revealed that the incident between Resident #46 and Resident #74, which occurred on 08/22/25 at approximately 5:45 PM, had been reported to the Office of Health Facility Licensure and Certification (OHFLAC) and Adult Protective Services (APS) at approximately 6:00 PM on 08/22/25.Facility records also revealed that the five-day follow-up report had been submitted to OHFLAC on 08/25/25 at 8:32 PM.Report submitted to OHFLAC at 08/25/25 at 8:32 PM.A review of the facility's investigative records revealed the following statements from facility staff:A statement by Nursing Assistant (NA) #32 on 08/25/25 stated: Before dinner was served, the residents were gathered in the dining room, waiting for supper services. Resident #74 was ambulating throughout the dining room, adjusting tablecloths when she approached Resident #46's table, he told her to get away from his table, and she replied No, we then were heading toward the table to intervene (NA #51 and I). Before we got there , he had struck Resident #74 in the arm shoulder area with a closed fist. (I was sitting near the kitchen; NA #51 was passing drinks). Resident #74 then pointed at Resident #46 and said something, but I could not hear her. Resident #46 continued to yell to get that stupid bitch away from me. NA #51 escorted Resident #74 out of the dining room to the North nurses station. Resident #46 refused to leave separate from the dining room. He calmed down and ate dinner. We kept him under one-on-one supervision. Resident #74 then returned to the dining room after being assessed by the nurse and ate her dinner. No change in mood or behavior noted. Another verbal statement by Licensed Practical Nurse (LPN) #70 stated:I was [Resident #74's] nurse. [Resident #74] did not act any differently than usual. Resident went to dining room for dinner and showed no agitation at that time. [Resident #74] after the event was fine. She showed no signs of being upset.Interviews were conducted with Residents #52, #59 and #62 on 09/09/25 at approximately 11:44 AM. Residents #59 and #62 had no knowledge of the incident because they ate their meals in their rooms. Resident #52 stated that her memory was bad, and she was unable to remember any incident.Record review on 09/09/25 at 1:20 PM revealed that the facility investigation consisted of asking the residents the following two questions: 1. Do you feel safe here?2. Has any resident hit you? The facility failed to conduct a thorough investigation of the incident by not interviewing any residents regarding the incident that occurred in the dining room on 08/22/25.
Jul 2025
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation and staff interview, the facility failed to provide a dignified experience while receiving an administration of insulin for Resident #44. This was a random opportunity fordiscover...
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Based on observation and staff interview, the facility failed to provide a dignified experience while receiving an administration of insulin for Resident #44. This was a random opportunity fordiscovery. Resident Identifier: #44. Facility Census: 84.Findings Include: a) Resident #44On 07/08/25 at 12:08 PM, an observation of Licensed Practical Nurse (LPN) #45 administering Humalog insulin to Resident #44 in the hallway.On 07/0/25 at 12:09 PM, an interview was held with LPN #45. LPN #45 was asked, Did you administer an injection in the hallway? LPN #45stated, Yes, but I'm running behind, there is always an issue with obtaining the blood sugars in the morning, night shift won't do it.On 07/08/25 at 12:11 PM, the Corporate Registered Nurse (RN) was notified and confirmed the injection should not have been given in the hallway.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on observation and staff interviews, the facility failed to ensure the call system was accessible to residents while in their bed or other sleeping accommodations within the resident'sroom. This...
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Based on observation and staff interviews, the facility failed to ensure the call system was accessible to residents while in their bed or other sleeping accommodations within the resident'sroom. This was a random opportunity for discovery. Resident identifier: #12. Facility Census 84Findings include: a) Resident #12On 07/07/25 at 1:10 PM, Resident #12 was heard yelling for help and continued yelling until 1:35 PM. Upon checking on the resident and entering her room, Resident #12 was observed sitting in her wheel chair at the end of her bed. Her call bell was out of her reach on her bed near the pillow.On 07/07/25 at 1:35 PM, in and interview withLicensed Practical Nurse #17, she acknowledged the call button was not within reach of the resident and stated that she was unaware as a nurse aide was just with the resident.
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
Based on record review and staff interview, the facility failed to develop the a comprehensive personal care plan for Resident #80. This was true for one (1) of six (6) residents reviewedduring the su...
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Based on record review and staff interview, the facility failed to develop the a comprehensive personal care plan for Resident #80. This was true for one (1) of six (6) residents reviewedduring the survey process. Resident Identifier: #80. Facility Census: 84Findings Include: a) Resident #80On 07/08/25 at approximately 2:00 PM, the care plan was reviewed for Resident #80. The review found the care plan was blank under multiple focus areas. The following areas were included:--Focus area: The resident has or a potential for: (acute pain-less than 30 days/sub acute pain 30-90 days/Chronic pain greater than 90 days)Pain/Pain Potential is Related to: (Typed as written.) No further information was listed under the focus area.Under the interventions of this focus area lists the following: The resident prefered to have pain controlled by: (SPECIFY) medication, treatment). No further information was listed with thisintervention.--Focus area: The resident has bowel incontinence r/t (related to). No further information is listed under the focus area.--Focus area: The resident has a communication problem r/t (blank). No further information is listed under the focus area.The goals found under the focus area are: The resident will maintain current level of communication function by (SPECIFY how, with what assistance i.e. making sounds, using appropriate gestures, responding yes/no questions appropriately, using communication board, writing messages) through the next review date. An additional goal was listed as: The resident will be able to make basic needs known by (SPECIFY) on a daily basis through the next review.Upon further review of the record as well as an resident interview, the resident did not have any type of issues with communication.--Focus area: Requires assistance with Activities of Daily Living. The intervention listed states, Walking Assist: (independent, supervision/oversight, setup, verbal cues/encouragement, non-weight bearing assistance, weight-bearing assistance, total dependence). No further information is listed.On 07/08/25 at approximately 3:15 PM, the Corporate Registered Nurse (RN) confirmed the care plan was incomplete and contained the wrong information regarding a communication issue.
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, resident interview, and staff interview the facility failed to provide care in accordance with professional standards of care by not following physician 's orders for woundtrea...
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Based on record review, resident interview, and staff interview the facility failed to provide care in accordance with professional standards of care by not following physician 's orders for woundtreatments, and medication administration. This failed practice was found true for (5) five of (5) five residents reviewed for medication administration and wound care during the complaint survey. Resident identifiers: #80, #5, #40, #76 and #6. Facility Census: 84 Findings included:a) Resident #80On 06/11/25 at 3:33 PM, the Emergency Medical Services (EMS) staff, reported to the ED that the resident was found to be lying in urine and feces, and red, raw irritated skin was noted on the buttocks as well as the perineum. Upon examination the ED doctor documented the condition of the wound were as follows:A left leg wound that is necrotic and decubitus to the sacral area and severe skin breakdown.Upon further review of the ED Physician affidavit, obtained from Adult Protective Services (APS) stated, Unclean physical condition, significant excoriations to the perineal and groin area, which appear to be due to inability to care for personal hygiene/lack of appropriate care from the facility. Significant pain with any amount of movement to this area.A further review of the facility's medical record for Resident #80 revealed no treatment had been ordered to the severely excoriated areas.On 07/08/25 at 9:50 AM, Resident #80, who continued to be hospitalized , was interviewed via telephone. The resident stated, More attention was needed for my wounds, the incontinence care hurt like hell. The wait to receive incontinence care would be approximately (2) two hours and the aides had a bad attitude and were rough when providing the care. In addition, the interview continued with the Medical Power of Attorney (MPOA), who was present. The MPOA agreed that the resident did not receive the care she should have received.A record review on 07/08/25 at 10:40 AM, revealed nothing in her medical record that indicated MASD was present, or any treatments were in place for it.On 07/09/25 at approximately 4:00 PM, the Corporate Registered Nurse (RN) and Director of Nursing (DON) were notified and confirmed immediate skin sweeps would be completed on all the other residents within the facility.On 07/09/25 at 4:30 PM, the report entitled, Medication Administration Audit Report was requested for Resident #80. The report included missed and late medications. The facility has a liberalized medication administration schedule which allows the medication to be administered two (2) hours prior and two (2) hours after the scheduled time. This period of time, also, allows for the one (1) hour prior and one (1) hour after the two (2) hour time frame. For example, if a medication is scheduled for 8:00 AM, the nurse has from 6:00 AM to 11:00 AM to administer the medication before it is considered late. Although, the facility had a five (5) hour window, the following medications were administered late:--Tylenol 325 mg (milligram) by mouth four times daily for pain ordered for 06/01/25 at 4:00 PM, administered at 7:08 PM, this was 8 minutes past the 5-hour timeframe.--Multivitamin one tablet by mouth daily vitamin deficiency was ordered for 06/03/25 at 8:00 AM, administered at 11:06 AM, this was 6 minutes past the 5-hour timeframe.--Vitamin D3 25 mcg (microgram) by mouth daily for vitamin deficiency was ordered for 06/03/25 at 8:00 AM, administered at 11:06 AM, this is 6 minutes past the 5-hour timeframe.--Magnesium Oxide 400 mg by mouth twice daily was ordered for 06/03/25 at 8:00 AM, administered at 11:06 AM, this is 6 minutes past the 5-hour timeframe.--Eliquis 5 mg by mouth twice daily anticoagulant was ordered for 06/03/25 at 8:00 AM, administered at 11:06 AM, this is 6 minutes pastthe 5-hour timeframe.--Amiodarone 200 mg (milligram) by mouth daily was ordered for 06/03/25 at 8:00 AM, administered at 11:05 AM, this is 5 minutes past the 5-hour timeframe.--Sennosides 8.6 mg (milligram) by mouth daily constipation was ordered for 06/03/25 at 8:00 AM, administered at 11:06 AM, this is 6 minutes past the 5-hour timeframe.--Tylenol 325 mg by mouth four times daily for pain was ordered for 06/03/25 at 8:00 AM, administered at 11:06 AM, this is 6 minutes past the 5-hour timeframe.--Lasix 40mg by mouth daily for blood pressure was ordered for 06/03/25 at 8:00 AM, administered at 11:06 AM, this is 6 minutes past the 5-hour timeframe.--Lisinopril 5mg by mouth daily for blood pressure was ordered for 06/03/25 at 8:00 AM, administered at 11:06 AM, this is 6 minutes past the 5-hour timeframe.--Aspirin 81 mg by mouth daily anticoagulant was ordered for 06/03/25 at 8:00 AM, administered at 11:05 AM, this is 5 minutes past the 5-hour timeframe.--Juven 1 packet by mouth two times daily was ordered for 06/03/25 at 8:00 PM, administered at 11:25 PM, this is 25 minutes past the 5-hour timeframe.--Famotidine 20 mg by mouth two times daily was ordered for 06/03/25 at 8:00 AM, administered at 11:06 AM, this is 6 minutes past the 5-hour timeframe. --ProSource 30 ml (milliliter) by mouth three times daily was ordered for 06/03/25 at 8:00 AM, administered at 11:06 AM, which is 6 minutes past the 5-hour timeframe.--Miralax 17gr (gram) by mouth daily for constipation was ordered for 06/03/25 at 8:00 AM, was administered at 11:06 AM, this is 6 minutes past the 5-hour timeframe.--Juven 1 packet by mouth two times daily for wound healing was ordered for 06/03/25 at 8:00 AM, administered at 11:06 AM, this is 6 minutes past the 5-hour timeframe.--Zinc 50 mg by mouth daily for wound healing was ordered for 06/03/25 at 8:00 AM, administered at 11:06 AM, this is 6 minutes past the 5-hour timeframe.--Vitamin C 500 mg by mouth two times daily for wound healing was ordered for 06/03/25 at 8:00 AM, administered at 11:06 AM, this is 6 minutes past the 5-hour timeframe.--Insulin Glargine (Lantus) inject 15 units subcutaneously (SQ) one time daily for diabetes management was ordered for 06/03/25at 8:00 AM, administered at 11:08 AM, this is 8 minutes past the 5-hour timeframe.--Tylenol 325 mg by mouth four times daily for pain was ordered for 06/09/25 at 8:00 AM, administered at 1:28 PM, this is 1 hour and 28 minutes past the 5-hour timeframe.--ProSource 30 m1 by mouth three times daily for wound healing was ordered for 06/09/25 at 8:00 AM, administered at 1:28 PM, this is 1 hour and 28 minutes past the 5-hour timeframe.The following are missed treatments for Resident #80:--NPWT (negative pressure wound therapy): Document amount of drainage. Call MD (medical doctor) if > (greater) than 100mIs in 8 hours or if frank red blood is in the cannister (turn off and leave dressing in place and call MD) ordered for 05/25/25 at 7:00 AM.--NPWT: dressing change three times a week and PRN (as needed). Clean wound bed with normal saline, apply skin sealant to surrounding tissue (skin prep or cavilon spray). (Apply adaptive or Mepitel to wound bed if fragile and indicated). Cut sponge to wound size and place in wound. Cover with transparent dressing. Attach NPWT at (specify setting) (intermittent/continual) to (specify wound/dressing site). every day shift every Monday, Wednesday, Friday for wound care and management ordered for 05/28/25 at 7:00 AM.NPWT: Document amount of drainage. Call MD (medical doctor) if > (greater) than 100mIs in 8 hours or if frank red blood is in the cannister (turn off and leave dressing in place and call MD) ordered for 05/30/25 at 7:00 AM.NPWT: Document amount of drainage. Call MD (medical doctor) if > (greater) than 100mIs in 8 hours or if frank red blood is in the cannister (turn off and leave dressing in place and call MD) ordered for 06/01/25 at 7:00 AM.Check settings, dressing, and suction every shift wound therapy ordered for 06/01/25 at 7:00 AM. wounds and infection every shift ordered for 06/01/25 at 7:00 AMMonitor bruising to RUA (right upper arm), report any changes every shift for bruising ordered for 06/01/25 at 7:00 AM.NPWT: dressing change three times a week and PRN (as needed). Clean wound bed with normal saline, apply skin sealant to surrounding tissue (skin prep or cavilon spray). (Apply adaptive or Mepitel to wound bed if fragile and indicated). Cut sponge to wound size and place in wound. Cover with transparent dressing. Attach NPWT at (specify setting) (intermittent/continual) to (specify wound/dressing site). every day shift every Monday, Wednesday, Friday for wound care and management ordered for 06/02/25 at 7:00 AM.R (right) lower leg: cleanse with IHW (in house wound cleanser), pat dry, apply small piece of purocol (collegen), cover with dry dressing every other day every shift Monday, Wednesday, Friday for wound care ordered for 06/02/25 at 7:00 AM.Change NPWT cannister every week and PRN day shift every Monday, Wednesday, Friday for wound therapy ordered for 06/02/25 at 7:00 AM.Check settings, dressing, and suction every shift wound therapy ordered for 06/02/25 at 7:00 AM.NPWT: Document amount of drainage. Call MD (medical doctor) if > (greater) than 100mIs in 8 hours or if frank red blood is in the canister (turn off and leave dressing in place and call MD) ordered for 06/02/25 at 7:00 AM.R (right) lower leg: cleanse with IHW (in house wound cleanser), pat dry, apply small piece of purocol (collegen), cover with dry dressing every other day every shift Monday, Wednesday, Friday for wound care ordered for 06/04/25 at 7:00 AM.Monitor bruising to RUA (right upper arm), report any changes every shift for bruising ordered for 06/04/25 at 7:00 AM.NPWT: Document amount of drainage. Call MD (medical doctor) if > (greater) than 100mIs in 8 hours or if frank red blood is in the canister (turn off and leave dressing in place and call MD) ordered for 06/05/25 at 7:00 AM. Vital signs q (every) shift x 72 hours post admission then monthly every shift for 3 days ordered on 06/06/25 at 7:00 AM.Rooke boots while in bed every shift ordered for 06/10/25 at 7:00 AM.Rt (right) upper thigh-monitor stitches for drainage and infection. Leave OTA (open to air) every shift ordered for 06/10/25 at 7:00 AM.NPWT: Document amount of drainage. Call MD (medical doctor) if > (greater) than 100mIs in 8 hours or if frank red blood is in the canister (turn off and leave dressing in place and call MD) ordered for 06/10/25 at 7:00 AM.Enhanced barrier precautions related to: wounds and infection every shift ordered for 06/10/25 at 7:00 AMCheck settings, dressing, and suction every shift wound therapy ordered for 06/10/25 at 7:00 AM.On 07/10/25 at approximately 9:30 AM, the Corporate Registered Nurse (N) was notified of the late medications and missing treatments. The Corporate RN confirmed the medications were late and the treatments were missed.b) Resident #5On 07/09/25 at 4:30 PM, the report entitled, Medication Administration Audit Report was requested for Resident #5. The report included missed and late medications. The facility had a liberalized medication administration schedule which allows the medication to be administered two (2) hours prior and two (2) hours after the scheduled time. This period, also, allows for the one (1) hour prior and one (1) hour after the two (2) hour time frame. For example, if a medication is scheduled for 8:00 AM, the nurse has from 6:00 AM to 11:00 AM to administer the medication before it is considered late. Although, the facility has a five (5) hour window, the following medications were administered late:Clotrimazole-Betamethasone Cream 1-0.05% apply to rash on chest topically two times daily for tinea corporis was ordered on 06/02/25 at 8:00 AM, administered at 1:41 PM, this is 2 hours and 41 minutes past the 5-hour timeframe.Clotrimazole-Betamethasone Cream 1-0.05% apply to rash on chest topically two times daily for tinea corporis was ordered on 06/07/25 at 8:00 AM, administered at 12:08 PM, this is 1 hour and 8 minutes past the 5-hour timeframe.Clotrimazole-Betamethasone Cream 1-0.05% apply to rash on chest topically two times daily for tinea corporis was ordered on 06/09/25 at 8:00 AM, administered at 2:20 PM, this is 3 hours and 20 minutes past the 5-hour timeframe. Metformin 500 mg by mouth two times daily for diabetes ordered for 06/20/25 at 8:00 AM, administered at 11:49 AM, this is 49 minutes past the 5-hour timeframe.Gabapentin 300mg by mouth four times daily for neuropathy ordered for 06/20/25 at 8:00 AM, administered at 11:50 AM, this is 50 minutes past the 5-hour timeframe. Senokot S 8.6-50mg by mouth two times daily bowel protocol ordered for 06/20/25 at 8:00 AM, administered at 11:50 AM, this is 50 minutes past the 5-hour timeframe.Lasix 20mg by mouth daily for peripheral edema ordered for 06/20/25 at 8:00 AM, administered at 11:50 AM, this is 50 minutes past the 5-hour timeframe.Multivitamin by mouth daily supplement ordered for 06/20/25 at 8:00 AM, administered at 11:49 AM, this is 49 minutes past the 5-hour timeframe.Doxycycline 100 mg by mouth two times daily for antimicrobial therapy for multiple infections was ordered for 06/20/25 at 8:00 AM, administered at 11:49 AM, this is 49 minutes past the 5-hour timeframe.Loratadine 10 mg by mouth daily for allergy symptoms ordered for 06/20/25 at 8:00 AM, administered at 11:50 AM, this is 50 minutes past the 5-hour timeframe.Cymbalta 60 mg by mouth daily antidepressant ordered for 06/20/25 at 8:00 AM, administered at 11:50 AM, this is 50 minutes past the 5-hour timeframe.Risperdal l mg by mouth daily for mood disorderordered for 06/20/25 at 8:00 AM, administered at 11:50 AM, this is 50 minutes past the 5-hour timeframe.On 07/10/25 at approximately 9:30 AM, the Corporate (RN) was notified of the late medications. The Corporate RN confirmed the medications were late.c) Resident #76On 07/09/25 at 4:30 PM, the report entitled, Medication Administration Audit Report was requested for Resident #76. The report included missed and late medications. The facility has a liberalized medication administration schedule which allows the medication to be administered two (2) hours prior and two (2) hours after the scheduled time. This period of time, also, allows for the one (1) hour prior and one (1) hour after the two (2) hour time frame. For example, if a medication is scheduled for 8:00 AM, the nurse has from 6:00 AM to 11:00 AM to administer the medication before it is considered late. Although, the facility has a five (5) hour window, the following medications were administered late:--Humalog inject 4 units SQ three times daily for diabetes ordered for 06/02/25 at 8:00 AM, administered at 11:58 AM, this is 58 minutes past the 5-hour timeframe.--Acetaminophen 650 mg by mouth four times daily for pain ordered for 06/02/25 at 8:00 AM, administered at 11:17 AM, this is 17 minutes past the 5-hour timeframe.--Prosource 30 ml by mouth three times daily ordered for 06/02/25 at 8:00 AM, administered at 11:58 AM, this is 58 minutes past the 5-hour timeframe. --Prosource 30 ml by mouth three times daily ordered for 06/03/25 at 8:00 AM, administered at 11:41 AM, this is 41 minutes past the 5-hour timeframe.--Acetaminophen 650 mg by mouth four times daily for pain ordered for 06/03/25 at 8:00 AM, administered at 11:41 AM, this is 41 minutes past the 5-hour timeframe.--Humalog inject 4 units SQ three times daily for diabetes ordered for 06/03/25 at 8:00 AM, administered at 11:41 AM, this is 41 minutes past the 5-hour timeframe.--Humalog inject 4 units SQ four times daily for diabetes ordered for 06/07/25 at 8:00 PM, administered on 06/08/25 at 12:00 AM, this is 1 hour past the 5-hour timeframe.--Prosource 30 ml by mouth three times daily ordered for 06/07/25 at 8:00 AM, administered on 06/08/25 at 12:00 AM, this is 1 hour past the 5-hour timeframe.--Acetaminophen 650 mg by mouth four times daily for pain ordered for 06/07/25 at 8:00 PM, administered on 06/08/25 at 12:00 AM, this is 1 hour past the 5-hour timeframe.--Lantus inject 18 units SQ daily for diabetes was ordered for 06/07/25 at 8:00 PM, administered on 06/08/25 at 12:00 AM, this is 1 hour past the 5-hour timeframe.--Prosource 30 ml by mouth three times daily ordered for 06/09/25 at 8:00 AM, administered at 11:16 AM, this is 16 minutes past the 5-hour timeframe.--Acetaminophen 650 mg by mouth four times daily for pain ordered for 06/09/25 at 8:00 AM, administered at 11:17 AM, this is 17 minutes past the 5-hour timeframe.--Lantus inject 18 units SQ daily for diabetes ordered for 06/13/25 at 8:00 Pm, administered on 06/14/25 at 12:44 AM, this is 1 hour and 44 minutes past the 5-hour timeframe.--Acetaminophen 650 mg by mouth four times daily for pain ordered for 06/13/25 at 8:00 PM, administered on 06/14/25 at 12:44 AM, this is 1 hour and 44 minutes past the 5-hour timeframe.--Humalog inject 4 units SQ four times daily for diabetes, ordered for 06/13/25 at 8:00 PM, administered on 06/14/25 at 12:44 AM, this is 1 hour and 44 minutes past the 5-hour timeframe.--Prosource 30 ml by mouth three times daily wound healing ordered for 06/13/25 at 8:00 PM, administered on 06/14/25 at 12:44 AM, this is 1 hour and 44 minutes past the 5-hour timeframe.--Humalog inject 4 units SQ four times daily for diabetes, ordered for 06/14/25 at 8:00 PM, administered at 11:58 PM, this is 58 minutes past the 5-hour timeframe.--Humalog inject 4 units SQ three times daily for diabetes ordered for 06/15/25 at 8:00 AM, administered at 11:06 AM, this is 6 minutes past the 5-hour timeframe.--Humalog inject 4 units SQ three times daily for diabetes ordered for 06/18/25 at 8:00 AM, administered at 11:06 AM, this is 6 minutes past the 5-hour timeframe.--Acetaminophen 650mg by mouth four times daily for pain ordered for 06/21/25 at 8:00 PM, administered at 12:27 PM, this is 1 hour and 27 minutes past the 5-hour timeframe.--Humalog inject 4 units SQ three times daily for diabetes ordered for 06/21/25 at 8:00 AM, administered at 12:27 PM, this is 1 hour and 27 minutes past the 5-hour timeframe.--Prosource 30 ml by mouth three times daily wound healing ordered for 06/22/25 at 8:00 PM, administered at 11:20 PM, this is 20 minutes past the 5-hour timeframe.--Acetaminophen 650 mg by mouth four times daily for pain ordered for 06/22/25 at 8:00 PM, administered at 11:20 PM, this is 20 minutes past the 5-hour timeframe.--Lantus inject 18 units SQ daily for diabetes ordered for 06/22/25 at 8:00 PM, administered at 11:26 PM, this is 26 minutes past the 5-hour timeframe.--Prosource 30m1 by mouth three times daily wound healing ordered for 06/21/25 at 8:00 AM, administered at 12:27 PM, this is 1 hour and 27 minutes past the 5-hour timeframe.On 07/10/25 at approximately 9:30 AM, the Corporate (RN) was notified of the late medications. The Corporate RN confirmed the medications were lated) Resident #40On 07/09/25 at 4:30 PM, the report entitled, Medication Administration Audit Report was requested for Resident #40. The report included missed and late medications. The facility has a liberalized medication administration schedule which allows the medication to be administered two (2) hours prior and two (2) hours after the scheduled time. This period, also, allows for the one (1) hour prior and one (1) hour after the two (2) hour time frame. For example, if a medication is scheduled for 8:00 AM, the nurse has from 6:00 AM to 11:00 AM to administer the medication before it is considered late. Although, the facility has a five (5) hour window, the following medications were administered late:--Voltaren External Gel 1% apply topically to bilateral wrists three times daily for carpel tunnel ordered for 06/01/25 at 8:00 AM, administered at 2:17 PM, this is 3 hours and 17 minutes past the 5-hour timeframe.--Voltaren External Gel 1% apply topically to bilateral wrists three times daily for carpel tunnel ordered for 06/02/25 at 8:00 AM, administered at 1:56 PM, this is 2 hours and 56 minutes past the 5-hour timeframe.--Voltaren External Gel 1% apply topically to bilateral wrists three times daily for carpel tunnel ordered for 06/03/25 at 8:00 AM, administered at 12:32 PM, this is 1 hour and 32 minutes past the 5-hour timeframe.--Voltaren External Gel 1% apply topically to bilateral wrists three times daily for carpel tunnel ordered for 06/03/25 at 8:00 PM, administered on 06/04/25 at 12:32 AM, this is 1 hour and 32 minutes past the 5-hour timeframe--Voltaren External Gel 1% apply topically to bilateral wrists three times daily for carpel tunnel ordered for 06/05/25 at 8:00 AM, administered at 12:57 PM, this is 1 hour and 57 minutes past the5-hour timeframe.--Voltaren External Gel 1% apply topically to bilateral wrists three times daily for carpel tunnel ordered for 06/05/25 at 8:00 PM, administered at 11:46 PM, this is 46 minutes past the 5-hour timeframe.--Nicoderm CQ transdermal 21mg/24 hour patch apply topically daily for nicotine dependence ordered for 06/03/25 at 8:00 AM, administered at 12:57 PM, this is 1 hour and 57 minutes past the 5-hour timeframe.--Mucinex 800mg by mouth two times daily for cough ordered for 06/16/25 at 8:00 PM, administered at 11:08 PM, this is 8 minutes past the 5-hour timeframe.--Cetirizine 5mg by mouth daily for allergies was ordered for 06/20/25 at 8:00 PM, administered at 11:22 PM, this is 22 minutes past the 5-hour timeframe.--Protonix 40mg by mouth daily for GERD (gastroesophageal reflux disease) ordered for 06/24/25 at 8:00 AM, administered at 3:57 PM, this is 4 hours and 57 minutes past the 5-hour timeframe.On 07/10/25 at approximately 9:30 AM, the Corporate (RN) was notified of the late medications. The Corporate RN confirmed the medications were late.e) Resident #6During an interview on 07/08/25 at 11:15 AM, Resident #6 stated, My butt feels like raw hamburger. They just are not doing the right thing for it. I tell them about it and they say, We will just put some cream on it.A record review on 07/08/25 at 1:30 PM of Resident # 6's weekly skin assessments, revealed that on 06/27/25 it was identified that the resident had Moisture Associated Skin Damage (MASD). No new orders were noted related to the findings.Further record review showed that Resident #6 was ordered Z guard as preventative measures for redden areas to coccyx every shift and as needed (PRN) on 02/06/25. A review of the Treatment Administration Record (TAR) for the month of 06/2025 showed that the Z guard was not administered on the following dates:06/01/25- day shift 06/06/25-day shift 06/10/25- day shift 06/14/25-day shift 06/21/25-day shift 06/29/25-day shiftDuring an observation of peri/and wound care by Health Facilities Nurse Surveyor (HFNS) with Licensed Practical Nurse (LPN) #60 (Wound Nurse), on 07/08/25 at 2:30 PM, Resident #6 was found to have Severe MASD to her abdominal fold, perineal area, upper inner thighs, and bilateral buttocks. There was a small open area to the buttocks. There was also noted to be a square that was red, where a patch had been placed.During the observation Resident #6 stated, They usually put a patch on there. Licensed Practical Nurse (LPN) #60 then stated, I told them to stop doing that. There is not order and it is holding moisture. I am putting Calazime, Z guard and antifungal cream on here. Health Facility Nurse Surveyor stated, Do you feel like all that cream might be holding in the moisture and making it worse?
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, interview and policy review the facility failed to properly store food in accordance with professional standards. This is true for the facility kitchen and nourishmentpantry. Thi...
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Based on observation, interview and policy review the facility failed to properly store food in accordance with professional standards. This is true for the facility kitchen and nourishmentpantry. This had the potential to affect all residents in the facility. Facility census: 84.residents in the facility. Facility census: 84. Findings included:a) On 07/07/25 at 12:27 PM, during a Brief Tourof The Kitchen, with The Dietary Manager # 87who acknowledged the following in the Chest Freezer with no label or dates:- A Bucket of vanilla ice cream.- 2 pints of ice cream inside a brown paper bagOn 07/08/25 at 6:00 PM a review facility policy labeled HCSG Policy 019, Food Storage: ColdFoods. Procedures, number 5 stated All foods will be stored wrapped or in covered containers,labeled and dated, and arranged in a manner toprevent cross contamination.03/4/25 11:30 AM Observation of Kitchen Pantry:- A Package of Elbow Macaroni with no label or dateOn 07/08/25 at 6:00PM during a review of facility policy marked HCSG Policy 018 Food Storage:Dry Goods, listed under procedures number six(6) stated: 'Storage areas will be neat, arranged for easy identification, and date marked as appropriate.
May 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 allegation of suspected abuse within (2) two hours after discovering the occurrence. This failed practice was found true for...
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Based on record review and staff interview the facility failed to report an allegation of suspected abuse within (2) two hours after discovering the occurrence. This failed practice was found true for (1) of (3) residents reviewed for reportable allegations of abuse, neglect, and misappropriation of property. Resident identifier: #40. Facility Census: 68.
Findings Included:
a) Resident #40
A review of the facilities reportables, on 05/21/24 at 9:00 AM, revealed that Resident # 40 had a bruise of unknown origin on the posterior upper left arm described as large deep purple bruising according to the skin assessment completed on 04/25/24. The incident was reported on 04/26/24 at 3:45 PM, which was 16.5 hours post incident.
A medical record review, on 05/21/24 at 9:15 AM, revealed a nurse's note written on 04/25/24 at 11:15 PM, that reads as follows: Called to room by aide. Large deep purple bruise noted to posterior left upper arm. Denies pain at present. Normal ROM to arm. No warmth or nodules noted to the area. MD, Administrator, and DON notified.
Further medical record review revealed the following social services note written on 04/25/24 at 4:00 AM, that reads as follows:
I met with the patient due to her reporting that staff had caused her bruising. The patient was not able to give me any information, she was oriented x 1 and thought process was confused for any new information. She scored a 6 on the BIMS. She was not able to give me any information about what had happened. This information was reported to the administrator.
During an interview, on 05/21/24 at 11:50 AM, with the Corporate Registered Nurse (CRN), and the Social Worker (SW), when asked by surveyor, If you didn't feel it was abuse why did we have a note saying that Resident # 40 reported that staff had caused the bruising? CRN stated, (SW name), why did you put that note in there. SW did not respond at this time.
A further interview, at 11:55 AM on 05/21/24, with the SW she confirmed that suspected abuse allegations should be reported with-in (2) two hours.
Review of the facilities policy, on 05/22/24 at 1:30 PM titled Freedom from Abuse and Neglect Policy revealed that all alleged violations must be reported no later than two (2) hours if the alleged violations involve abuse or 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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on record review, staff interviews, the facility failed to follow the physician's order for antibiotics. Resident #73 did not receive Zyvox as ordered by the attending physician. Resident identi...
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Based on record review, staff interviews, the facility failed to follow the physician's order for antibiotics. Resident #73 did not receive Zyvox as ordered by the attending physician. Resident identifier: #73. Facility census: 68.
Findings included:
a) Resident #73
A medical record review revealed Resident #73 had a physician order for Zyvox dated 02/14/24. The medication was ordered to be given twice a day. During a confidential interview with a nurse the nurse said when they went to administer the morning dose on 02/14/24 they clicked administered but the medication was not available in the Alixa. The nurse said they needed to strike themedicaiton out and called Alixa to see if the medication was approved or enroute. The nurse said that LPNs or floor nurses are not allowed to approve medications nor do they receive emails to approve medications.
On the evening of 02/14/214 the medication was ordered but had not arrived in the facility. The nurse said the medication was on hold due to the cost. The cost had to be approved by the facility. The Director of Nursing approved the medication but it did not arrive until it was time for the morning dose of 02/15/24. By this time the resident had already missed two (2) doses of Zyvox. The medication arrived in the early morning of 02/15/24. After this happened the Director of Nursing said Zyvox was put into the Alixa.
On 02/15/24 the resident's son arrived at the facility and questioned whether or not his father had received the medication which was prescribed for a UTI. The resident's son requested his father be sent out of the facility due to him missing two (2) doses of the medicaiton.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on record review, staff interviews, the facility failed to provide pharmaceutical services to meet the needs of a resident. Resident #73 did not receive Zyvox as ordered by the attending physici...
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Based on record review, staff interviews, the facility failed to provide pharmaceutical services to meet the needs of a resident. Resident #73 did not receive Zyvox as ordered by the attending physician. Resident identifier: #73. Facility census: 68.
Findings included:
Based on record review, staff interviews, the facility failed to follow the physician's order for antibiotics. Resident #73 did not receive Zyvox as ordered by the attending physician. Resident identifier: #73. Facility census: 68.
Findings included:
a) Resident #73
A medical record review revealed Resident #73 had a physician order for Zyvox dated 02/14/24. The medication was ordered to be given twice a day. During a confidential interview with a nurse the nurse said when they went to administer the morning dose on 02/14/24 they clicked administered but the medication was not available in the Alixa. The nurse said they needed to strike themedicaiton out and called Alixa to see if the medication was approved or enroute. The nurse said that LPNs or floor nurses are not allowed to approve medications nor do they receive emails to approve medications.
On the evening of 02/14/214 the medication was ordered but had not arrived in the facility. The nurse said the medication was on hold due to the cost. The cost had to be approved by the facility. The Director of Nursing approved the medication but it did not arrive until it was time for the morning dose of 02/15/24. By this time the resident had already missed two (2) doses of Zyvox. The medication arrived in the early morning of 02/15/24. After this happened the Director of Nursing said Zyvox was put into the Alixa.
On 02/15/24 the resident's son arrived at the facility and questioned whether or not his father had received the medication which was prescribed for a UTI. The resident's son requested his father be sent out of the facility due to him missing two (2) doses of the medicaiton.
Mar 2024
31 deficiencies
2 IJ (2 facility-wide)
CRITICAL
(L)
📢 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
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c2) Resident 331
During a tour of the facility on 03/11/24 at 01:27 PM, Resident #331 was observed to be lying on the floor on h...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c2) Resident 331
During a tour of the facility on 03/11/24 at 01:27 PM, Resident #331 was observed to be lying on the floor on his left side and his wheelchair was laying over on its side directly behind him. Three staff members were observed to be standing around him and they all three lifted him by his upper body and simultaneously picked the wheelchair upright and sat him in it. During an interview with the Licensed Practical Nurse Unit Manager (LPN-UM) #30, she stated that the facility was not a no lift facility, and they can pick him up if he is safe. Staff identified to assist LPN-UM #30 physically picking up the resident and the chair are LPN # 64 and Certified Nursing Assistant (CNA) #99.
03/11/24 02:17 PM During an interview with Assistant Director of Nursing (ADON) #42, he stated that he had completed the resident's assessment himself and Resident #331 was a total lift. He further stated that LPN-UM #30 had been educated on this previously and a lift should have been used with this fall. The residents ELC Lift Transfer Reposition Evaluation dated 03/06/24, physicians order dated 03/06/24 and care plan with the total lift intervention revision dated 03/07/24 that identified the resident being a total lift was provided by the ADON at this time.
Based on observation, record review, staff interview, and resident interview the facility failed to ensure residents were free from abuse and neglect. The survey team witnessed the failure of staff to provide timely incontinence care to Resident's #6 and #237. When the observations of the surveyors were presented to the facility, the facility reported the incident to the state agency as required. Immediate jeopardy (IJ) occurred when the facility failed to provide education and servicing to one of the witnessed perpetrators before allowing this staff person to return to work. This failure placed all residents currently residing in the facility at an immediate risk for serious harm and/or death.
After the immediacy was removed a deficient practice remained for Resident #331 who was improperly lifted off the floor after 2 falls. This was a random opportunity for discovery and had the potential to affect all residents at the facility. Therefore, the scope and severity was decreased from a L to a D.
The facility was first notified of the IJ at 4:24 PM, on 03/06/24. The state agency (SA) received the Plan of Correction (POC) at 8:45 PM on 03/06/24. The SA accepted the POC on 03/06/24 at 9:00 PM.
The SA observed for the implementation of the POC and the IJ was abated on 03/11/24 at 2:30 PM.
Resident identifiers #6, #237, and #331. Facility census 82.
Findings included:
a) Resident #6
Upon an unannounced entrance to the facility on [DATE] at 11:08 PM, staff member Licensed Practical Nurse (LPN) #62 and Nursing Assistant (NA) #63 were observed sitting in the room labeled Conference room with their feet propped up in a chair looking at their cell phones. These staff members were unable to see resident call lights.
An observation, on 02/27/24 at 11:10 PM, of the North Nurse's station revealed six (6) call lights were going off, according to the call light board on the wall.
An observation, on 02/27/24 at 11:15 PM, of North 2 (two) hall revealed the following:
- At 11:15 PM Resident #6's call light came on.
- At 11:30 PM NA #63 went into Resident #6's room, and his light went off. NA #63 came out of the room at 11:31 PM.
-At 11:33 PM Resident #6's light came back on.
During an interview, on 02/27/24 at 11:34 PM, Resident # 6 stated, I just want changed. They came in and turned my light off and told me they would be back. I just want to get dry and go to sleep. I am sick of this.
Observation on 02/27/24 at 11:40 PM, of North Nurses station found NA# 63, NA#65, LPN #63, and LPN #43 at the nursing station.
During an observation, on 02/27/24 at 11:44 PM, of the North Nurses station, the surveyor heard LPN # 40 announce, I am going on my 15-minute break, because I am supposed to get it. I will set my watch.
Resident #6's call light continued to go off.
Further observation at 11:47 PM, showed LPN #62 going into Resident #6's room and immediately walked back out. The call light was turned off. She then stated, He is a 2 person assist, I got to wait on help.
An observation on 02/27/24 at 11:50 PM, showed LPN #62 and NA #63 going into Resident #6's room to change him.
Resident #6's room was under constant observation by a surveyor from 02/27/24 at 11:15 PM to 02/27/24 at 11:50 PM.
Assistance and incontinence care was not provided to Resident #6 until 02/27/24 at 11:50 PM.
On 02/28/24 at 12:35 AM the Director of Nursing (DON) confirmed residents should not wait that long to be changed and staff should not be turning call lights off and saying I will be back. She further stated, yes, this is neglectful.
A record review, on 02/28/24 at 12:15 PM, of Resident #6's care plan found the following:
-Focus: I have the Potential for Skin Issues related to incontinence of bowel and bladder, decreased mobility/ability to reposition myself.
-Goal: My skin will remain intact without signs of breakdown by next review.
-Interventions: Turn and reposition frequently to decrease pressure.
Further review of the care plan reads as follows:
Focus: I have an ADL self-care performance deficit due to limited mobility.
Goal: I will maintain current level of function in all ADL's through the review date.
Interventions: Assist resident to bathroom for toileting every 2 hours.
Toilet use: I require extensive assistance by staff for toileting.
A review of the facilities Abuse and Neglect policy on 02/28/24 at 11:30 AM described Neglect as 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 stress.
The facility reported these allegations to the proper State authorities on 02/28/24. Employees #62 and NA #63 were suspended from 02/28/24 through 03/05/24. The facility stated they were going to in-service all staff on Resident Rights, Abuse/Neglect, using the care plans, call lights, safe lifting, teamwork, customer service, meals/snacks.
At 2:45 PM on 03/06/24 the assistant director of nursing (ADON) confirmed NA #63 had not been in-serviced and NA #63 had worked from 7:00 PM to 7:00 AM on 03/05/24. Further review of the sign in sheets found NA #63 did not sign the acknowledgement of training before returning to work.
B) Resident #237 02/27/24 Incident
During an unannounced visit to the facility on 2/27/24 at 11:05 PM, the following observations were made:
At 11:08 PM, Resident # 237 was lying in bed with his feet hanging over the right side of the bed touching the floor. His bottom was in the middle of the bed, his head and his upper torso leaning towards the left side of the bed off the pillows. A strong smell of urine appeared to come from the room.
Another observation on 02/27/24 at 11:35 PM, showed Resident # 237 continued to be laying in the same position with the sheet now on the floor yelling, [NAME], [NAME] get the car let's go.
Another observation on 02/27/24 at 11:53 PM, showed Resident # 237' s feet continued to be on the right side touching the floor. Now his head was hanging over the bed on the left side.
Another observation on 02/28/24 at 12:05 AM, showed Resident # 237 was in the same position as before. The smell of bowel movement was present. This was observed by another surveyor as well. At that time, Resident # 237 was pulling the privacy curtain and yelling out.
Another observation, on 02/28/24 at 12:08 AM, Resident # 237 was yelling [NAME], [NAME]. Nursing Assistant (NA) #31 walked to another resident's room to tell NA #6 in the room she needed assistance when she was done.
An observation on 02/28/24 at 12:09 AM, revealed NA #31 told NA #6, I guess I will see what [Resident # 237] wants but he is not my resident.
Another observation on 02/28/24 at 12:10 AM, showed NA #31 entered and exited Resident # 237's room without providing assistance.
An observation, on 02/28/24 at 12:11 AM, showed NA #31 went to another resident's room where NA #6 was assisting the resident in that room. NA #31 stated, He needs changed. You can do it when you are done. He is not mine so I am not cleaning him up.
An observation on 02/28/24 at 12:15 AM, showed NA #6 was in Resident #237's room assisting him.
Resident #237's room was in constant observation by a surveyor from 02/27/24 at 11:08 PM to 02/28/24 at 12:15 AM. Assistance and incontinence care was not provided to the resident until 12:15 AM on 02/28/24, despite the resident yelling for help beginning at 11:08 PM on 02/27/24.
During an interview on 02/28/24 at 1:30 AM, the DON stated, Are you kidding me. The nursing staff tells me all of this is being taken care of. They never mention call lights are not being answered. I thought everything was ok. They should not turn off a call light without the need being addressed, if they can't get to it they should leave it on until the resident is changed or whatever they need. And everyone can answer a call light not just the aides. That's not my job or my resident doesn't fly. Sounds to me like a bunch [staff] need to be in the unemployment line. That should have never happened, they should work as a team. He should have never laid there that long without assistance.
On 02/28/24 at 1:34 PM, the Corp RN #97 stated, The DON told me there were small issues last night, call lights not answered and late medications. RN #97 was unsure if the incidents with the call lights not answered, and residents being left soiled were reported. She said she would have to look around and see what she could find. DON was unavailable for any further comment at that time and not in the facility.
The OHFLAC (Office of Health Facilities Licensure and Certification) 225 Allegation reporting form dated 02/28/24 completed by Social Worker #36.
Alleged Victim Name: Resident #237's Name
Alleged Perpetrator Name: name of Nurse Aide (NA) #31
Position/title: Certified Nsg (nursing) Assistant
Date of Incident: 02/27/24
Time of Incident: Night Shift
Location of Incident: room [ROOM NUMBER]-1
Brief Description of the Incident: Allegation was received that (Resident #237's) name was waiting for an extended period of time for his call light to be answered for incontinence care.
The 5 five day follow up determination on Resident #237 was completed and faxed to the state agencies on 03/05/24.
c) Resident #237 03/03/24 incident
On 03/03/24 at 11:00 PM, an unannounced visit was made to the facility.
During an observation on 03/03/24 at 11:05 PM, Resident # 237 was resting in bed with a pillow under his legs.
During an observation on 03/03/24 at 11:35 PM, Resident # 237 ' s legs were hanging over the right side of the bed.
Observation on 03/03/24 at 11:38 PM, Resident # 237 was yelling Hello. His head was now almost to the middle of the bed, and his feet continued to be on the floor.
The following further observations were made:
03/03/04 at 11:41 PM, LPN #28 walked by Resident # 237 room.
03/03/24 at 11:44 PM, Resident #237 was yelling Help in here.
03/03/24 at 11:45 PM, Corporate nurse #97 was going from room to room.
03/03/34 at 11:47 PM, LPN #28 walked by resident's room again.
03/03/24 at 11:53 PM, NA #57 walked by Resident # 237's looking into his room.
03/03/24 at 11:56 PM, Resident # 237 yelling Help in here Hello, Help.
03/03/24 at 11:59 PM, Resident # 237 yelling Hello Corporate's Nurse #97 stated to Resident # 237 Hang on, let me get someone.
03/04/24 at 12:04 AM, Corporate RN #97 stating Did that fix it? [Resident # 237] pulled the call light halfway out of the wall, that is where the emergency light was coming from.
During an interview on 03/04/24 at 1:34 PM, the DON and SW were informed of the incidents occurring on 03/03/24.
During an interview on 03/05/24 at 11:30 AM, the Corporate Nurse #97 stated I will watch the cameras to see if I feel a report needs to be filed.
During an interview on 03/05/24 at 2:35 PM, the ADON stated they do not feel a report needs to be done.
On 03/06/24 at 5:47 PM, social worker #237 gave this report to the surveyor.
The OHFLAC (Office of Health Facilities Licensure and Certification) 225 Allegation reporting form dated 03/05/24 completed by Social Worker # 36.
Alleged Victim Name: Resident #237 ' s Name
Alleged Perpetrator Name: Unknown
Date of Incident: 03/04/24 Night Shift
Time of Incident: Night Shift
Location of Incident: Name of the Nursing Home Facilities
Brief Description of the Incident: Surveyor alleged on 03/04/24 that Resident #237 ' s name was neglected with delayed response time in addressing his needs during night shift 03/03/24 into 03/04/24.
The 5 five day follow up determination on Resident #237 was not completed upon exiting the facility on 03/11/24.
Two (2) surveyors on 03/05/24 at 7:39 PM, Resident # 237 stated This is the best day since I have been here. I have not slept in four (4) days and I slept well last night, sleeping like a baby. I ate everything today, my dinner was good. I think I was admitted on Friday but I was so out of it, I am not really sure.
Resident # 237 was asked, do you need assistance with the bathroom?
Resident # 237 stated they make me use the call light when i need to use the bathroom, but they take so long to get here I pee myself. The other night I laid in pee all night.
The DON was made aware of the above interview with Resident #237.
d) Resident #331
On 02/27/24 at 11:54 PM Resident #331 was witnessed by a Surveyor falling out of his wheelchair in the hallway near the nurse's station on the south side. Resident scooted to the edge of his wheelchair, and leaned forward and fell out onto the floor. The Resident landed on his right side with his head against the wall. The Resident's right leg and arm were pinned under him. Resident was laying across the leg of the floor stand blood pressure monitor. Resident was yelling Oh, Oh, Oh damn. RN #55 came up the hallway and asked the resident if he was ok? RN #55 pulled up the sweatshirt sleeve of his right arm and said. I don't see anything; you did hit hard I bet that hurt. RN #55 was then joined by CNA #31 and they proceeded to try to lift the resident back into the wheelchair by grabbing his pants and reaching under his arms. RN #55 lifted under the right arm and CNA # 31 lifted under the left arm and they both grabbed the back of the resident's pants. After the third try with the wheelchair sliding backwards, RN #55 and CNA #31 tossed the resident back into the wheelchair. Resident #331 continued to yell, Oh. Oh, Oh damn it the entire time. RN #55 said, Yea he's heavy! RN #55 then reported to the Surveyor, Don't worry, he is care planned for falls, he slides out of his chair all the time. Once resident was back in chair at 12:00 AM, RN #55 attempted to take residents blood pressure and stated, This don't seem to be working right, but I think he's ok. Resident #331 was wearing an AAA (hinged) knee brace in place on his left lower extremity and was non weight bearing to left lower extremity at the time of the fall. The Resident was wearing regular socks at the time of the incident.
Record review of care plan found an intervention of mechanical lift with two person assist for all transfers, resident was unable to bear weight with the right foot was not initiated until 02/28/2024.
Record review showed no progress note to indicate the Power of Attorney (POA) was notified of the fall.
On 02/28/24 at 10:50 AM, the Incident report for the fall (which occurred 02/27/24 at 11;54 PM) was requested from Corp RN #97. The report was given for a fall that happened on 02/27/24 during the day shift. Corporate RN #97 stated, Oh sorry about that I am sure they done one if not I will have them to do a late entry.
Record review showed a radiology report dated 02/24/28 indicated Resident #331 had fractured right clavicle and slightly displaced fracture at the distal clavicle age indeterminate. Results for bilateral hips and pelvis showed a postoperative change at the right hip with a pin and side plate in place. Mild arthritic changes in both hip joints.
Review of incident report dated 02/27/24 at 11:30 PM for a fall that occurred on 02/27/24 at 11:54 PM, completed by the Director of Nursing (DON). The DON was asked how she completed the incident when she wasn't there to witness the fall. The DON stated, The other nurse started it and never finished it. I thought I was already here at that time. If the time is wrong its because I redone it. You are right I never witnessed the fall.
-The incident description stated (typed as written), resident fell out of wheelchair outside of his room near the Rosies that were plugged into the wall. This RN witnessed the fall from down the hallway.
-The incident reports' immediate action taken stated, (typed as written), Before putting him [resident #331] back into the wheelchair this RN [#55] did a full body assessment checking for injuries. Resident stated that he banged his elbow, assessment of elbow was done including visual assessment and full ROM [range of motion] to right hand and right shoulder. After confirming there were no injuries, the resident was assisted by myself and CNA to his wheelchair.
During a phone interview on 03/05/24 at 1:50 PM Resident #331's Power of Attorney (POA) stated, I don't think they are calling me every time he is falling. He falls so much. I can tell you they did not call me Tuesday night (02/27/24) when he fell around midnight. They called me Tuesday on the 27th (02/27/24) during the evening sometime to tell me he fell that day. The POA further stated that when he was admitted they promised her he would be close to the nurses station and when she got there he could not have been further away. She made them move him closer and would not leave until they put some fall mats down for him. The POA stated, I am physical therapist myself; they are not transferring him right either. He is not supposed to be bearing weight on that one leg and they just drag him around everywhere. I don't know why they don't use a lift.
On 03/04/24 at 3:04 PM the Assistant Director of Nursing (ADON) verified a mechanical lift should have been used to pick the resident up off the floor when he fell from the wheelchair on 02/27/24. The ADON stated, Especially since [resident #331 name] is unable to put any weight on his leg and wearing that brace.
e) Resident 331
During a tour of the facility, on 03/11/24 at 01:27 PM, Resident #331 was observed to be lying on the floor on his left side and his wheelchair was laying over on its side directly behind him. Three staff members were observed to be standing around him and they all three lifted him by his upper body and simultaneously picked the wheelchair upright and sat him in it. During an interview with the Licensed Practical Nurse Unit Manager (LPN-UM) #30, she stated that the facility was not a no lift facility, and they can pick him up if he is safe. Staff identified to assist LPN-UM #30 physically picking up the resident and the chair are LPN # 64 and Certified Nursing Assistant (CNA) #99.
03/11/24 02:17 PM During an interview with Assistant Director of Nursing (ADON) #42, he stated that he had completed the resident's assessment himself and Resident #331 was a total lift. He further stated that LPN-UM #30 had been educated on this previously and a lift should have been used with this fall. The residents ELC Lift Transfer Reposition Evaluation dated 03/06/24, physicians order dated 03/06/24 and care plan with the total lift intervention revision dated 03/07/24 that identified the resident being a total lift was provided by the ADON at this time.
f) Plan of Correction (POC)
HOW WILLL CORRECTIVE ACTIONS BE ACCOMPLISHED FOR THOSE RESIDENTS FOUND TO BE AFFECTED BY THE DEFICIENT PRACTICE?
The allegation of neglect was reported by state surveyor to VPCO and ADON on 2/28/24. The allegation was reported to the state survey office, APS and Ombudsman, by Social Worker on 2/28/24. A thorough investigation was initiated.
Resident # 237
A skin assessment was completed on 2/28/24 by a nurse.
A trauma assessment was completed 3/1/24 by Social worker.
Resident # 6
A skin assessment was completed on 2/28/24 by ADON.
A trauma assessment was completed on 3/1/24 by the Social Worker.
Resident # 237 was assessed on 2/28/24 by social worker, with no concerns noted. A thorough investigation was initiated on 2/28/24 and completed on 3/4/24 by social worker.
Resident # 6 was assessed on 2/28/24 by social worker, with no concerns noted. A thorough investigation was initiated on 2/28/24 and completed on 3/4/24 by social worker.
HOW WILL THE FACILITY IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE DEFICIENT PRACTICE AND WHAT CORRECTIVE ACTIONS WILL BE TAKEN TO PREVENT REOCCURENCE?
Current residents have been assessed for any signs and symptoms of abuse/neglect. Those residents with BIMs >8 were interviewed by the management team for any abuse/neglect concerns 2/28/24 through 3/1/24. Those residents with BIMs < 8 were physically assessed by the nursing supervisors for any signs and symptoms of abuse/neglect on 2/29/24. Abuse/neglect assessments, interviews and questionnaires were reviewed by the Administrator on 3/1/24 for any indications of abuse/neglect concerns. There were 5 concerns voiced during the interviews and were addressed at time of concern.
Grievances/concerns were reviewed for the last 60 days with no trends noted by social worker and Administrator on 3/6/24.
WHAT MEASURES WILL BE PUT IN PLACE OR SYSTEMATIC CHANGES MADE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT REOCCUR?
All staff will be re-educated on abuse/neglect starting on 3/6/24 and completed by 3/7/24 by the ADON or designee. This training was performed to facilitate discussion and question and include examples. Staff who were unable to attend will be provided with the education prior to working their next scheduled shift. Any new staff will be educated upon hire prior to providing patient care. Agency staff will be educated prior to working their next scheduled shift.
5 Call light audits will be conducted per shift by DON or designee daily x 30 days. 5 residents will be interviewed per day by DON or designee daily x 30 days for care concerns/allegations of neglect. Observations for resident needs will be conducted of 5 residents on day shift and 5 residents on night shift daily x 30 days. The results of these audits will be reviewed through the QAPI committee weekly.
A nurse from the regional team or corporate office has been onsite or available by phone since 2/26/24 and will follow up with facility daily for 2 weeks, then daily M-F for 2 weeks. The nurses from the regional team or home office assist with investigations, observing staff treatment of residents, performing chart audits and providing oversight and consultation.
CRITICAL
(L)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Investigate Abuse
(Tag F0610)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
**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 potential allegation...
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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 potential allegations of neglect were thoroughly investigated and failed to provide a corrective action for an allegation that did happen prior to letting the Nursing Assistant (NA) #63 return to work. This placed resident #6 and #237 in an immediate jeopardy situation by not thoroughly investigating allegations of neglect, and letting the alleged perpetrator return to work without the required Abuse and Neglect training. This deficient practice had the potential to affect all residents currently residing in the facility and was a random opportunity for discovery.
In addition, the facility failed to maintain accurate records and investigate medication distribution for controlled substances for Resident #64, and #65. This deficient practice had the potential to affect all residents currently residing in the facility and was a random opportunity for discovery.
The state agency determined these failures caused Resident #6 and #237 to suffer psychosocial harm because of the allegation of neglect not being thoroughly investigated. The facility allowed NA #63 to return to work without having The Abuse and Neglect training, and by not interviewing the day shift, which was the next following shift. Not only did these failures harm Residents #6 and #237, but they also placed them and the remaining 80 residents at risk for serious harm because the alleged perpetrator was not given the proper training prior to her return to work, and the allegation was not thoroughly investigated. This placed all 82 residents in an immediate jeopardy (IJ) situation.
The facility was first notified of the IJ at 4:24 PM, on 03/06/24. The state agency (SA) received the Plan of Correction (POC) at 8:45 PM on 03/06/24. The SA accepted the POC on 03/06/24 at
9:00 PM.
The SA observed for the implementation of the POC and the IJ was abated on 03/11/24 at 2:30
PM.
Once the Immediate Jeopardy was abated a deficient practice did remain for Resident #64 and #65. Therefore, the scope and severity were decreased from a L to a F.
Resident identifiers #6, #237 #64 and #65. Facility census 82.
a) Resident #6
Upon an unannounced entrance to the facility on [DATE] at 11:08 PM, staff member Licensed Practical Nurse (LPN) #62 and Nursing Assistant (NA) #63 were observed sitting in the room labeled Conference room with their feet propped up in a chair looking at their cell phones.
An observation on 02/27/24 at 11:10 PM, of the North Nurse's station revealed that 6 call lights were going off, according to the call light board on the wall.
An observation on 02/27/24 at 11:15 PM, of North 2 (two) hall revealed the following:
- At 11:15 PM Resident #6's call light came on.
- At 11:30 PM NA #63 went into Resident #6's room, and his light went off. NA #63 came out of
room at 11:31.
-At 11:33 PM Resident #6 ' s light came back on.
During an interview on 02/27/24 at 11:34 PM, Resident # 6 stated, I just want changed. They
came in and turned my light off and told me they would be back. I just want to get dry and go to
sleep. I am sick of this.
Observation on 02/27/24 at 11:40 PM, of North Nurses station showed NA# 63, NA#65, LPN #63, and LPN #43 at the nursing station. Nobody appeared to be paying any attention to the light going off in resident # 6's room.
Observation on 02/27/24 at 11:44 PM, of North Nurses station surveyor heard LPN # 40 announce, I am going on my 15-minute break, because I am supposed to get it. I will set my watch.
Resident #6's call light continued to go off.
Further observation at 11:47 PM, showed LPN #62 going in Resident #6's room and immediately walked back out. The call light was turned off.
She then stated, He is a 2 person assist, I got to wait on help.
An observation on 02/27/24 at 11:50 PM, showed LPN #62 and NA #63 going into Resident #6's room to change him.
Resident #6's room was under constant observation by a surveyor from 02/27/24 at 11:10 PM to
02/27/24 at 11:50 PM.
Assistance and incontinence care was not provided to Resident #6 until 02/27/24 at 11:50 PM.
An interview with the Director of Nursing (DON) on 02/28/24 at 12:35 AM she confirmed the residents should not wait that long to be changed and staff should not be turning call lights off and saying I will be back. She further confirmed that yes this is neglectful.
A review of the facilities Abuse and Neglect policy on 02/28/24 at 11:30 AM describes Neglect as 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 stress.
A record review on 02/28/24 at 12:15 PM, of Resident #6 ' s care plan reads as follows:
-Focus: I have the Potential for Skin Issues related to incontinence of bowel and bladder, decreased mobility/ability to reposition myself.
-Goal: My skin will remain intact without signs of breakdown by next review.
-Interventions: Turn and reposition frequently to decrease pressure.
Further review of the care plan reads as follows:
Focus: I have an ADL self-care performance deficit due to limited mobility.
Goal: I will maintain current level of function in all ADL ' s through the review date.
Interventions: Assist resident to bathroom for toileting every 2 hours.
Toilet use: I require extensive assistance by staff for toileting.
b) Resident #237 02/27/24 Incident
During an unannounced visit to the facility on 2/27/24 at 11:05 PM, the following observations were made:
At 11:08 PM, Resident # 237 was lying in bed with his feet hanging over the right side of the bed touching the floor. His bottom was in the middle of the bed, his head and his upper torso leaning towards the left side of the bed off the pillows. A strong smell of urine appeared to come from the room.
Another observation on 02/27/24 at 11:35 PM, showed Resident # 237 continued to be laying in the same position with the sheet now on the floor yelling, [NAME], [NAME] get the car let's go.
Another observation on 02/27/24 at 11:53 PM, showed Resident # 237' s feet continued to be on the right side touching the floor. Now his head was hanging over the bed on the left side.
Another observation on 02/28/24 at 12:05 AM, showed Resident # 237 was in the same position as before. The smell of bowel movement was present. This was observed by another surveyor as well. At that time, Resident # 237 was pulling the privacy curtain and yelling out.
Another observation on 02/28/24 at 12:08 AM, Resident # 237 was yelling [NAME], [NAME]. Nursing Assistant (NA) #31 walked to another resident's room to tell the NA #6 in the room she needed assistance when she was done.
An observation on 02/28/24 at 12:09 AM, revealed NA #31 told NA #6, I guess I will see what [Resident # 237] wants but he is not my resident.
Another observation on 02/28/24 at 12:10 AM, showed NA #31 entered and exited Resident # 237's room without providing assistance.
An observation on 02/28/24 at 12:11 AM, showed NA #31 went to another resident's room where NA #6 was assisting the resident in that room. NA #31 stated, He needs changed. You can do it when you are done. He is not mine, so I am not cleaning him up.
An observation on 02/28/24 at 12:15 AM, showed NA #6 was in Resident #237's room assisting him.
Resident #237's room was in constant observation by a surveyor from 02/27/24 at 11:08 PM to 02/28/24 at 12:15 AM. Assistance and incontinence care was not provided to the resident until 12:15 on 02/28/24, despite the resident beginning to yell for help at 11:08 PM on 02/27/24.
During an interview on 02/28/24 at 1:30 AM, the DON stated, Are you kidding me. The nursing staff tells me all of this is being taken care of. They never mention call lights are not being answered. I thought everything was ok. They should not turn off a call light without the need being addressed, if they can't get to it they should leave it on until the resident is changed or whatever they need. And everyone can answer a call light not just the aides. That's not my job or my resident doesn't fly. Sounds to me like a bunch [staff] need to be on the unemployment line. That should have never happened, they should work as a team. He should have never laid there that long without assistance.
On 02/28/24 at 1:34 PM, the Corp RN #97 stated, The DON told me there were small issues last night, call lights not answered and late medications. RN #97 was unsure if the incidents with the call lights not answered, and residents being left soiled were reported. She said she would have to look around and see what she could find. DON was unavailable for any further comment at that time and not in the facility.
The OHFLAC (Office of Health Facilities Licensure and Certification) 225 Allegation reporting
form dated 02/28/24 completed by Social Worker # 36.
Alleged Victim Name: Resident #237 ' s Name
Alleged Perpetrator Name: Nurse Aide (NA) #31
Position/title: Certified Nursing Assistant
Date of Incident: 02/27/24
Time of Incident: Night Shift
Location of Incident: room [ROOM NUMBER]-1
Brief Description of the Incident: Allegation was received that Resident #237's name was waiting for an extended period for his call light to be answered for incontinence care.
The 5 five day follow up determination on Resident #237 was completed and faxed to the state agencies on 03/05/24.
c) Resident #237 03/03/24 incident
On 03/03/24 at 11:00 PM, an unannounced visit was made to the facility.
During an observation on 03/03/24 at 11:05 PM, Resident # 237 was resting in bed with a pillow under his legs.
During an observation on 03/03/24 at 11:35 PM, Resident # 237's legs were hanging over the right side of the bed.
Observation on 03/03/24 at 11:38 PM, Resident # 237 was yelling Hello. His head was now almost to the middle of the bed, and his feet continued to be on the floor.
The following further observations were made:
03/03/04 at 11:41 PM, LPN #28 walked by Resident # 237 room.
03/03/24 at 11:44 PM, Resident #237 was yelling Help in here.
03/03/24 at 11:45 PM, Corporate nurse #97 was going from room to room.
03/03/34 at 11:47 PM, LPN #28 walked by resident's room again.
03/03/24 at 11:53 PM, NA #57 walked by Resident # 237's looking into his room.
03/03/24 at 11:56 PM, Resident # 237 yelling Help in here Hello, Help.
03/03/24 at 11:59 PM, Resident # 237 yelling Hello Corporate's Nurse #97 stated to Resident # 237 Hang on, let me get someone.
03/04/24 at 12:04 AM, Corporate RN #97 stating Did that fix it? [Resident # 237] pulled the call light halfway out of the wall, that is where the emergency light was coming from.
During an interview on 03/04/24 at 1:34 PM, DON and SW were informed of the incidents occurring on 03/03/24.
During an interview on 03/05/24 at 11:30 AM, the Corporate Nurse #97 stated I will watch the cameras to see if I feel a report needs to be filed.
During an interview on 03/05/24 at 2:35 PM, the ADON stated they do not feel a report needs to be done.
On 03/06/24 at 5:47 PM, social worker #237 gave this report to the surveyor.
The OHFLAC (Office of Health Facilities Licensure and Certification) 225 Allegation reporting form dated 03/05/24 completed by Social Worker # 36.
Alleged Victim Name: Resident #237 ' s Name
Alleged Perpetrator Name: Unknown
Date of Incident: 03/04/24 Night Shift
Time of Incident: Night Shift
Location of Incident: Name of the Nursing Home Facilities
Brief Description of the Incident: Surveyor alleged on 03/04/24 that Resident #237 ' s name was neglected with delayed response time in addressing his needs during night shift 03/03/24 into 03/04/24.
The 5 five day follow up determination on Resident #237 was not completed upon exiting the facility on 03/11/24.
Two (2) surveyors on 03/05/24 at 7:39 PM, Resident # 237 stated This is the best day since I have been here. I have not slept in four (4) days and I slept well last night, sleeping like a baby. I ate everything today, my dinner was good. I think I was admitted on Friday but I was so out of it, I am not really sure.
Resident # 237 was asked, do you need assistance with the bathroom?
Resident # 237 stated they make me use the call light when I need to use the bathroom, but they take so long to get here I pee myself. The other night I laid in pee all night.
The DON was made aware of the above interview with Resident #237.
d) Interview wit Nurse Aide (NA) #49
On 02/28/24 at 12:07 PM, NA #49 asked to speak to surveyors in private. NA #49 stated, I
guess the best way I can put it is this place is awful and residents are being neglected. NA #49
stated this morning Resident #237 and Resident #6 were brown ringed, meaning the residents '
urine had seeped out of the adult briefs, leaving brown stains on the sheets. NA #49 stated, It
happens all the time. Resident #237 brief was so saturated with urine it started to disintegrate.
We have taken this issue to Human Resources (HR), and we are not on good terms and nothing
is being done. Administration is stressing on us now to get showers done because the state is
here, but any other time they do not care. CNA #49 informed surveyor that she relieved NA #63
and CNA #57 this morning and was not sure which one or if both were assigned to the residents left wet. CNA #57 stated she told the ADON this morning what shape she found Resident #237 and Resident #6 very saturated with urine.
e) Facility investigation for Resident #6 and #237
A review of the investigation on 03/06/24 at 9:00 AM, revealed that the Allegation was unsubstantiated. No day shift staff, which was the staff that followed the shift, that was accused of the allegation, had been interviewed.
The facility reported these allegations to the proper State authorities on 02/28/24. Employees #62 and NA #63 were suspended from 02/28/24 through 03/05/24.The facility stated they were going to in service all staff on Resident Rights, Abuse/Neglect, using the care plans, call lights, safe lifting, teamwork, customer service, meals/snacks.
At 2:45 PM on 03/06/24 the assistant director of nursing (ADON) confirmed NA #63 had not been in-serviced and NA #63 had worked from 7:00 PM to 7:00 AM on 03/05/24. Further review of the sign in sheets found NA #63 did not sign the acknowledgement of training before returning to work.
f) Morgantown Health and Rehabilitation Place of Correction (POC).
Typed as written:
HOW WILL CORRECTIVE ACTIONS BE ACCOMPLISHED FOR THOSE RESIDENTS FOUND TO BE AFFECTED BY DEFICIENT PRACTICE?
1. The allegation of neglect was reported by state surveyor to VPCO and ADON on 2/28/24.
The allegation was reported to the state survey office, APS and Ombudsman, by Social
Worker on 2/28/24. A thorough investigation was initiated.
Resident # 237
1. A skin assessment was completed on 2/28/24 by a nurse.
2. A trauma assessment was completed 3/1/24 by Social worker.
Resident # 6
1. A skin assessment was completed on 2/28/24 by ADON
2. A trauma assessment was completed on 3/1/24 by the Social Worker.
Resident # 237 was assessed on 2/28/24 by social worker, with no concerns noted. A thorough
investigation was initiated on 2/28/24 and completed on 3/4/24 by social worker.
Resident # 6 was assessed on 2/28/24 by social worker, with no concerns noted. A thorough
investigation was initiated on 2/28/24 and completed on 3/4/24 by social worker.
HOW WILL THE FACILITY IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY DEFICIENT PRACTICE AND WHAT CORRECTIVE ACTIONS WILL BE TAKEN TO PREVENT REOCCURENCE?
2. Current residents have been assessed for any signs and symptoms of abuse/neglect. Those
residents with BIMs above 8 were interviewed by the management team for any abuse/neglect concerns 2/28/24 through 3/1/24. Those residents with BIMs below 8 were physically assessed by the nursing supervisors for any signs and symptoms of abuse/neglect on 2/29/24.
Abuse/neglect assessments, interviews and questionnaires were reviewed by the
Administrator on 3/1/24 for any indications of abuse/neglect concerns. There were 5
concerns voiced during the interviews and were addressed at time of concern.
3. Grievances/concerns were reviewed for the last 60 days with no trends noted by social worker and Administrator on 3/6/24.
WHAT MEASURES WILL BE PUT IN PLACE OR SYSTEMATIC CHANGES MADE TO ENSURE THAT THE DEFICIENT PRACTICE DOES NOT REOCCUR?
4. [NAME] President of Clinical Operations will educate Administrator, DON, ADON, and Social Services on conducting a thorough to include interviewing all potential witnesses.
investigation by 3/7/24.
5. All potential witnesses will be interviewed to identify any further potential allegations of abuse or neglect by 3/7/24.
6. All staff will be re- educated on abuse/neglect starting on 3/6/24 and completed by 3/7/24 by the ADON. to facilitate discussion and question and include examples. Staff who were unable to attend will be provided with education prior to working their next scheduled shift.
Any new staff will be educated upon hire prior to providing patient care. Agency staff will be educated prior to working their next scheduled shift.
7. 5 Call light audits will be conducted per shift by DON or designee daily x 30 days. 5 residents will be interviewed per day by DON or designee daily x 30 days for care concerns/allegations of neglect. Observations for resident needs will be conducted of 5 residents on day shift and 5 residents on night shift daily x 30 days. The results of these audits will be reviewed through the QAPI committee weekly.
8. A nurse from the regional team or corporate office has been onsite or available by phone since 2/26/24 and will follow up with facility daily for 2 weeks, then daily M-F for 2 weeks. The nurses from the regional team or home office are assisting with investigations, observing staff treatment of residents and providing oversight and consultation.
g) Resident #64
On 02/26/24 at 3:35 PM Resident #64 stated he is not getting the right meds. Resident said about a week ago on a Sunday (02/18/24) he got the wrong blue pill for pain. Resident produced pictures from his iPhone of the pill he was given and the right medication lying beside it. Resident stated he looked it up and the medicine he was given was Finasteride, that he wasn't even prescribed to take. (Finasteride is used to shrink an enlarged prostate in adult men by decreasing the amount of a natural body hormone). The incorrect blue tablet had F5 stamped on the pill and the Resident knew it wasn't right. The Resident should have gotten morphine sulphate. The resident said the staff brings his medicine and leaves it set for him to take when he is ready overnight. Resident stated he has gotten the wrong medication for pain twice.
On 02/28/24 at 10:00 AM Resident stated it was the Sunday before Presidents' Day that he got the wrong medication. He was going to tell the Director of Nursing (DON) on Monday, but she was off for the holiday. Resident stated he showed the picture on his phone of the medications (blue pills) to the DON the Tuesday (02/20/24) of the week and told her what happened. Resident #64 stated, I feel like I need to be an advocate for these people. I am not your typical nursing home resident. I know my mediations and pay attention to what I get, some of these people can't speak for themselves. If it is happening to me, it is happening to others here.
Record review showed Resident #64 has the capacity to make medical decisions.
Record review showed an order for MS (Morphine Sulphate) Contin Oral Tablet Extended Release 15 mg. Give 15 mg by mouth two times a day for Pain. Start Date 09/09/2023.
On 03/04/24 at 4:00 PM the DON stated, Yea he told me about getting the wrong med and I thought the nurse that gave it told me it was Nifedipine (Nifedipine extended-release tablet 60 MG) that he gets. I never went and looked.
On 03/04/24 Licensed Practical Nurse (LPN) #101 reviewed mediations in cart and found no blue pills to match the description of the pill he got. Nifedipine that was prescribed to the resident just pulled out of drawer and reviewed. The Nifedipine tablet was brown/tan in color. The DON stated, Well it couldn't have been that then.
On 03/05/24 at 9:52 AM the DON stated, You are right, I was off president's day just like he [Resident #64] said I was. He gave me the pill, but I didn't look it up, he said he already researched it. The DON further stated, It may have been a reportable, I will have to let you.
Record review shows a reportable completed on 03/05/24 for Resident #64 for the alleged incident on 02/18/22. The reportable stated, State surveyor reported misappropriation of medication. Date of incident 02/18/24.
During an interview on 03/06/24 at 4:07 PM Corporate Registered Nurse (CRN) #97 stated, He [Resident #64] didn't take the wrong pill so it technically wasn't a medication error and so it didn't hurt because he didn't take it. When we talked to her [RN # 55] she said they were correct. He said he got his morphine so there was no cause for concern. No misappropriation of funds to begin with.
h) Resident #65
On 02/27/24 9:45 AM, LPN #64 stated We got a problem here with controlled substances coming up missing. The DON knows about it . This is my license. See here, this hydromorphone for [Resident #65's name] was signed out and he wasn't even taking it. LPN #64 showed surveyor the controlled substance sign-out book for Resident #65 where Registered Nurse (RN) #55 signed out the pain medication on 02/08/24. LPN #64 then stated, I clean out the med cart at the end of my shift and only leave enough pain meds for the night. That's what I was told to do.
Record review shows and order for Hydromorphone HCl Oral Tablet 2 MG (Hydromorphone HCl). Give1 tablet by mouth every 24 hours as needed for pain control. Order was discontinued on 10/17/23. Review of the controlled substance sign-out long showed RN #55 signed out one (1) Hydromorphone 2mg tablet on 02/08/24 at 11:00 PM. No documentation of where the hydromorphone was administered to the Resident.
On 03/04/24 at 4:15 PM the DON stated, Now that does spark my interest. CRN #97 stated, How did she sign it out and administer it if the was no order was discontinued? DON stated, I done a med error on it, she said he needed something for pain and that was the first thing she saw and pulled it out and gave it.
Record review shows no pain medication to documented as given on 02/08/24 at 11:00 PM.
On 03/05/24 at 9:31 AM no reportable or investigation was found to have been done. The DON said this wasn't a reportable issue.
On 03/05/24 at 9:52 AM DON stated they are still investigating what the Surveyor has brought to their attention and it may end up being reportable. DON stated, I told you I didn't know about this, but I guess I did. When they gave me the mediations to destroy last week the nurse told me I may want to take a look at that this one, a pill was missing.
Record review of the Controlled substance destruction log showed Hydromorphone 2 tabs were destroyed on 02/29/24 by the DON and pharmacist. At that time DON was made aware of the missing hydromorphone tablet by nursing staff.
On 03/05/24 at 11:30 AM the DON presented a form titled Employee Warning form and stated she had filled this report out for RN #63 due to Resident #65's mediation error. The reason for the written warning was Mediation was given without an order. No follow up completed. All medications given must have an order and all PRN meds must have a follow up to verify effectiveness. Always follow the 5 rights of medications Administration. The DON clarified the form was originally completed for resident #65 but could be used for both Resident #64 and #65 since they both involved pain pills. The form was signed by the DON on 02/22/24, by the Administrator on 03/04/24, by RN #63 on 02/22/24.
Record review shows a reportable completed on 03/05/24 for Resident #64 for the alleged incident on 02/18/22. The reportable stated, State surveyor reported misappropriation of medication. Date of incident 02/08/24.
During an interview on 03/06/24 at 4:07 PM Corporate Registered Nurse (CRN) #97 stated, We went ahead and reported [Resident #65 name] missing hydromorphone pill as misappropriation of property since we done [Resident #64's] since we don't know what was done with the hydromorphone that was signed out.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0697
(Tag F0697)
A resident was harmed · This affected 1 resident
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Based on record review, resident and staff interview, and observation the facility failed to ensure pain management was provided in accordance with professional standards of practice for two (2) of ...
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Based on record review, resident and staff interview, and observation the facility failed to ensure pain management was provided in accordance with professional standards of practice for two (2) of seven (7) residents reviewed for pain. Resident #331 was not provided pain medication after continued presentation of pain. Resident #181 was not provided with adequate pain medication for pain control or prior to physical therapy to allow adequate participation. This failed practice resulted in Resident #331 and Resident #181 suffering actual harm becuase thier pain was not assessed and/or treated timely resulting in the pain lasting longer than needed. This failed practice had the potential to affect only a limited number of residents. Resident identifiers: #331, #181. Facility census: 82.
Findings include:
a) Resident #331
Upon entrance at 11:05 PM on 02/27/24, Resident #331 was in wheelchair following Registered Nurse (RN) #55 around in the hallway while she passed medications. Resident #331 was grimacing, extending his right leg and writhing in his wheelchair. RN #55 was asked if Resident had anything ordered for pain and she stated, He has a muscle relaxer due that should help.
Record review showed Methocarbamol Oral Tablet 500 MG tablet to be used for muscle spasms was given 2/27/24 at 11:40 PM. No pain medication was ordered or administered.
On 02/27/24 at 11:54 PM, Resident #331 was witnessed by Surveyor falling out of his wheelchair in the hallway near the nurse's station on south side. Resident scooted to edge of his wheelchair, and leaned forward and fell out onto the floor. Resident landed on his right side with his head against the wall. The Resident's right leg and arm were pinned under him. Resident was laying across the leg of the floor stand blood pressure monitor. Resident was yelling Oh, Oh, Oh damn. RN #55 came up the hallway and asked the resident if he was ok? RN #55 pulled up the sweatshirt sleeve of his right arm and said. I don't see anything; you did hit hard I bet that hurt. RN #55 was then joined by CNA #31 and they proceeded to try to lift the resident back into the wheelchair by grabbing his pants and reaching under his arms. RN #55 lifted under the right arm and CNA # 31 lifted under the left arm and they both grabbed the back of the resident's pants. After the third try with the wheelchair sliding backwards, RN #55 and CNA #31 tossed the resident back into the wheelchair. Resident #331 continued to yell, Oh. Oh, Oh damn it the entire time. RN #55 said, Yea he's heavy! RN #55 then reported to the Surveyor, Don't worry, he is care planned for falls, he slides out of his chair all the time. Once resident was back in chair at 12:00 AM, RN #331 attempted to take residents BP and stated, This don't seem to be working right, but I think he's ok. Resident #331 was wearing a AAA (hinged) knee brace in place on his left lower extremity and was non weight bearing to left lower extremity at the time of the fall. The Resident was wearing regular socks at the time of the incident.
On 03/03/24 at 11:07 PM Resident #331 was heard yelling from his room. Oh, oh, help. Resident was observed laying cross ways in the bed writhing and flinging his legs. The resident was grabbing at his right leg hip area and legs were twitching. Certified Nursing Assistant (CNA) #9 went into the Resident's room and came back out and told LPN #40, He's in pain. LPN #40 stated to surveyor, He's been repositioned for pain. At 11:30 PM, LPN #40 stated I guess I'll get him an order for pain. An order was added for Tylenol Oral Tablet 325 MG, give 650mg for pain every 6 hours PRN . At 11:37 PM Tylenol was given for pain.
On 03/05/24 at 4:30 PM Resident was observed setting at nurses station grimmacing and rubbing his leg. Resident was asked if he was hurting? The Resident stated, I hurt all the damn time. LPN #64 stated, Yea I just called the doctor and got him some Tramadol (pain medication), I was tired of watching him thrash around.
Record review showed physicains orders for:
Tylenol Oral Tablet 325 MG (Acetaminophen) Give 650 mg by mouth every 6 hours as needed for pain. Start Date 03/03/2024 at 11:30 PM.
Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 6 hours for Pain Management. Start Date 03/05/2024 at 6:00 PM.
b) Resident #181
During an interview on 02/27/24 at 1:00 PM, Resident # 181 stated, I hurt all the time, I feel like I need a different pain medicine or something.
An observation on 03/05/24 at 3:32 PM, showed Resident #181 in the hallway rocking in her wheelchair back and forth saying, I want a pain pill.
Further observation at 3:32 PM, showed the Assistant Director of Nursing (ADON) walking by and telling her the nurse would be there in a minute to give her a pain pill.
An observation at 03/05/24 at 4:00 PM, showed that Resident #181 was taken to therapy.
During an interview on 03/05/24 at 4:14 PM, with the Registered Nurse Unit Manager (RNUM), she stated, I am doing her finger stick.
A record review on 03/05/24 at 4:16 PM, of Resident #181's Medication Administration Record (MAR) revealed that residents documented pain was 10 and was given a PRN order of oxycodone 15 milligrams.
An interview on 03/05/24 at 4:33 PM, with Physical Therapy Assistant (PTA) # 100, she stated, (Resident #181 name) did not say she was in pain, but she was moaning. So it's really hard to tell.
An interview and observation on 03/05/24 at 5:05 PM, with Resident #181, showed resident sitting on the edge of her bed doubled over. She stated, I don't even feel like I have had pain medicine.
An observation on 03/05/24 at 5:24 PM, of Resident #181, she continues to sit on the edge of her bed with her head in her lap.
A record review on 03/05/24 at 5:28 PM, of Resident #181's MAR, shows that she has not been assessed to see if the pain medicine was effective.
Further record review of Resident #181's Minimum Data Set (MDS), Section F, Question JO520 is marked that the resident occasionally has pain that interferes with therapy activities.
A review on 03/06/24 at 10:00 AM, of the facilities policy titled Administering Pain Medications under general guidelines number (5) five reads: Acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after onset and reassessed as indicated until relief is obtained.
An interview on 03/06/24 at 10:05 AM, with ADON, he stated, I will have them reasses her pain, and see what's going on. She does have a history of drug seeking but, pain should be assessed 30 minutes to an hour after pain medication is given.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews, the facility failed to inform and provide written information to the reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews, the facility failed to inform and provide written information to the resident on their right to formulate an advance directive. This was true for one (1) of four (4) residents reviewed for the care area of advance directives during the annual survey. Resident identifier: #179. Census: 82.
Findings included:
a) Resident #179
On 03/04/24 at approximately 11:00 AM during a record review of Resident #179's medical record it was identified the resident admitted to the facility on [DATE] for short term rehab care.
It was noted in the Minimum Data Set (MDS) with the Assessment Reference Date (ARD)/Target of 02/28/24 that Resident #179 had a Brief Interview for Mental Status (BIMS) of 15 which indicated the resident was cognitively intact. Upon review of the resident's physician orders, there was not an order for end-of-life care.
During a review of the miscellaneous uploaded medical records, no end-of-life documents were found on file. No nursing notes were found regarding advance directives being offered.
During an interview with the Director of Nursing (DON) on 03/04/24 at 2:43 PM, the DON agreed the facility did not have an advance directive completed and on file for Resident #179. A copy of the facilities Advanced Directives policy effective date of 04/15/20 was then provided by DON.
During a review of the facilities Advanced Directives policy on 03/05/24 at approximately 1:15 PM the following information was identified under the Policy Interpretation and Implementation on Page 2:
1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so.
.8. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives.
8a. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision.
8b. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance.
On 3/05/24 at 1:26 PM during an interview with the Assistant Director of Nursing (ADON) #42, he confirmed the advance directive was not noted to have been offered to Resident #179 upon admission and is now being completed as of 3/04/24 after surveyor intervention.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
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Based on observation, record review and staff interview the facility failed to ensure privacy during administration of nasal spray for Resident #330. This was a random opportunity for discovery. Res...
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Based on observation, record review and staff interview the facility failed to ensure privacy during administration of nasal spray for Resident #330. This was a random opportunity for discovery. Resident identifier: #330. Facility census: 82.
Findings included:
a) Resident #330
On 02/27/24 at 11:13 PM Resident #330 stated, I need my nasal spray, I want to go to bed. I can't breathe my nose is plugged up.
On 02/28/24 at 12:08 AM Resident #330 came out into the hallway in his wheelchair outside of his room door. Resident #330 asked Registered Nurse (RN) #55 if he could have his nasal spray so he could go to bed. RN #55 replied, Yes roll up here (in wheelchair) and I will give it to you. RN #55 then administered nasal spray to Resident #55 while he was sitting in his wheelchair in the hallway.
Record review revealed an order for Saline Nasal Solution 0.9 % (Saline). 1 spray resident in each nostril every 6 hours as needed for Dry Nose.
During an interview, on 02/28/24 at 10:00 AM, the Assistant Director of Nursing stated RN #55 should not have administered any medications in the hallway, especially nasal spray.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
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Based on record review, staff interview, and resident interview the facility failed to report alleged violations related to misappropriation of property and failed to report the results of all inves...
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Based on record review, staff interview, and resident interview the facility failed to report alleged violations related to misappropriation of property and failed to report the results of all investigations to the proper authorities within required time frames. This failed practice was a random opportunity for discovery. Resident identifiers: #64, #65. Facility census: 82.
Findings include:
a) Resident #64
On 02/26/24 at 3:35 PM Resident #64, stated he is not getting the right meds. Resident said about a week ago on a Sunday (02/18/24) he got the wrong blue pill for pain. Resident produced pictures from his iPhone of the pill he was given and the right medication lying beside it. Resident stated he looked it up and the medicine he was given was Finasteride, that he wasn't even prescribed to take. (Finasteride is used to shrink an enlarged prostate in adult men by decreasing the amount of a natural body hormone). The incorrect blue tablet had F5 stamped on the pill and the Resident knew it wasn't right. The Resident should have gotten morphine sulphate. The resident said the staff brings his medicine and leaves it set for him to take when he is ready overnight. Resident stated he has gotten the wrong medication for pain twice.
On 02/28/24 at 10:00 AM, Resident #64 stated it was the Sunday before Presidents' Day that he got the wrong medication. He was going to tell the Director of Nursing (DON) on Monday, but she was off for the holiday. Resident stated he showed the picture on his phone of the medications (blue pills) to the DON the Tuesday (02/20/24) of the week and told her what happened. Resident #64 stated, I feel like I need to be an advocate for these people. I am not your typical nursing home resident. I know my mediations and pay attention to what I get, some of these people can't speak for themselves. If it is happening to me, it is happening to others here.
Record review showed Resident #64 to have capacity to make medical decisions.
Record review showed an order for MS (Morphine Sulphate) Contin Oral Tablet Extended Release 15mg. Give 15 mg by mouth two times a day for Pain. Start Date 09/09/2023.
On 03/04/24 at 4:00 PM the DON stated, Yea he told me about getting the wrong med and I thought the nurse that gave it told me it was Nifedipine (Nifedipine extended release tablet 60 MG) that he gets. I never went and looked.
On 03/04/24, Licensed Practical Nurse (LPN) #101 reviewed mediations in cart and found no blue pills to match the description of the pill he got. Nifedipine that was prescribed to the resident just pulled out of drawer and reviewed. The Nifedipine tablet was brown/tan in color. The DON stated, Well it couldn't have been that then.
On 03/05/24 at 9:52 AM the DON stated, You are right, I was off president's day just like he [Resident #64] said I was. He gave me the pill, but I didn't look it up, he said he already researched it. The DON further stated, It may have been a reportable, I will have to let you.
Record review shows a reportable completed on 03/05/24 for Resident #64 for the alleged incident on 02/18/24. The reportable stated, State surveyor reported misappropriation of medication. Date of incident 02/18/24.
During an interview on 03/06/24 at 4:07 PM Corporate Registered Nurse (CRN) #97 stated, He [Resident #64] didn't take the wrong pill so it technically wasn't a medication error and so it didn't hurt him because he didn't take it. When we talked to her [RN # 55] she said they were correct. He said he got his morphine so there was no cause for concern. No misappropriation of funds to begin with.
b) Resident #65
On 02/27/24 9:45 AM, LPN #64 stated We got a problem here with controlled substances coming up missing. The DON knows about it . This is my license. See here, this hydromorphone for [Resident #65's name] was signed out and he wasn't even taking it. LPN #64 showed surveyor the controlled substance sign-out book for Resident #65 where Registered Nurse (RN) #55 signed out the pain medication on 02/08/24. LPN #64 then stated, I clean out the med cart at the end of my shift and only leave enough pain meds for the night. That's what I was told to do.
Record review shows and order for Hydromorphone HCl Oral Tablet 2 MG (Hydromorphone HCl). Give1 tablet by mouth every 24 hours as needed for pain control. Order was discontinued on 10/17/23. Review of the controlled substance sign-out log showed RN #55 signed out one (1) Hydromorphone 2mg tablet on 02/08/24 at 11:00 PM. No documentation of where the hydromorphone was administered to the Resident was found.
On 03/04/24 at 4:15 PM the DON stated Now that does spark my interest. CRN #97 stated, How did she sign it out and administer it if there was no order? DON stated, I done a med error on it, she said he needed something for pain and that was the first thing she saw and pulled it out and gave it.
Record review shows no pain medication was documented as given on 02/08/24 at 11:00 PM.
On 03/05/24 at 9:31 AM no reportable or investigation was found to have been done. The DON said this wasn't a reportable issue.
On 03/05/24 at 9:52 AM, the DON stated they are still investigating what the Surveyor has brought to their attention and it may end up being reportable. DON stated, I told you I didn't know about this, but I guess I did. When they gave me the mediations to destroy last week the nurse told me I may want to take a look at that this one, a pill was missing.
Record review of the Controlled substance destruction log showed Hydromorphone 2 tabs were destroyed on 02/29/24 by the DON and pharmacist. At that time the DON was made aware of the missing hydromorphone tablet by nursing staff.
On 03/05/24 at 11:30 AM the DON presented a form titled Employee Warning form and stated she had filled this report out for RN #63 due to Resident #65's mediation error. Reason for written warning was Mediation was given without an order. No follow up completed. All medications given must have an order and all PRN meds must have a follow up to verify effectiveness. Always follow the 5 rights of medications Administration. The DON clarified the form was originally completed for resident #65 but could be used for both Resident #64 and #65 since they both involved pain pills. The form was signed by the DON on 02/22/24, by the Administrator on 03/04/24, by RN #63 on 02/22/24.
Record review shows a reportable completed on 03/05/24 for Resident #64 for the alleged incident on 02/08/24. The reportable stated, State surveyor reported misappropriation of medication. Date of incident 02/08/24.
During an interview on 03/06/24 at 4:07 PM, Corporate Registered Nurse (CRN) #97 stated, We went ahead and reported [Resident #65 name] missing hydromorphone pill as misappropriation of property since we done [Resident #64's] since we don't know what was done with the hydromorphone that was signed out.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to ensure a complete and accurate discharge Minimum Data Set (...
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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 complete and accurate discharge Minimum Data Set (MDS) Assessment for one (1) of one (1) residents reviewed for the care area of discharge. Resident Identifier: #77. Facility census: 82.
Findings include:
a) Resident #77
Review of Resident #77's medical records showed the resident was admitted for short-term rehabilitation on 11/29/23. He was discharged to home on [DATE].
A Social Service Progress Note written on 12/03/23 stated, Resident had a brief stay here from 11/29/2023 to 12/1/2023 when he opted to discharge to home. He stated he no longer needed to be in SNF [skilled nursing facility] for rehab [rehabilitation].
Review of Resident #77's combined five (5) day and discharge Minimum Data Set (MDS) Assessment with Assessment Reference Date (ARD) 12/01/23 coded the resident's discharge as Discharge assessment - return anticipated.
On 03/05/24 at 05:13 PM, the Assistant Director of Nursing (ADON) confirmed Resident #77's medical records contained no evidence the resident was expected to return to the facility. The ADON confirmed Resident #77's MDS with ARD 12/02/23 was incorrect.
No further information was provided through the completion of the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
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Based on medical record review, family interview, resident interview and staff interviews, the facility failed to complete an accurate Minimum Data Set (MDS) assessment for one (1) of 24 residents r...
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Based on medical record review, family interview, resident interview and staff interviews, the facility failed to complete an accurate Minimum Data Set (MDS) assessment for one (1) of 24 residents reviewed during the Long-Term Care Survey (LTCSP). The MDS's for Resident #233 did not accurately reflect the residents' status for communication deficit. Resident Identifiers: #233. Facility Census: 82
Findings Include:
a) Resident #233
During the initial interview on 02/26/24 at 3:36 PM, Resident #233 and her daughter were present during the interview. Resident shook her hand to respond yes and no to some answer and looked at her daughter for other responses. The daughter stated she has some communication issues due speaking Spanish and having a stroke. She mostly understands others but has some issues communicating needs to others. She mostly responds by shaking her head.
During an interview on 02/27/24 at 4:56 PM, the Director of Nursing (DON) stated they have books and other things to help communicate with (Resident # 233's name).
During a record review on 03/04/24 at 2:02 PM, Resident #233's medical record revealed a Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 02/19/24. Section B, titled Hearing, Speech and Vision
Section B0600 Speech Clarity Select best description of speech pattern was coded 0(zero) for clear speech-distinct intelligible words
Section B0700 Makes Self Understood was coded 0 (zero)Understood
Section B0800 Ability to Understand Others was coded 0 (zero) Understands-clear comprehension.
During an interview on 03/04/24 at 2:42 PM, DON acknowledged the MDS with an ARD of 02/19/24 were coded inaccurate for unclear speech, makes self understood and ability to understand.
During an interview on 03/05/24 at 11:18 AM, Nurse Aide (NA) #45 stated Resident #233 has some communication struggles, she will point to stuff, sometimes the struggle is more from her stroke than language. She speaks mostly Spanish and some English.
During an interview on 03/05/24 at 11:21 AM, Licensed Practical Nurse (LPN) #64 stated Resident #233 has a language barrier but we do very well, she answers yes or no questions with yes or no or shaking her head. She has a tablet with her family pictures on it. You pick up the tablet, press the family member and someone is always available for facetime. They are always there to help with what she is trying to say to us. It is so easy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
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Based on medical record review, family interview, resident interview and staff interviews, the facility failed to complete a baseline care plan for Resident #233's communication deficit. This was tr...
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Based on medical record review, family interview, resident interview and staff interviews, the facility failed to complete a baseline care plan for Resident #233's communication deficit. This was true for one (1) of 24 residents reviewed during the Long-Term Care Survey (LTCSP). Resident Identifier: #233. Facility Census: 82.
Findings Include:
a) Resident #233
During the initial interview on 02/26/24 at 3:36 PM, Resident #233 and her daughter were present during the interview. Resident shook her hand to respond yes and no to some answer and looked at her daughter for other responses. The daughter stated she has some communication issues due to speaking Spanish and having a stroke. She mostly understands others but has some issues communicating needs to others. She mostly responds by shaking her head.
During an interview on 02/27/24 at 4:56 PM, the Director of Nursing (DON) stated they have books and other things to help communicate with (Resident # 233's name).
During a record review on 03/04/24 at 2:06 PM, Resident #233 medical records revealed a care plan with an initiated date of 02/13/24. This care plan showed no focus, goal or interventions for Resident #233's language deficit.
During an interview on 03/04/24 at 2:42 PM, the DON acknowledged the care plan with an initiated date of 02/13/24 did not address the communication deficit.
During an interview on 03/05/24 at 11:18 AM, Nurse Aide (NA) #45 stated Resident #233 has some communication struggles, she will point to stuff, sometimes the struggle is more from her stroke than language. She speaks mostly Spanish and some English.
During an interview on 03/05/24 at 11:21 AM, Licensed Practical Nurse (LPN) #64 stated Resident #233 has a language barrier but we do very well, she answers yes or no questions with yes or no or shaking her head. She has a tablet with her family pictures on it. You pick up the tablet, press the family member and someone is always available for facetime. They are always there to help with what she is trying to say to us. It is so easy.
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 and staff interview, the facility failed to ensure residents with indwelling urinary catheters receive treatment and care in accordance with professional standards of practice. ...
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Based on observation and staff interview, the facility failed to ensure residents with indwelling urinary catheters receive treatment and care in accordance with professional standards of practice. These were random opportunities for discovery. Resident Identifiers: #179 and #29. Facility Census: 82.
Findings Include:
a) Resident #179
On 03/03/24 at 11:08 PM, the resident was observed to have a urinary foley catheter. The urinary foley catheter drainage bag was touching the floor.
On 03/03/24 at 11:12 PM, Licensed Practical Nurse (LPN) #126 was notified and confirmed the urinary foley catheter drainage bag should not be touching the floor.
No further information was obtained during the survey process.
b) Resident #29
On 02/26/24 at 3:30 PM observation was made of Bedside Urinary Drainage bag under the middle of Resident #29's bed. Urine was backed up in the tubing up to the Resident's leg. Licensed Practice Nurse Unit Manager (LPN) #38 was called into room to verify finding. LPN #38 stated, Oh, well hospice just bathed her a bit ago and must have left it [catheter bag] like that. LPN #38 picked the catheter bag up out of the floor and hooked the catheter bag to the bedside. LPN #38 stated, I guess we need to start checking residents after hospice leaves them to make sure they are tucked in ok.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview the facility failed to ensure residents receive necessary respiratory care and services in accordance with professional standards of practice, by not safely ...
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Based on observation and staff interview the facility failed to ensure residents receive necessary respiratory care and services in accordance with professional standards of practice, by not safely storing oxygen tanks. This was a random opportunity for discovery. Facility census 82.
Findings include:
a) Oxygen storage
An observation on 03/03/24 at 11:20 PM, revealed an oxygen tank stored in the corner of the bathroom in the floor of Room # 130. No resident was in the room.
During an interview on 03/03/24 at 11:22 PM, with Licensed Practical Nurse (LPN) #61, she stated, No, that oxygen tank should not be in there. It should be locked up. I will have someone get it out.
A review of the facilities policy titled Oxygen Tank Storage on 03/04/24 at 10:00 AM, read:
-Policy: The facility must ensure that the resident environment remains as free of accident hazards as possible.
-Procedure: All pressurized oxygen canisters will be secured in a rack or fastened to a wheeled carrier. This includes full, partially full, and empty canisters, and canisters that are located in the oxygen storage location or in use in the resident's room.
An interview on 03/03/24 at 12:00 PM, with Assistant Director of Nursing (ADON), confirmed oxygen was not stored in a safe manner.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview the facility failed to account for controlled substances within professional standards of practice for Resident #65. This failed practice was a random oppo...
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Based on record review and staff interview the facility failed to account for controlled substances within professional standards of practice for Resident #65. This failed practice was a random opportunity for discovery. Resident identifier: #65. Facility census: 82.
Findings include:
On 02/27/24 at 9:45 AM, LPN #64 stated We got a problem here with controlled substances coming up missing. The DON knows about it . This is my license. See here, this hydromorphone for [Resident #65's name] was signed out and he wasn't even taking it. LPN #64 showed surveyor the controlled substance sign-out book for Resident #65 where Registered Nurse (RN) #55 signed out the pain medication on 02/08/24. LPN #64 then stated, I clean out the med cart at the end of my shift and only leave enough pain meds for the night. That's what I was told to do.
Record review shows and order for Hydromorphone HCl Oral Tablet 2 MG (Hydromorphone HCl). Give1 tablet by mouth every 24 hours as needed for pain control. Order was discontinued on 10/17/23. Review of the controlled substance sign-out long showed RN #55 signed out one (1) Hydromorphone 2mg tablet on 02/08/24 at 11:00 PM. No documentation of where the hydromorphone was administered to the Resident.
On 03/04/24 at 4:15 PM the DON stated Now that does spark my interest. CRN #97 stated, How did she sign it out and administer it if the order was discontinued? DON stated, I done a med error on it, she said he needed something for pain and that was the first thing she saw and pulled it out and gave it.
Record review shows no pain medication documented as given on 02/08/24 at 11:00 PM.
On 03/05/24 at 9:31 AM no reportable or investigation was found to have been done. The DON said this wasn't a reportable issue.
On 03/05/24 at 9:52 AM, the DON stated they are still investigating what the Surveyor has brought to their attention and it may end up being reportable. DON stated, I told you I didn't know about this, but I guess I did. When they gave me the mediations to destroy last week the nurse told me I may want to take a look at that this one, a pill was missing.
Record review of the Controlled substance destruction log showed Hydromorphone 2 tabs were destroyed on 02/29/24 by the DON and pharmacist. At that time the DON was made aware of the missing hydromorphone tablet by nursing staff.
On 03/05/24 at 11:30 AM the DON presented a form titled Employee Warning form and stated she had filled this report out for RN #63 due to Resident #65's mediation error. Reason for written warning was Mediation was given without an order. No follow up completed. All medications given must have an order and all PRN meds must have a follow up to verify effectiveness. Always follow the 5 rights of medications Administration. The DON clarified the form was originally completed for resident #65 but could be used for both Resident #64 and #65 since they both involved pain pills. The form was signed by the DON on 02/22/24, by the Administrator on 03/04/24, by RN #63 on 02/22/24.
Record review shows a reportable completed on 03/05/24 for Resident #64 for the alleged incident on 02/18/22. The reportable stated, State surveyor reported misappropriation of medication. Date of incident 02/08/24.
During an interview on 03/06/24 at 4:07 PM Corporate Registered Nurse (CRN) #97 stated, We went ahead and reported [Resident #65 name] missing hydromorphone pill as misappropriation of property since we done [Resident #64's] since we don't know what was done with the hydromorphone that was signed out.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview the facility failed to ensure the drug regimen of each resident was reviewed at least once a month by a licensed Pharmacist. This failed practice was found...
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Based on record review and staff interview the facility failed to ensure the drug regimen of each resident was reviewed at least once a month by a licensed Pharmacist. This failed practice was found true for (1) one of (5) five residents reviewed for unnecessary medications during the Long Term Care Survey Process. Resident identifier #61. Facility census 82.
Findings include:
a) Resident #61
A record review on 03/05/24 at 1:50 PM, of Resident #61's Pharmacy notes revealed the following Pharmacy reviews: (Typed as written, leaving out the Pharmacist name)
-03/3/2024 18:34
Note Text: I reviewed this resident's medication regimen and have noted any irregularities and/or observations on a separate report to the Director of Nursing and prescriber.
Pharmacy
-02/7/2024 19:00
Note Text: I have completed the Pharmacy MMR for this patient for the month of FEBRUARY 2024, please see the report for specific comments. Thank you. Pharmacy
-01/7/2024 13:54
Note Text: I have completed the Pharmacy MMR for this patient for the month of JANUARY 2024, please see report for specific comments. Thank you.
Pharmacy
-11/1/2023 18:34
Note Text: I have completed the Pharmacy MMR for this patient for the month of NOVEMBER 2023, please see report for specific comments. Thank you.
Pharmacy
-10/2/2023 19:34
Pharmacy Note
Note Text: I have completed the Pharmacy MMR for this patient for the month of OCTOBER 2023, please see report for specific comments. Thank you.
Pharmacy
- 09/3/2023 14:42
Pharmacy Note
Note Text: I, have completed the Pharmacy MMR for this patient for the month of SEPTEMBER 2023, please see report for specific comments. Thank you.
Further record review revealed that there was no Pharmacy review completed for the month of December 2023.
During an interview on 03/05/24 at 2:10 PM, with Assistant Director of Nursing (ADON), he stated, No, I did not see one in her chart for the month of December.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed to monitor efficacy of psychotropic medications. This deficient practice had the potential to affect one (1) of five (5) residents rev...
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Based on record review and staff interview, the facility failed to monitor efficacy of psychotropic medications. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #47. Facility census: 82.
Findings include:
a) Resident #47
Review of Resident #47's medical records showed the resident had been ordered the medication mirtazapine for anxiety since 10/27/23 and the medication trazodone for anxiety since 11/16/23.
The resident's comprehensive care plan had a focus related to anxiety disorder. The goal initiated 06/17/23 was I will remain free from signs and symptoms of increased restlessness daily through the next review.
Resident #47's medical records contained no documentation the resident was monitored for signs and symptoms of anxiety.
During an interview on 03/05/24 at 1:45 PM, the Director of Nursing (DON) confirmed Resident #47's medical records contained no documentation the resident was monitored for signs and symptoms of anxiety.
No further information was provided through the completion of the 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
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation and staff interviews, the facility failed to provide residents with a safe, clean, comfortable, and homel...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation and staff interviews, the facility failed to provide residents with a safe, clean, comfortable, and homelike environment. A glove that appeared soiled was observed on the handrail; clean linens were not available; and dining room chairs were observed to be unclean. These failed practices were a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility Census: 82
Findings include:
a) glove
On 03/03/24 at 11:33 PM during a tour of facility, a glove which appeared tog be soiled was observed balled up and stuck in the top back edge of the hallway handrail at the entrance of room [ROOM NUMBER].
During an interview with Certified Nursing Assistant (CNA) #9 and CNA #56, both agreed the glove was stuck in the top back of the handrail and appeared soiled. CNA #9 then took the glove from the handrail and threw it away.
b) clean linens
On 03/05/24 at 10:34 AM during a tour of the building, the North Unit clean linen closet had no towels or washcloths. During an interview with Certified Nursing Assistant (CNA) # 51 on 03/05/24 at approximately 10:36 AM, she stated if she needed towels or wash clothes with this closet being empty, she would go to the laundry room. CNA #51 further stated, she sometimes had issues with having enough clean linens readily available when needed. Upon observation in the laundry room the staff was folding sheets and bed coverings. It was then observed on 03/05/24 at 10:40 AM the South Unit clean linen closet only had 10 towels and 20 wash clothes available.
During an interview with the Housekeeping Manager (HM) #92 on 03/05/24 at 10:42 AM, she stated there were not enough clean linens available for the facility at this time.
c) Unclean Main Dining Room Chairs
During an observation, on 02/27/24 at 12:15 PM, the main dining room chairs were found with several food stains and food particles on the chair seat and chair back.
During an interview, on 02/27/24 at 12:20 PM, Housekeeping Manager (HM) #92 stated the chairs were cleaned every two (2) weeks with a green machine (a portable machine which cleans carpets and upholstery). HM #92 said, We do not have a cleaning schedule or a record of the cleaning of the chairs. The last time the chairs were clean was the week of New Years Eve. I will get to it today; I have been short staffed and have not had the time.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, staff interview, and resident interview the facility failed to develop and/or implement care plans rel...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, staff interview, and resident interview the facility failed to develop and/or implement care plans related to dementia, pain, dialysis and Diabetes. This failed practice was found true for (4) four of 24 residents reviewed for care plans during the Long Term Care Survey Process. Resident identifiers #23, #181, #40, and #7. Facility Census 82.
Findings include:
a) Resident #23
During an interview on 02/27/24 at 4:45 PM, with Resident #23, she stated, The pain medicine does not always help me.
A record review on 03/05/24 at 10:03 AM, revealed Resident #23 is prescribed Percocet Tablet 10-325 MG (oxycodone-Acetaminophen) for pain, and she has a diagnosis of Dementia.
Further record review showed Resident #23 does not have a care plan developed for pain or Dementia.
An interview on 03/05/24 at 11:22 AM, with Assistant Director of Nursing (ADON) #42 , He confirmed a care plan for pain or Dementia was not developed for Resident #23.
b) Resident #181
During an interview on 2/27/24 at 1:00 PM, with Resident #181 she stated, I hurt all the time, I feel like I need a different pain medicine.
A record review on 03/05/24 at 10:15 AM, revealed that Resident #181 has a diagnosis of pain.
Further record review showed Resident #181 does not have a care plan developed for pain.
During an interview on 03/05/24 at 11:22 AM with Assistant Director of Nursing (ADON) #42 , he confirmed a care plan for pain was not developed for Resident #181.
c) Resident #4
Review of Resident #40's comprehensive care plan showed the following focus, The resident needs dialysis hemodialysis r/t [related to] ESRD [end stage renal disease]. An intervention dated 02/18/24 was to Check vital signs post dialysis q [every] shift x 24 hours. The resident's medical records contained documentation the resident's vital signs were checked immediately upon return from the dialysis unit. However, there was no documentation Resident #40's vital signs had continued to be checked every shift for 24 hours.
On 03/05/24 at 1:41 PM, the Assistant Director of Nursing (ADON) confirmed Resident #40's medical records contained no documentation to show the resident's vital signs were checked post dialysis every shift x 24 hours as specified in the resident's care plan.
No further information was provided through the completion of the survey process.
d) Resident #7
On 03/05/24 at 12:01 PM during a medical record review for Resident #7 who admitted on [DATE] had a Care Plan that was initiated on 01/30/23 to include a focus, goal and interventions for diabetes mellitus. Upon reviewing the physician diagnosis for Resident #7, the diagnosis of diabetes mellitus was not identified.
During an interview with the Assistant Director of Nursing (ADON) on 03/05/24 at approximately 12:07 PM, he stated the resident did not have diabetes mellitus and that the care plan was in error.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
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Based on record review, resident interview and staff interview, the facility failed to revise the care plan regarding bathing preferences and refusals of showers for Resident #58, diagnosis for anti...
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Based on record review, resident interview and staff interview, the facility failed to revise the care plan regarding bathing preferences and refusals of showers for Resident #58, diagnosis for antibiotic therapy and end-of-life wishes for Resident #76, multiple diagnoses including the use of a foley catheter, Gastromy (G-tube) tube and supplemental oxygen for Resident #179, pain for Resident #19, a splint for Resident #68, actual pain for Resident #10, and a diagnosis of dementia and pain for Resident #23. This was true for seven (7) of 24 residents reviewed during the survey process. Resident Identifier: #58, #76, #179, #19, #68, #10 and #23. Facility Census: 82.
Findings Included:
a) Resident #58
On 03/05/24 at 9:25 AM, a record review was completed for Resident #58. Upon completion of the review, the resident does not have a bathing preference or refusals of showers noted. The resident prefers bed baths to showers.
On 03/05/24 at 11:00 AM, the Director of Nursing (DON) stated, she refuses a lot (showers) she would rather have a bed bath. The DON also confirmed the care plan was not revised in regards to a bathing preference and refusals of shower.
No further information was obtained during the survey process.
b) Resident #76
On 03/04/24 at 12:38 PM, a record review was completed for Resident #76. The review found the care plan was not revised to include a diagnosis for antibiotic therapy and the terminal diagnosis for hospice services. The care plan also did not indicate the resident's code status had been changed to Do Not Resuscitate from a full code.
On 03/05/24 at 11:23 AM, the DON was notified and confirmed the care plan had not been revised to include the diagnosis for antibiotic therapy, a terminal diagnosis for hospice services and the change in code status.
No further information was obtained during the survey process.
c) Resident #179
On 03/04/24 at 10:30 AM, a record review was completed for Resident #179. The review found the care plan had not been revised to include the diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Asthma, Gastroesphoageal Disease (GERD), gastroparesis, the diagnoses and the reasons for a urinary foley catheter, G-tube and supplemental oxygen.
On 03/04/24 at 11:30 AM, the DON confirmed the diagnoses and reasons for the urinary foley catheter, G-tube and supplemental oxygen were not listed within the care plan.
No further information was obtained during the survey process.
d) Resident #19
On 03/06/24 at 12:15 PM, a record review was completed for Resident #19. The review found the care plan was not revised to indicate actual pain. The care plan stated potential for pain r/t (related to) decreased mobility, DMII (diabetes mellitus 2) and GERD. The resident is ordered Voltaren External Gel 1% (one percent) apply to lower extremities topically four (4) times a day for pain. The resident also has hydrocodone-acetaminophen 5-325mg give one (1) tablet by mouth every 4 (four) hours as needed for pain. The resident rated the pain she experienced as two (2) through seven (7) out of 10 on the pain scale.
On 03/06/24 at 2:02 PM, the DON confirmed the resident was having actual pain and the care plan would be updated.
No further information was obtained during the survey process.
e) Resident #68
On 03/04/24 at 11:00 AM, a record review was completed for Resident #68. The review found the care plan was not revised to include a right lower extremity drop splint.
On 03/04/24 at 12:03 PM, the Assistant Director of Nursing (ADON) #42 was notified and confirmed the right lower extremity drop splint was not included on the care plan.
No further information was obtained during the survey process.
f) Resident #10
On 03/06/24 at 12:15 PM, a record review was completed for Resident #19. The review found the care plan was not revised to indicate actual pain. The care plan stated Actual/Potential for Pain r/t (related to) Arthritis and decreased mobility. The resident was ordered Tylenol 325mg (milligrams) give two (2) tablets by mouth every 4 (four) hours as needed for pain. The resident has documented pain ranging from 2 (two)-5 (five) out of 10 on a pain scale. The care plan also included a focus area of I have a history of Insomnia. I may have difficulty sleeping some nights. One of the interventions stated Medicate with Melatonin for Insomnia per MD (medical doctor) orders. The Melatonin was discontinued on 02/24/24.
On 03/06/24 at 2:02 PM, the DON confirmed the resident was having actual pain and the Melatonin was discontinued. The DON stated, the care plan would be updated.
No further information was obtained during the survey process.
g) Resident #23
During an interview on 02/27/24 at 4:45 PM, with Resident #23, she stated, The pain medicine does not always help me.
A record review on 03/05/24 at 10:03 AM, revealed Resident #23 is prescribed Percocet Tablet 10-325 MG (oxycodone-Acetaminophen) for pain, and she has a diagnosis of Dementia.
Further record review showed Resident #23 does not have a care plan developed for pain or Dementia.
During an interview on 03/05/24 at 11:22 AM, with Assistant Director of Nursing (ADON) #42 , he confirmed a care plan for pain or Dementia was not developed for Resident #23.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, staff interview, and resident interview the facility failed to ensure residents were receiving the nec...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, staff interview, and resident interview the facility failed to ensure residents were receiving the necessary services to maintain good personal hygiene. Resident #44, #58 and #234 were not receiving showers. This failed practice was found true for (3) three of (9) nine residents reviewed for Activities of Daily Living (ADL's) during the Long Term Care Survey Process. Resident identifiers #44, #58, and #234. Facility census 82.
Findings include:
a) Resident #44
During an interview on 02/26/24 at 3:58 PM, Resident #44 stated, I don't always get my showers.
A record review on 03/04/24 at 12:31 PM, of Resident #44's care plan found following:
-Focus: Requires assistance with ADL's due to self care deficit, weakness, decreased mobility, debility, pain.
-Goal: Will continue to have needs met on a daily basis through review date: remaining clean, dry, dressed, groomed and free of odors.
-Intervention: Showering Assit: ( Independent, Supervision/Oversight, Set-Up, Verbal Cues/Encouragement, Non-Weight-Bearing Assistance, Weight-Bearing Assistance, Total Dependence)
Further review of the facilities shower schedule shows Resident #44 was to get showers on Tuesday's and Friday's on day shift. During the month of January 2024 she received one tub bath, (3) three bed baths, and (2) two showers, only (1) one of which was given on her scheduled day. During the month of February 2024 she received (1) one bed bath and (2) two showers on her scheduled days. She had not received a shower for the month of March 2024 by the end of the survey.
An interview with Assistant Director of Nursing (ADON) on 03/04/24 at 2:00PM , he confirmed Resident # 44 had not been given her showers as scheduled.
b) Resident #58
On 03/04/24 at 10:02 AM, during the initial interview, the resident stated I've only had one (1) shower recently.
On 03/04/24 at 2:40 PM, a record found the resident was scheduled for showers two (2) x (times) weekly on Tuesday and Friday on nightshift. The resident is listed as requires extensive assistance of one (1) staff for personal hygiene. The bathing documentation was reviewed from 02/02/24 through 03/02/24. There were nine (9) scheduled opportunities for showers on the following dates:
--02/02/24
--02/05/24
--02/09/24
--02/12/24
--02/16/24
--02/19/24
--02/23/24
--02/26/24
--03/01/24
The review found one (1) shower was given on 02/17/24 which was not a scheduled shower day which was documented in the progress notes. There also was one refusal documented on 02/20/24 which was not a scheduled shower day.
On 03/04/24 at 2:40 PM, the Director of Nursing (DON) was notified regarding the showers not being documented. The DON stated, they need to chart if there were refusals.
No further information was obtained during the survey process.
c) Resident #234
During an interview on 02/27/24 at 9:05 AM, Resident #234 stated I have been here for a week and I got my first bath last night at 3 AM this morning.
During a record review on 03/04/24 02:37 PM, Resident # 234's medical records revealed the resident was admitted on [DATE].
Further review of medical records revealed the bathing/shower task was coded for the following:
-02/21/24 NA (Not Applicable)
-02/22/24 NA
-02/23/24 BB(Bed Bath) 4(Total Dependence) 2(one person assist)
-03/01/24 Shower 4(Total Dependence) 2(one person assist)
The Shower schedule received on 03/04/24 revealed the following shower days for Resident #234 the AM shift on Tuesday and Friday.
Further record review revealed a care plan with an initiated date of 02/22/24 read as follows:
Focus: Requires assistance with ADL's due to weakness, decreased mobility.
Interventions: .Assist as needed with showers twice weekly or per resident preference.
During an interview on 03/04/24 at 3:47 PM, the DON acknowledged Resident #234 did not receive the scheduled amount of showers they should have.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, record review, resident interview, and staff interview the facility failed to provide an ongoing program...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, record review, resident interview, and staff interview the facility failed to provide an ongoing program of activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. This failed practice was found true for (3) three of (4) four residents reviewed for the care of activities during the Long Term Care Survey Process. Resident identifiers #35, #6, and #233. Facility census 82.
Findings include:
a) Resident #35
During an interview on 02/26/24 at 3:36 PM, Resident #35 stated, I don't like much that they do here.
An observation on 02/27/24 at 10:00 AM, of Resident # 35, showed the resident was sitting on his bed, touching and rubbing his catheter tubing and bag that he had taken off of his wheelchair.
An observation on 03/04/24 at 11:00 AM, of Resident # 35, revealed the resident was lying in his bed, rubbing his sheets.
A record review on 03/04/24 at 2:20 PM, of Resident # 35's Activity Participation Records (APR) revealed during the month of January and February 2024 he participated in 11 out of room activities.
Further record review of Resident # 35's Minimum Data Set (MDS), section F, question F, with an Assessment Refrence Date (ARD) date of 02/02/24 revealed it is somewhat important for him to do his favorite activities.
A review of Resident # 35's care plan on 03/04/24 at 2:25 PM, read as follows:
-Focus: I prefer independent and one on one activities.
-Goal: Resident will participate in one on one activities that promote socialization.
-Intervention: Redirect/divert resident if he becomes irritated/overwhelmed during conversation.
Resident converses one on one with staff and spends time in the Activity room.
Further review of Resident #35's APR for the months of January and February 2024 shows he has no (1) one to (1) one visits documented.
During an interview on 3/04/24 at 3:35 PM, with the facilities Activity director (AD), she stated, ' I am new and still learning this role, no there is not much documentation for him.
b) Resident #6
During an observation on 02/26/24 at 3:45 PM, Resident # 6 showed him lying in the bed, in the dark with no stimulation.
During an interview on 02/26/24 at 3:45 PM, with Resident # 6, he stated, I just lay here all day, and wait for the time to pass.
During an observation on 03/04/24 at 11:15AM, showed Resident # 6 lying in the bed, in the dark with no stimulation.
A record review on 03/04/24 at 3:00 PM of Resident # 6's APR, revealed during the month of January and February 2024 he participated in (6) six out of room activities. No (1) one to (1) one visits are documented on the participation records.
Further record review of Resident # 6's MDS, section F, question E, revealed it is very important for him to do things with groups of people. Question F is answered it is very important for him to participate in his favorite activities.
A review of Resident # 6's care plan on 03/04/24 at 2:05 PM, read as follows:
-Focus: Resident enjoys one on one activities with fellow residents and independent activities.
-Goal: Resident will participate in activities to promote socialization.
-Intervention: Enjoys relaxing: Listening to music and watching TV
I enjoy spending time outside when it's nice.
There is no mention in the careplan of Resident # 6's interest according to his Activity Assessment completed on 10/27/23. His interest include trivia, discussion, reading and word puzzles.
During and interview on 3/04/24 at 3:35 PM, with the facilities Activity director (AD), she stated, ' I am new and still learning this role, no there is not much documentation for him.
c) Resident # 233
During a record review on 03/04/24 at 2:19 PM, Resident #233's medical records revealed a Activities assessment dated [DATE] which read as follows:
A3. Attendance:
1. Small Group Attendance: daily
2. Large Group Attendance: daily
3. 1:1 Attendance: daily
A9. Activity Review the following categories were checked:
a. Cognitive
c. Creative
d. Entertainment
e. Outings
f. Games
h. Spiritual
i. Sensory
j. Social
Further record review revealed a monthly participation sheet was void any documentation for the following dates:
-02/18/24
-02/13/24
-02/12/24
The Monthly participation sheet was documented GS (General Socialization) but no other group activities were documented for the following days:
-03/04/24
-03/02/24
-03/01/24
-02/29/24
-02/28/24
-02/27/24
-02/24/24
-02/19/24
-02/15/24
Further record review revealed the care plan with a initiated date of 02/13/24 read as follows:
Focus: Activities come join and socialize with others.
Goal: Get up and come to the activities that I like to come to.
Interventions: Go ask her to come to bingo and crafts. Ask about coming to spay day as well.
During an interview on 03/05/24 at 11:29 AM, the AD acknowledged Resident #233 did not receive the invitation to the group activities of interest. The AD stated we documented she attends the lunch and dinner meals in the dining room for group socialization, but she has attended some other group activities, but we have not invited or documented the attendance or refusal of all the activity participation.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on resident interview, record review, and staff interview, the facility failed to ensure residents received treatment an...
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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 ensure residents received treatment and care in accordance with professional standards of practice. This deficient practice had the potential to affect five (5) of 24 residents reviewed in the long-term care survey sample. For residents #44, #40, and #7, physicians' orders were not followed. Additionally, Resident #19 was receiving a medication without an order. Resident #7's diagnoses were not complete in the electronic health records. Resident #179 did not have a physician's assessment for capacity to make medical decisions. Also, a random opportunity for discovery found Residents #331, #64, #330, #65, and #47 were given their evening medications late. Resident identifiers: #44, #40, #19, #7, #179, #331, and #64. Facility census: 82.
Findings included:
a) Resident #44
During an interview on 02/26/24 at 4:19 PM, Resident #44 stated the physician had ordered a urinalysis test for her, but it took five (5) days for the facility to collect it.
Review of Resident #44's progress note showed a physician's progress note written on 1/16/24 at 6:39 PM stated, The pt [patient] has ongoing urine complaints and says has to pee all the time.
Resident #44's physician's orders showed urinalysis and culture and sensitivity testing was ordered on 01/17/24, 01/19/24, and 02/01/24. Resident #44's medical records showed urinalysis and culture and sensitivity testing results for 02/01/24 only.
On 03/05/24 at 11:12 AM, the Assistant Director of Nursing stated urinalysis and culture and sensitivity testing was not done for Resident #44 as ordered on 01/17/24 and 01/19/24 because the physician's orders were incorrectly entered into the computer.
No further information was provided through the completion of the survey.
b) Resident #40
Review of Resident #40's physician's orders showed an order written on 02/02/24 for wound care to an abdominal surgical incision every day shift. The order was to clean with wound cleanser, pack with Dakins solution and gauze, and cover with a pad.
Review of Resident #40's Treatment Administration Record (TAR) for February 2024 showed the dressing change was not signed by the nurse to indicate the treatment had been performed on the following dates: 02/02/24, 02/05/24, 02/07/24, 02/16/24, 02/19/24 and 02/22/24.
On 03/04/24 at 2:12 PM, the Director of Nursing verified there was no documentation Resident #40's abdominal incision dressing change had been performed on 02/02/24, 02/05/24, 02/07/24, 02/16/24, 02/19/24 and 02/22/24.
No further information was provided through the completion of the survey process.
c) Resident #19
On 02/26/24 at 2:30 PM, an initial interview was held with Resident #19 and the Resident Representative (RR). The RR stated, the resident was showered today and still waiting on the pad to be put back on her knee for pain control. The resident stated, my shower was around 9:00-10:00 AM this morning. The resident was told she had to wait until after the shower and they would put the pad on. At the time of the interview, no staff had returned with the pad.
On 03/06/24 at 11:00 AM, a review of the physician's order found no order for any type of pain patch.
On 03/06/24 at 11:45 AM, Licensed Practical Nurse (LPN) #64 confirmed the resident's nephew brings the over-the-counter pain patches from home and applies the patches to the resident's knee. LPN #64 also confirmed the nephew visits every Monday, Wednesday and Friday of every week. LPN #64 verified the resident does not have an order for the pain patches from home.
On 03/06/24 at 12:05 PM, the Director of Nursing (DON) stated, we have to have an order for those even if the nephew brings them in from home.
No further information was obtained during the survey process.
d) Resident #7
On 03/04/24 at approximately 11:15 AM during a review of Resident #7 medical administration record, the following medications were identified to have not been administered per the physicians orders on each date listed. There were no nursing notes to identify the reason the medications were not administered.
* Artificial Tears Ophthalmic Solution- 02/20/24
* Artificial Tears Ophtalmic Solution- 02/21/24 (4 doses- 0900, 1300, 1700, 2100)
* Artificial Tears Ophtalmic Solution- 02/22/24 (3 doses- 0900, 1300, 1700, 2100)
* Enhanced Barrier Precaution r/t: wounds- 02/27/24
* Observe resident for side affection of psychotropic medications- 02/27/24
* Artificial Tears Ophthalmic Solution- 02/28/24
* Levothyroxine Sodium Oral Tablet 150 MCG- 02/28/24
* Percocet Oral Tablet 1-325- 02/28/24
During an interview on 03/04/24 at approximately 3:37 PM the Director of Nursing (DON) agreed the medication administration was not completed per the physician orders.
e) Resident #179
On 03/04/24 at approximately 11:00 AM during a medical record review of Resident # 179, it was identified the resident admitted on [DATE] for short term rehab care. A Brief Interview of Mental Status (BIMS) of 15 is identified in the Minimum Data Set (MDS) with Assessment Reference Date (ARD)/Target Date of 02/28/24. Upon review of the residents miscellaneous uploaded medical records, a physician determination of capacity form was not identified to be on file.
During an interview with the DON on 03/04/24 at 2:43 PM, she agreed the facility does not have a capacity form completed and on file for Resident #179.
f) Late Medications
1) Resident #331
On 02/27/24 at 11:10 PM Registered Nurse (RN) #55 asked if she was still working on her evening mediation pass? She stated, Yes I am behind I have the entire South Hallway to myself and residents have been crawling out of bed and everything. I have to help with that. RN # 55 stated, There is usually two (2) nurses on south hallway, but it's just me tonight.
On 02/27/24 at 11:14 PM Resident #331 stated, I need my nasal spray, I want to go to bed. I can't breathe, my nose is plugged up.
On 02/28/24 at 12:08 AM Resident #330 came to the hallway outside his room door and asked RN #55 if he could have his nasal spray so he could go to bed. The RN then said yes roll up here (in wheelchair) and administered nasal spray.
Record review shows the following medications were administered late by Registered Nurse (RN) #55:
Oxymetazoline HCl Nasal Solution 0.05 % (Oxymetazoline HCl) 1 spray in both nostrils in the evening for Rhinitis. Time ordered to be given: 7:00 PM. Time administered: 12:19 AM
Tamsulosin HCl Oral Capsule 0.4 MG (Tamsulosin HCl). Give 1 capsule by mouth at bedtime for urinary retention. Time ordered to be given: 9:00 PM. Time administered: 12:19 AM
Senna Oral Tablet 8.6 MG (Sennosides) Give 1 tablet by mouth at bedtime for constipation. Time ordered to be given: 9:00 PM. Time administered: 12:19 AM
Isosorbide Dinitrate Oral Tablet 10 MG (Isosorbide Dinitrate). Give 1 tablet by mouth three times a day for hypertension. Time ordered to be given: 9:00 PM. Time administered: 12:19 AM
Methocarbamol Oral Tablet 500 MG (Methocarbamol). Give 0.5 tablet by mouth three times a day for muscle spasms. Time ordered to be given: 9:00 PM. Time administered: 12:19 AM
Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol Tartrate). Give 1 tablet by mouth two times a day for HTN. Time ordered to be given: 9:00 PM. Time administered: 12:19 AM
Melatonin Oral Tablet 3 MG (Melatonin). Give 3 tablet by mouth at bedtime for insomnia. Time ordered to be given: 9:00 PM. Time administered: 12:19 AM
Atorvastatin Calcium Oral Tablet 40 MG (Atorvastatin Calcium). Give 1 tablet by mouth at bedtime for HLD. Time ordered to be given: 9:00 PM. Time administered: 12:19 AM
2) Resident #64
On 02/27/24 at 11:13 PM Resident #64, stated he had not had his nighttime meds, no pain medication since 1:00 PM that day. He had not seen a nurse for night shift. Resident further stated he would like to have his meds so he could go to bed.
Record review shows the following medications were administered late by Registered Nurse (RN) #55:
MagOx 400 Oral Tablet (Magnesium Oxide Supplement). Give 1 tablet by mouth two times a day for supplement administer with 8 oz of water. Time ordered to be given: 9:00 PM. Time administered: 12:22 AM.
Methocarbamol Oral Tablet 500 MG (Methocarbamol). Give 1 tablet by mouth three times a day for muscle relaxer. Time ordered to be given: 9:00 PM. Time administered: 12:22 AM.
Aspirin Oral Tablet (Aspirin). Give 81 mg by mouth two times a day for supplement. Time ordered to be given: 9:00 PM. Time administered: 12:22 AM.
Atorvastatin Calcium Oral Tablet 80 MG (Atorvastatin Calcium). Give 1 tablet by mouth at bedtime for high cholesterol. Time ordered to be given: 9:00 PM. Time administered: 12:22 AM.
Melatonin Oral Tablet (Melatonin). Give 6 mg by mouth at bedtime for supplement. Time ordered to be given: 9:00 PM. Time administered: 12:22 AM.
Mirtazapine Oral Tablet 7.5 MG (Mirtazapine). Give 1 tablet by mouth at bedtime for depression. Time ordered to be given: 9:00 PM. Time administered: 12:22 AM.
Gabapentin Oral Capsule 400 MG (Gabapentin). Give 1 capsule by mouth two times a day for pain. Time ordered to be given: 9:00 PM. Time administered: 12:22 AM.
Oxycodone HCl Oral Tablet 10 MG (Oxycodone HCl). Give 1 tablet by mouth every 8 hours for pain. Time ordered to be given: 10:00 PM. Time administered: 12:22 AM.
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, record review, staff and resident interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Med...
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Based on observation, record review, staff and resident interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Medications were left in Resident #64's room unsupervised. Resident #236 and #72 were unknowingly smoking without supervision in an outside non-smoking recreation area. These failed practices were a random opportunity for discovery. Resident identifiers: #64, #236, and #72. Facility census: 82.
Findings include:
a) Resident #64
On 02/28/24 at 12:25 AM, Registered Nurse (RN) #55 was observed taking Resident #64's medications into his room. Surveyor entered the room at after RN #55 exited and found the Resident going through the pills which were left in the room. The Resident stated that they do it all the time, leave the pills for him to take when he wants. At 12:30 PM RN #55 was called back into the room and asked if the Resident had an order to self administer the mediations and she stated no I thought he took them. RN #55 then said to the Resident, Well can you take them now so I don't get into more trouble.
During an interview on 02/28/24 at 10:01 AM the Assistant Director Nursing (ADON) stated, Yea I heard about the meds being left in [Resident #64's name] room, they know better than that. I guess I'll educate some more.
b) Resident #236 and Resident #7
During an observation on 02/26/24 at 6:24 PM, three state surveyors were exiting the facility, two residents; Resident #236 and Resident #72 were observed sitting outside on the porch area. One surveyor thought she observed the residents passing a cigarette. The three surveyors continued to observe the residents from the parking lot.
On 02/26/24 at 6:25 PM, The Director of Nursing (DON) and the Maintenance Director (MD) #32 appeared on the porch to approach Residents #236 and Resident #72. The three (3) surveyors approached the porch. The MD #32 stated he was informed by another staff member the residents were smoking, I went and got the DON. The MD #32 stated I got the pack of cigarettes from them. It had two cigarettes left in it. The DON asked the resident if they knew the facility was a smoke free facility. Resident #7 stated someone told us we could smoke outside on the patio. Resident #236 stated I will not tell you who it is so I don't get her in trouble. I went home today and got some stuff and I brought the pack of cigarettes and the lighter back . When the DON questioned Resident #236, pulled the lighter out of his sweat pants pocket and gave it to the DON.
The DON was asked Were either Residents offered a Nicotine Patch?
The DON stated We did not know they smoked, or they would have been offered?
During an interview on 02/27/24 at 2:00 PM, Resident #236 stated, I went out yesterday and got some shoes and shirts. We went to the bank. I got all my money out and paid my rent.
During an interview on 02/27/24 at 2:35 PM, the DON stated we completed smoking evaluation for the residents. They both knew we were a non smoking facility.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected multiple residents
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Based on resident interview, record review and staff interview, the facility failed to provide dialysis care and services in accordance with professional standards of practice. Resident #40 was erro...
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Based on resident interview, record review and staff interview, the facility failed to provide dialysis care and services in accordance with professional standards of practice. Resident #40 was erroneously monitored for a thrill and bruit. This deficient practice had the potential to affect one (1) of one (1) resident reviewed for dialysis. Resident identifier: #40. Facility census: 82.
Findings include:
a) Resident #40
During an interview on 03/05/24 at 12:21 PM, Resident #40 stated she received dialysis through a Permacath access in her right chest. The resident stated she did not have a fistula dialysis access.
Review of Resident #40's physician's orders showed an order written on 02/01/24 to Auscultate bruit and palpate thrill every shift.
A dialysis fistula is an access made by joining an artery and vein in the arm. To make sure the fistula is working, a bruit, or whooshing sound, is auscultated with a stethoscope and a thrill, or buzzing, is palpated with the fingers.
Review of Resident #40's Medication Administration Records (MARs) for February 2024 and March 2024 showed the nurses had signed off as auscultating for bruit and palpating for a thrill every shift.
On 03/05/24 at 1:40 PM, the Assistant Director of Nursing (ADON) confirmed Resident #40 did not have a fistula access for dialysis. The ADON confirmed that, therefore, a bruit could not be auscultated and a thrill could not be palpated.
No further information was provided through the completion of the survey process.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, record review, and staff interview, the facility failed to ensure medications were stored and labeled in...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, record review, and staff interview, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles. A syringe of injectable medication had been in use for longer than manufacturer's recommendations. This was a random opportunity for discovery. Resident identifier: #61. Facility census: 82.
Findings include:
a) Medication Cart - North 2
On [DATE] at 9:11 AM, the North 2 medication cart was inspected with Licensed Practical Nurse (LPN) #44 in attendance.
A pen-injector for Resident #61 containing Tymlos (Abaloparatide) was in the cart. This medication is given subcutaneously for osteoporosis. A date written on the pen-injector indicated the medication had been opened on [DATE]. LPN #44 stated she did not know how long Tymlos could be used after the syringe had been opened. There was no product insert with the pen-injector.
The Tymlos medication guide available on-line at www.tymlos.com stated, Throw away the Tymlos pen after 30 days even if some medicine is left in the pen.
On [DATE] at 9:45 AM, LPN #44 was told the Tymlos pen-injector had expired 30 days after being opened. She stated she would throw it away.
No further information was provided through the completion of the 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
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
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Based on observation, resident interview and staff interview the facility failed to ensure food was served at a safe and palatable temperature. The failed practice had the potential to affect all re...
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Based on observation, resident interview and staff interview the facility failed to ensure food was served at a safe and palatable temperature. The failed practice had the potential to affect all residents currently receiving nutrition from the facility's kitchen. Resident Identifiers: #61. Facility Census: 82.
Findings Include:
a) Resident #61
During an interview on 02/26/24 at 3:33 PM, Resident #61 states my food is often cold. The other day the Salisbury steak was so cold. I sent it back and got tomato soup.
b) Noon Meal Temperatures
During a dining observation on 03/05/24 at 12:25 PM, the noon meal trays arrived in the North 1 hall. This surveyor asked the Dietary Aide to ask the Dietary Manager (DM) to bring a noon meal tray for the resident and the facility thermometer.
At the time of point of service (when the trays are being served to the residents) the temperatures were obtained by the DM using the facility ' s thermometer at 12:34 PM the temperatures were as follows:
-Meatballs: 128 degrees Fahrenheit
-Vegetables: 117 degrees Fahrenheit
-White Rice: 127 degrees Fahrenheit
During an immediate interview the DM stated the meal should be 135 degrees and above at the point of service. The DM acknowledged the meal was not at a palatable serving temperature. All facility noon meal trays were served by the end of obtaining the temperatures.
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 store food in accordance with professional standards for food safety. The facility failed to label and date food items ...
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Based on observation, policy review and staff interview the facility failed to store food in accordance with professional standards for food safety. The facility failed to label and date food items that were open and failed to dispose of expired food items. The facility failed to keep the equipment clean and sanitary. The facility also failed to accurately document resident refrigerator temperature logs. The facility also failed to not store other food in the resident's refrigerator. This failed practice had the potential to affect all residents currently receiving nourishment from the facility's kitchen and the Resident's refrigerator. Facility Census: 82
FIndings Include:
a) Policy Review
During a review of the facility policy titled Labeling and Dating with no date read as follows:
Guidelines for Labeling and Dating:
-All foods should be dated upon receipt before being stored.
-Food labels must include:
The food item name
The date of preparation/receipt/removal from freezer
The use by date as outlined in the attached guidelines
Leftovers must be labeled and dated with the date they are prepared and the use by date.
a) Opened food
A tour of the kitchen on 02/27/24 at 11:39 AM, revealed the following issues:
-Grill spray no cap no open date or use by date
-Cornstarch opened and exposed to the elements.
-Baking soda opened and exposed to the elements.
-Rotisserie Chicken Seasoning lid was open and exposed to the elements.
-Garlic Powder lid was open and exposed to the elements.
-Chili Powder lid was open and exposed to the elements.
-Ground Allspice lid was open and exposed to the elements
The Dietary Manager (DM)acknowledged the failure to close the lids after use and failure to label food items with a Date Opened and/or Use by Date. Also indicated the item needed to be discarded because they were opened and not dated.
b) Unsanitary equipment
During a tour of the kitchen on 02/27/24 at 11:39 AM, an employee's personal cell phone was laying on the serving/prep table.
During an immediate interview the DM acknowledged the unsanitary equipment. The DM stated they know better.
c) South Nourishment Rooms
During a tour of the South Nourishment on 02/27/24 at 11:57 AM, with DM revealed the following issues:
-A storage bag with a bagel dated 11/15
-A opened bottle of grape juice with open date of 11/15
-A opened bottle of apple juice with open date of 11/15
-A opened container of Greek yogurt with no open date
-two containers of rice pudding with a manufacture expiration date of 02/01/24
-a container of Greek yogurt with a manufacture expiration date of 02/23/24
-a opened vegetable tray with no open date
-a opened container of buffalo dip with no open date
d) North Nourishment Room:
During a tour of the North Nourishment on 02/27/24 at 11:59 AM, with DM revealed the following issues:
-A storage bag with a bagel and roll dated 02/13
e) South Nourishment Room temperatures
During a observation of the South Nourishment Room on 03/03/24 at 11:22 PM, revealed the following:
The temperature log for the following days were void the temperatures:
-03/02/24 AM Refrigerator
-03/03/24 AM Refrigerator
-03/03/24 AM Freezer
On 03/03/24 at 12:15 PM The Administrator acknowledged the temperature logs were incomplete.
f) North Nourishment Room temperatures
During an observation on 03/04/24 at 11:26 PM, the temperature log were void the following dates:
-03/02/24 AM Refrigerator
-03/02/24 AM Freezer
On 03/03/24 at 12:15 PM, The Administrator acknowledged the temperature logs were incomplete
g) South Nourishment Room Refrigerator
During an observation of the South Nourishment Room on 03/03/24 at 11:22 PM, there was a black lunch box in the refrigerator. Nurse Aide (NA)#9 acknowledged it was her personal lunch box and should not have been with the residents' food.
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 observation, record review and staff interview, the facility failed to maintain an accurate and complete medical reco...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, record review and staff interview, the facility failed to maintain an accurate and complete medical record for Resident #58's oral assessment, did not obtain a physician's order for the gastrostomy (G-tube) flushes and a diagnosis for the urinary foley catheter for Resident #179, Resident #10's incomplete consent for psychoactive medication, Resident #236's the Physician's Orders for Scope of Treatment (POST) form, documentation of snacks that were not delivered for Resident #32, #57, and #7, a diagnosis of neuropathy for Resident #7, and correct dosage on the physician's orders for medication and documentation for medication side effects for Resident #47. This is true for eight (8) of 24 residents reviewed during the survey process. Resident Identifiers: #58, #179, #10, #236, #32, #57, #7 and #47. Facility Census: 82.
Findings Included:
a) Resident #58
On 03/04/24 at 9:00 AM, a record review was completed for Resident #58. The review found an oral assessment dated [DATE] was incorrect. The oral assessment noted the resident was edentulous (lacking teeth) and had decayed or broken teeth/roots or very worn down teeth. The resident was observed on 02/26/24 at 5:08 PM with fragments of teeth.
On 03/04/24 at 2:36 PM, the Director of Nursing (DON) was notified of the oral assessment being incorrect. The DON stated, it can't be both.
No further information was obtained during the survey process.
b) Resident #179
On 03/04/24 at 10:30 AM, a record review was completed for Resident #179. The record review found the resident had a urinary foley catheter with no diagnosis and no current order for the gastomy (G-tube) tube flushes.
On 03/04/24 at 11:15 AM, Assistant Director of Nursing (ADON) #42 was notified and confirmed there is no diagnosis for the urinary foley catheter and no current physician's order for the G-tube flushes. ADON #42 stated, we will get this corrected.
No further information was obtained during the survey process.
c) Resident #10
On 03/05/24 at 9:00 AM, a record review was completed for Resident #10. The record review found the following medications did not have the correct dosage:
--Aspirin give one tablet by mouth daily for hypertension.
--Guaifensin oral tablet give 600 mcg (micrograms) by mouth every 12 hours as needed for cough, congestion
The physician's order for Aspirin does not list a dosage. The order for Guaifensin is for micrograms (mcg) instead of milligrams (mg).
On 03/05/24 at 9:42 AM, ADON #42 was notified and confirmed the physician's orders were not correct.
No further information was obtained during the survey process.
d) Resident #236
During a record review on 02/27/24 at 11:26 AM, Resident #236's medical record revealed a Physician Orders for Scope of Treatment (POST) form showed the Patient Information section was void Resident #236's last four(4) Social Security Number (SSN). Section E. Titled: Signature: was void of a date Resident #236 signed. Page two (2) of the POST section titled Professional Assisting Health Care Provider with Form Completion was void of any documentation
The 2021 POST form guidance titled, Using the POST Form: Guidance for Health Care Professionals, 2021 edition, available on-line, stated The Center wants to avoid a patient's POST form being confused with another ' s because there was not sufficient information about the patient to distinguish one from another. The demographic information requested on the POST form includes the patient's full name, address, date of birth , gender, and last four digits of the patient's social security number. 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 03/04/24 at 11:56 AM, the Assistant Director of Nursing #42 acknowledged Resident #236 POST was the void of the SSN and was void a person completing the POST form.
e) Resident #32
During a tour of the facility on 02/27/24 at 11:45 PM, HS (at bedtime) snacks were observed laying on a cart by the South Nourishment Room. A fruit cup and a package of graham crackers dated 02/27/24 with Resident #32's name.
During an observation on 02/27/24 at 11:59 PM, two surveyors witnessed NA #31 throwing the snacks in the trash can.
On 02/28/24 at 1:13 PM, this surveyor received a facility document titled Snack Summary for the Week of 02/26/24 which read as follows:
Resident #32 name: fruit cup 0.5 Cup at HS
graham crackers 1 package at HS
During a record review on 03/05/24 at 4:30 PM, Resident #32 medical records revealed a Nutrition Snack at HS task 02/27/24 was documented coded 4 (four) 76%-100% at 10:59 PM.
During an interview on 03/05/24 at 5:11 PM, the Assistant Director of Nursing (ADON) was informed of the above information. The ADON acknowledged the documentation for the snacks stated Resident #32 received and ate 76-100% of the HS snack. However, this was not possible since the CNA had placed the snacks in the trash can on 02/27/24.
f) Resident #57
During a tour of the facility on 02/27/24 at 11:45 PM, HS snacks were observed laying on a cart by the South Nourishment Room. A creamy peanut butter and jelly sandwich dated 02/27/24 with Resident #57's name was on the cart.
During an observation on 02/27/24 at 11:59 PM, two surveyors witnessed NA #31 throwing the snacks in the trash can.
On 02/28/24 at 1:13 PM, this surveyor received a facility document titled Snack Summary for the Week of 02/26/24 which read as follows
(Resident #57 name) creamy peanut butter and jelly sandwich 0.5 Sandwich HS
During a record review on 03/05/24 at 4:40 PM, Resident #57 Nutrition Snack at HS 02/27/24 was documented coded 3 for 51%-75% at 10:59 PM
During an interview on 03/05/24 at 5:11 PM, the Assistant Director of Nursing (ADON) was informed of the above information. The ADON acknowledged the documentation for the snacks stated Resident #57 received and ate 51%-75% of the HS snack. However, this snack was placed in the trash by a CNA on 02/27/24.
g1)Resident #7
During a tour of the facility on 02/27/24 at 11:45 PM, HS snacks were observed laying on a cart by the South Nourishment Room. A cup of pudding dated 02/27/24 HS with Resident #7's name on it.
An observation on 02/27/24 at 11:59 PM, two surveyor witnessed NA #31 throwing the snacks in the trash can.
On 02/28/24 at 1:13 PM, this surveyor received a facility document titled Snack Summary for the Week of 02/26/24 which read as follows:
Resident #7's name:assorted pudding 0.5 cup HS
A record review on 03/05/24 at 4:30 PM, Resident #7 medical records revealed a Nutrition Snack at HS task 02/27/24 was documented coded 4 (four) 76%-100% at 10:59 PM. However, this snack was placed in the trash on te night of 02/27/24.
Further record review revealed a physician order dated 08/04/23 planned snack at 8 PM sent per dietary at bedtime
During an interview on 03/05/24 at 5:11 PM, the Assistant Director of Nursing (ADON) was informed of the above information. The ADON acknowledged the documentation for the snacks stated Resident #32 received and ate 76-100% of the HS snack.
g2) Resident #7
On 03/04/24 at approximately 11:00 AM, a medical record review of Resident # 7's physician orders identified Gabapentin Oral Tablet 600 MG (Gabapentin) Give 2 tablet by mouth every 8 hours for neuropathy. A review of the physician diagnosis did not identify a neuropathy diagnosis. Upon review of the medical records uploaded in Resident #7s medical record from the admitting hospital the diagnosis was identified.
During an interview on 03/04/24 at approximately 3:34 PM, the Director of Nursing (DON) agreed the facility physician diagnosis in the medical record is inaccurate because the diagnosis of neuropathy was not included.
h) Resident #47
Review of Resident #47's medical records showed the following order written on 09/24/22, Observe resident for side effects of psychotropic medication. (Antidepressants, Antipsychotics, Hypnotics, and Anxiolytics) every shift for observation of side effects Side Effects- Psychoactive Meds: Indicate letter if observed: A=Sedation; B= Drowsiness; C= Dry Mouth; D= Blurred Vision; E= EPS [extrapyramidal effects] F= Sweating; G= decreased appetite, H=Nausea, I= Jaw clenching, J= Headache, K= itching, N/A= not applicable.
Review of Resident #47's Medication Administration Records (MARs) for February 2024 and March 2024 showed most documentation for this order was n or 0. However, on day shift 02/14/24 and day shift 03/04/23, a y was recorded. The MAR chart codes did not contain any information regarding n, 0, or y.
Resident #47's progress notes contained no information regarding the resident having side effects from psychotropic medication on 02/14/24 or 03/04/24.
During an interview on 03/05/24 at 9:25 AM, the Director of Nursing (DON) stated an n means no and a y means yes. She stated she did not believe the resident was experiencing side-effects on 02/14/24 or 03/04/24 and that a y had been documented in error.
No further information was provided through the completion of the survey.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to establish and maintain an infection prevention a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections while serving a sandwich to Resident #25. The facility did not complete hand hygiene while administering wound care for Resident #7. Surveyors observing a soiled glove in Resident #235's room. The facility staff did not follow enhanced-barrier precautions for Resident #23. The nursing staff administered nasal spray to Resident #330 without donning gloves and placed a dirty dining tray on a clean dining cart. These were random opportunities for discovery that had the potential to affect more than an isolated number of residents. Resident identifiers: #25, #7, #235, #23 and #330.
Findings included:
a) Resident #25
On 03/03/24 at 11:58 PM, Nurse Aide (NA) #57 was observed serving Resident #25 a sandwich and milk. However, NA #57 did not don gloves prior to removing the sandwich from the plastic wrap.
The sandwich was served to Resident #25 with bare hands.
On 03/04/24 at 12:02 AM, Licensed Practical Nurse (LPN) #126 was notified. LPN #126 stated let me get her a new one. LPN #126 removed the contaminated sandwich and provided a new sandwich for Resident #25.
b) Resident #7
On 03/06/24 at 1:10 PM, LPN #64 was observed providing wound care for Resident #7. Throughout the process, LPN #64 had multiple instances when hand hygiene should have been completed and was not.
On 03/06/24 at 1:20 PM, LPN #64 was made aware of the missed opportunities to complete hand hygiene. LPN #64 stated, oh okay.
On 03/06/24 at 1:30 PM, Corporate Nurse #97 was notified and confirmed hand hygiene should have been completed throughout the wound care.
c) Resident #235
On 03/05/24 at 4:13 PM during a tour of the facility in the room of Resident #235, a surgical glove was observed to appear soiled and had been turned inside out as it laid balled up on the floor.
During an interview on 03/05/24 at 4:13 PM with Certified Nursing Assistant (CNA) #49, she stated she didn't know who had disposed of the glove in the floor but acknowledged it should not be there. She then picked up the glove and disposed of it.
d) Resident # 23
On 02/27/24 at 9:38 AM CNA #49 and CNA #15 entered Resident #23's room to provide incontinent care without donning Personal Protective Equipment (PPE). The sign on the resident's door stated, Enhanced Barrier Precautions. Registered Nurse (RN) #67 then entered the room to administer medications and did not put on any PPE. RN #67 applied a lidocaine patch to residents' right ankle. At 9:40 AM the Director of Nursing (DON) approached the room door. The DON was asked to verify the staff was not wearing any of the indicated PPE while providing direct care to the resident. The DON looked at the sign on door and stated, Oh I see that, they should have it on. Yes. Especially since they are touching her.
Record review showed an order for Enhanced Barrier Precautions related to: wounds/MRSA every shift for wounds. Start date 12/06/23.
Record review showed an order for Lidocaine External Patch 5 % (Lidocaine). Apply to Right Ankle topically one time a day for Pain. Start date 11/16/23.
e) Resident #330
On 02/27/24 at 11:13 PM Resident #330 stated, I need my nasal spray, I want to go to bed. I can't breathe, my nose is plugged up.
On 02/27/24 at 12:08 AM, Resident #330 came out into the hallway in his wheelchair outside of his room door. Resident #330 asked Registered Nurse (RN) #55 if he could have his nasal spray so he could go to bed. RN #55 replied, Yes roll up here (in wheelchair) and I will give it to you. RN #55 then administered nasal spray to Resident #55 without putting gloves on. RN #55 then set the nasal spray back on top of the cart, opened the medication cart door, and randomly dropped back into the drawer. RN #55 opened the door to resident room [ROOM NUMBER] and used hand sanitizer from the wall in the room and returned to the medication cart.
Record review shows an order for Saline Nasal Solution 0.9 % (Saline). 1 spray resident in each nostril every 6 hours as needed for Dry Nose.
During an interview the Assistant Director of Nursing stated RN #55 should have worn gloves during administration of nasal spray. The ADON further stated the nasal spray should have been wiped down before putting it back directly back into the cart.
f) Noon Meal tray
During a dining observation on 03/05/24 at 12:09 PM, LPN #30 was observed removing a tray from a resident's room and placing it on the noon meal cart with several trays which were not yet served and was clean.
During an immediate interview LPN #30 stated this is (Resident #241's name) tray she is a feeder, and we will have to wait. I did not put the tray in her room.
LPN #30 acknowledged she should not have brought the tray from the room and placed it on the cart with the trays not served/clean trays. She stated I will take the whole cart back to the kitchen to get new ones made.
During an immediate interview The Nurse Aide (NA) #14 stated the noon trays which were on the meal cart were for the residents residing in rooms 142-146.
On 03/05/24 at 12:14 PM The Infection Prevention (IP)/Assist Director of Nursing (ADON) was made aware of the issue.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected multiple residents
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The facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a centralized staff work area from the ...
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The facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a centralized staff work area from the resident's bedside. Resident call light location was not identifiable on the call light annunciator panel. This was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifier: #237. Census: 82.
Findings included:
a) Resident #237
During a tour of the facility, on 03/03/24 at 11:30 PM, the call light system was sounding with no light indicator for what room or location was lit on the North or South Unit annunciator panels.
On 03/03/24 at 11:40 PM the call light system continued to sound and the Certified Nursing Assistance (CNA) #11 stated, the light indicator on the annunciator panel sometimes doesn't work for the bathroom call lights. CNA #11 then notified all staff who began to check all call lights throughout the facility on 03/03/24 at approximately 11:43 PM.
During an interview with the Administrator, at 11:48 PM, on 03/03/24, the Administrator stated she was aware of the issue and was assisting with rounding to identify where the call light had been activated. At 11:59 PM on 03/03/24 the Administrator stated as she passed this surveyor in the hallway, that she would be calling the tech out for the panel.
During the observation of staff attempting to locate the activated call light on 03/04/24 at 12:04 AM the Corporate Registered Nurse #97 stepped out into the hallway on the South Unit. She stated to everyone that she had discovered the room that the call light was activated in, and she thought she had fixed it. She identified Resident #237 to have partially pulled the call light cord from the wall. The Corporate Registered Nurse then expressed her need for the staff to assist her with the resident right now.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0680
(Tag F0680)
Could have caused harm · This affected most or all residents
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Based on observation and staff interviews the facility failed to ensure the activities program is directed by a qualified professional. This had a potential to affect all residents residing in the f...
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Based on observation and staff interviews the facility failed to ensure the activities program is directed by a qualified professional. This had a potential to affect all residents residing in the facility. Facility Census: 82.
Findings Include:
a) Qualified Activity Professional
During an observation on 02/26/24 at 12:35 PM, the activity office was void of any documentation of a certification of an activity professional.
During an interview on 02/26/24 at 12:35 PM, the Activity Director(AD) was asked to see her activity certification. The AD stated I do not have a certificate, I will start the class in March. The Occupational Therapist reviews my stuff. I was thrown into this position when the other person was let go.
During an interview on 02/27/24 at 2:44 PM, the Director of Nursing (DON) stated the Occupational Therapist stated she has not been working with the activity department for a few months. The DON acknowledged there is no certified Activity Professional.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected most or all residents
Based on observation, record review, resident interview, and staff interview, the facility failed to ensure nursing staff possessed the competencies and skill sets necessary to provide nursing and rel...
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Based on observation, record review, resident interview, and staff interview, the facility failed to ensure nursing staff possessed the competencies and skill sets necessary to provide nursing and related services. This deficient practice had the potential to affect all residents residing in the facility. Facility census: 82.
Findings included:
#600
#610
all findings for #697
#684 late med pass
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0847
(Tag F0847)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review and staff interview the facility failed to ensure, the binding arbitration agreement ...
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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 ensure, the binding arbitration agreement was explained to each resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands. This failed practice has the potential to affect more than a limited number of residents. Resident Identifiers: #72, #8, and #500. Facility Census: 82.
Findings Include:
a) Resident #72
On 03/06/24 at 11:39 AM during an interview with Resident #72, the resident stated he knew the facility Alternative Dispute Resolution Agreement had to do with a dispute between him and this facility and there would be someone else to fix it. He stated he knew he didn't have to sign it but was not aware of being able to revoke it. Resident #72 has a Brief Interview for Mental Status (BIMS) of 15 on the Minimum Data Set (MDS) dated [DATE]. Resident #72's physician determined he has capacity to make medical decisions.
b) Resident # 8
On 03/06/24 at 11:46 AM during an interview Resident #8, the resident stated she doesn't remember it , she was pretty out of it. In reviewing the facility Alternative Dispute Resolution Agreement document she stated it now sounds familiar and she has no complaints with it. She further stated she was fine with it and had no issues. She did not recall anything about being able to revoke it. Resident #8 admitted to the facility on [DATE] and has a Brief Interview for Mental Status (BIMS) of 15 on the Minimum Data Set (MDS) dated [DATE]. Resident #8's physician determined she had capacity to make medical decisions.
c) Resident #500
On 03/06/24 at 12:10 PM during an interview with Resident #500, the resident stated she was not aware if she had been explained the facility Alternative Dispute Resolution Agreement. She reviewed the facility Alternative Dispute Resolution Agreement document and stated she had received it when she admitted . She further stated, it was not explained in detail at the time of her admission to the facility. Resident #500 admitted to the facility on [DATE] and has a Brief Interview for Mental Status (BIMS) of 15 on the Minimum Data Set (MDS) dated [DATE]. Resident #500's physician determined she has capacity to make medical decisions.
d) Admissions #33 interview.
On 03/06/24 at 11:58 AM during an interview with the Admissions Director #33 she stated when she reviews the facility Alternative Dispute Resolution Agreement document she lets the resident know if they have a concern to let the facility staff know first so they can fix it. She then explains to them this gives up their rights to a trial by jury and it is handled outside the courts. She then presents the facility Alternative Dispute Resolution Agreement document to the resident and if they choose to sign she shows them where to sign. She stated, she doesn't review the entire document but she does provide them a copy. She further stated, she does not discuss all the necessary components of the facility Alternative Dispute Resolution Agreement document to the residents.
Jun 2023
1 deficiency
MINOR
(C)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on observation and staff interview, the facility failed to ensure the staff posting included the total number of licensed and unlicensed nursing staff directly responsible for resident care per ...
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Based on observation and staff interview, the facility failed to ensure the staff posting included the total number of licensed and unlicensed nursing staff directly responsible for resident care per shift. This had the potential to affect all residents who might wish to review the daily staffing. Facility census: 72.
Findings included:
a) Staff posting
Observation of the staff posting for 06/07/23 at 8:45 AM, found the number of licensed nursing staff and nurse aides working for the day shift was not posted.
At 9:00 AM on 06/07/23, the staff posting was reviewed with the Director of Nursing (DON.) The DON said she would correct the posting.
Jul 2022
30 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
Could have caused harm · This affected 1 resident
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Based on observation, medical record review, resident interview and staff interview the facility failed to ensure Resident #71 was provided care in a manner which preserved her dignity. Resident #71...
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Based on observation, medical record review, resident interview and staff interview the facility failed to ensure Resident #71 was provided care in a manner which preserved her dignity. Resident #71 was wearing an adult disposable brief with adhesive tabs instead of a panty line which was her preference. This was an random opportunity of discovery. Resident Identifier: #71 Facility Census: 74
Findings included:
a) Resident #71
During the Resident Council meeting held on 07/19/22 at 2:33 PM Resident #71 stated staff informed the Residents the facility was unable to get panty liner pads, I have to use paper towels for my panty liner or wear a diaper.
An observation of the central supply room on 07/19/22 at 3:40 PM with Medical Record Staff (MRS) #38, This surveyor along with another survey found six (6) packages of 30 count Restore panty liner pads on the central supply shelving unit.
An observation on 07/19/22 at 3:56 PM this surveyor along with another survey observed several adult disposable brief with adhesive tabs laying on residents #71's bed .
An observation on 07/20/22 at 8:00 AM found Resident #71 was wearing an adult disposable brief with adhesive tabs.
On 7/20/22 at 12:10 PM during an interview with MRS #38 they stated there are only two other Residents that use panty liners. MRS #38 stated they don't go by what insurance they have if they need them they can have them. The Nurse Aides said that Resident #71 had been wetting more lately and they may have changed her to briefs. We just don't want the aides to double pad on the residents.
A review of the Resident #71's care plan with an initiated date of 08/10/17 and revision date of 12/26/17 with a focus that reads I am unable to control my bladder at times related to my impaired mobility.
Resident's # 71's Care plan interventions with a initiated date of 08/10/17 and revision date of 02/03/22 that reads assist with incontinence care frequently and as needed. I use Incontinence products: panty liner. Observe for skin breakdown.
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 F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
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Based on observation, medical record review, resident interview and staff interview, the facility failed to promote and facilitate resident self-determination through support of resident choice in r...
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Based on observation, medical record review, resident interview and staff interview, the facility failed to promote and facilitate resident self-determination through support of resident choice in regard to having access and choosing their undergarment preference and the right to choose when and how often to shower. Residents' identifier: Resident #3, and #71. Facility Census: 74.
a) Resident #3
During an interview with Resident #3 on 07/18/22 at 11:44 AM, Resident #3 stated he normally (before coming here) would shower daily. Since being here at the facility it has been three (3) to four (4) days before can get showers.
A review of Resident #3 medical records in regards to shower documentation found, his shower days are scheduled for Mondays and Thursdays. A 30 day look back of the shower documentation revealed Resident #3 was actually documented as to having a total of seven (7) showers, on the following dates: 06/22/22, 07/07/22, 07/08/22, 07/09/22, 07/10/22, 07/14/22, and 07/18/22.
During an interview with Corporate Nurse #91 was informed of the above findings and asked if there was any other documentation about residents receiving showers. CN #91 stated no.
b) Resident #71
During the Resident Council meeting held on 07/19/22 at 2:33 PM Resident #71 stated staff informed the Residents the facility was unable to get panty liner pads. She stated, I have to use paper towels for my panty liner or wear a diaper.
During an observation of the central supply room on 07/19/22 at 3:40 PM with Medical Record Staff (MRS) #38, This surveyor along with another survey found six (6) packages of 30 count Restore panty liner pads on the central supply shelving unit.
During an observation on 07/19/22 at 3:56 PM this surveyor along with another survey observed several adult disposable brief with adhesive tabs laying on residents #71's bed .
An observation on 07/20/22 at 8:00 AM revealed Resident #71 was wearing an adult disposable brief with adhesive tabs.
On 7/20/22 at 12:10 PM during an interview with MRS #38 they stated there are only two other Residents that use panty liners. MRS #38 stated they don't go by what insurance they have if they need them they can have them. The Nurse Aides said that Resident #71 had been wetting more lately and they may have changed her to briefs. We just don't want the aides to double pad on the residents.
A review of Resident #71's care plan with an initiated date of 08/10/17 and revision date of 12/26/17 with a focus that reads I am unable to control my bladder at times related to my impaired mobility.
Resident #71's Care plan interventions with a initiated date of 08/10/17 and revision date of 02/03/22 that reads assist with incontinence care frequently and as needed. I use Incontinence products: panty liner. Observe for skin breakdown
No further information was provided through the completion of the survey.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview the facility failed to notify a family member of a fall that occurred at the facility. This failed practice had the position to affect a limited number of ...
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Based on record review and staff interview the facility failed to notify a family member of a fall that occurred at the facility. This failed practice had the position to affect a limited number of residents. Resident identifiers: #177. Facility census 74.
Findings included:
a) Resident #177
During a review of medical records, it found Resident #177 had an unwitnessed fall on 04/29/22.
On 04/29/22 it was found the space for who was notified was wrote: self, (Resident #177 lacked capacity at this time).
On 07/21/22 at 9:30 AM, Corporate Nurse #91 was notified of the above and no additional information was provided.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview the facility failed to maintain a sanitary and comfortable environment that includes, but is not limited to, preventing the spread of disease-causing organis...
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Based on observation and staff interview the facility failed to maintain a sanitary and comfortable environment that includes, but is not limited to, preventing the spread of disease-causing organisms by keeping resident care area clean and at a desirable temperature. The curtain in a Resident's room was dirty and the facility temperatures were not within a comfortable and safe temperature range. This had the potential to affect a limited number of residents residing in the facility. Resident Identifier # 34. Facility Census 74
Findings Included:
a) Resident #34
On 07/18/22 at 1:28 PM, during the long term care survey process this surveyor noticed Resident # 34 room curtain was soiled with several brown smudged spots.
A review of Resident #34's care plan focus found the following:
--I occasionally smear and chew my feces.
On 07/19/22 at 9:38 AM, in an interview with the Environmental Service Director (ESD) regarding Resident # 34's curtain and care plan the ESD stated I was unaware of the care plan.
On 07/20/22 at 1:20 PM, Corporate Nurse acknowledged there were no interventions in place to keep Resident #34's curtain clean.
b) Temperature checks
On 07/20/22 at 11:39 PM, Maintenance Director (MD) #21 was asked to check the ambient air temperature in the hallway, after noticing residents with sweaters on, plus it felt cool. The ambient air temperatures were checked at many locations in the hall with a range from 68 to 69 degrees. The thermostat located by the nurses station was about a foot and a half from the ceiling and it read 70 degrees.
On 07/20/22 at 1:00 PM, Corporate Nurse (CN) # 91 stated she instructed MD #21 to increase the temperature.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
p) Call lights
Observation on 07/19/22 at 12:15 PM, it was noted that three (3) call lights on the when arriving to the floor...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
p) Call lights
Observation on 07/19/22 at 12:15 PM, it was noted that three (3) call lights on the when arriving to the floor. room [ROOM NUMBER], 110, and 113. It was also noted three staff members were on the other on the hallway were seen walking past the rooms with the call lights on without stopping at any of the rooms with the call lights going off.
room [ROOM NUMBER] was answered at 12:33 PM, room [ROOM NUMBER] was answered at 12:37 PM, room [ROOM NUMBER]'s call light was not answered until 12:40 PM.
On 07/19/22 at 10:45 PM, call light for room [ROOM NUMBER] was on upon arrival to the facility. There was two nurse aides at the nurses station sitting in chairs at the time. It was noted that Licensed Practical Nurse (LPN) # 22 walked past room [ROOM NUMBER] without stopping at 11:00 PM, and again at 11:10 PM. On 07/19/22 at 11:20 PM, by Infection Preventionist answered the call light for room [ROOM NUMBER], after surveyor intervention. The resident was heard saying he wanted someone to turn off the lights so he could go to sleep.
q) Food complaints
q1) Resident #3
On 07/18/22 at 2:32 PM, Resident's daughter states her father is not happy with the diet and feels like he does not get enough to eat.
On 07/19/22 at 2:32 PM, Resident # 3 did not get his lunch until 2:32 PM today, and it was penne noodles and meatless red sauce. Resident # 3 stated he would be happy to eat a ham sandwich.
When he gets a hot dog, it is only one with a [NAME] on a bun two packets of mustard and catsup, portion sizes are small. Food is not always very warm.
q2) Resident #60
During the first phase of the survey process Resident #60 reported on 07/18/22 at 2:21 PM, that the food is not good, no seasoning, not hot enough, and very small portion sizes.
q3) Resident #56
On 07/18/22 at 12:24 PM, Resident #56 was asked if they were happy with the food. Resident #56 said, the food is awful does not taste good and in not always warm enough.
q4) Resident #44
On 07/18/22 at 12:03 PM, Resident #44 said the food is cold, small portion sizes, taste bad because of no seasoning on it.
q5) Temperatures
Food temperature checked on the south hall on 07/19/22 at 12:57 PM, Kitchen Manager checked the temperature of the food in the Styrofoam box. Baked Ziti 119 degrees, garden salad 62 degrees. Kitchen Manager agreed the Baked Ziti was not hot enough and the salad was too warm.
On 07/19/22 at 2:27 PM, Administrator was informed of the above findings.
Based on review of facility's grievance/concerns, policy review, resident interviews and staff interviews, the staff failed to act promptly to resolve individual complaint/concerns voiced by the residents. Some of which remain problems during the Long Term Care Survey. Resident identifiers: #74, #52, #71, #60, #56, #44, #3 and #26. Facility census: 74.
Findings include:
a) Resident #74
Concern form for Resident #74 dated 01/25/22 read: Takes staff a while to answer call bell. Food is sometimes cold when served. Desires staff to empty Foley catheter bag more frequently. Would like the physician to evaluate pain medication for increased pain control.
Action taken read: Spoke with resident. Notified resident that nursing staff will communicate pain medications evaluation with physician, Nursing staff education regarding call light wait times and emptying catheter bag every shift. Meet with dining service staff to ensure that the meals are being temped and that they are the correct temps. Also spoke with nursing staff to ensure they are passing trays in a timely manner.
b) Resident #52
Concern from Resident Council for Resident #52 dated 01/27/22 read: Activities: Don't like the way bingo prizes are given. Laundry: Not getting our laundry back in a timely manner. Housekeeping: Would like them to check bathroom for supplies to make sure we have enough daily. Dietary: Improve on the food quality. Would like alternate options to choose from.
Action taken was blank
c) Resident #71
Concern form from Resident Council for Resident #71 dated 01/27/22 read: Nursing short staffed and call lights not answered. Activities: Don't like how bingo prizes are given. Laundry: Not getting laundry back; gonna have to go naked. Housekeeping: Toilet paper not restocked in a timely fashion. Dietary: Hot water is not hot enough and vegetables not cooked enough.
Actions taken read: Will take temp of hot water it is 158.2. Asked resident what veggies aren't cooked enough for her. She said she wasn't sure she thinks it's sometimes not all the time. I asked her to let me know and I will get back with her.
d) Resident #12
Concern form for Resident #12 dated 02/15/22 read: Foods such as mashed potatoes don't have much taste. She added garlic and onions to her foods at home. Resident said she's lost weight since being admitted here.
Action taken read: Presented at the 02/24/22 Resident Council meeting.
e) Policy for Grievances/Concern:
Policy review: Grievance/Concern (Version 5) effective date 04/14/2020.
Purpose is to establish a process for responding to a resident or resident representative to resolve grievances a resident may have.
3. The Executive Director will be the designated Grievance Officer.
4. The Grievance Officer is responsible for overseeing the grievance process .
5. Upon identification of a resident or representative concern, complete the grievance/concern form identifying the issue and forward the form to the Grievance Officer.
7. The Grievance Officer will ensure that all written grievance decisions include the date the grievance was received, a summary statement of the grievance, the steps taken to investigate the grievance, a summary of the pertinent findings concern (s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued.
8. The facility will take the appropriate actions in response to a grievance to prevent further potential violations of resident rights during an investigation and report any allegations of neglect, abuse, injuries of unknown source, and/or misappropriation of resident property as indicated.
9. The Grievance Officer forwards the grievance/concern form to the appropriate department head for investigation, follow-up and resolution and tracks the concern on the electronic grievance log.
10. The assigned department head investigates the identified concern timely to identify the root cause of the issue or concern.
11. Once the root cause of the concern is identified, corrective action is taken to resolve the issue for the identified as well as potential systemic changes to reduce risk of recurrence or occurrence for others.
12. The assigned department head contacts the appropriate party (if known). All anonymously reported concerns will have no final notification once resolution has been completed. (No longer than five (5) working days unless nature of concern dictates extension).
13. Once resolved, the grievance/concern form is updated with the resolution of the concern and return to the Grievance Officer.
14. The Grievance Officer reviews outstanding/unresolved concerns during the morning meeting to determine status.
15. The Grievance Officer
or designee may complete a follow up call or meeting with the designated party (if known) to verify that concerns have been addressed.
16. Trends from the electronic grievance log are reported to the Quality Assurance Committee monthly and action as needed.
17. The facility will maintain evidence demonstrating the resolution of complaints and grievances for at least three (3) years.
Acting Nursing Home Administrator (NHA) and the acting Director of Nursing (DON) notified of the following issues that had been voiced in the Resident Council meetings as well as individual complaint/concerns which continues to be issues during the Long=term Care Survey Process (LTCSP) The areas which continue to be issues are call light response, food temperature and unappetizing food, restocking of paper towels and toilet paper and not enough staff to provide care needed (showers and transfers). No further information received.
F) Ongoing issues During the LTCSP
1. Call lights
Observation on 07/19/22 at 12:15 PM, it was noted three (3) call lights were on when the surveyor arrived to the floor. room [ROOM NUMBER], 110, and 113. It was also noted three staff members were on the hallway were seen walking past the rooms with the call lights on without stopping at any of the rooms.
room [ROOM NUMBER] was answered at 12:33 PM, room [ROOM NUMBER] was answered at 12:37 PM, room [ROOM NUMBER]'s call light was not answered until 12:40 PM.
On 07/19/22 at 10:45 PM, call light for room [ROOM NUMBER] was on upon arrival to the facility. There was two nurse aides at the nurses station sitting in chairs at the time. It was noted that Licensed Practical Nurse (LPN) # 22 walked past room [ROOM NUMBER] without stopping at 11:00 PM, and again at 11:10 PM. On 07/19/22 at 11:20 PM, the Infection Preventionist answered the call light for room [ROOM NUMBER], after surveyor intervention. The resident was heard saying he wanted someone to turn off the lights so he could go to sleep.
2. Food complaints
2-1) Resident #3
On 07/18/22 at 2:32 PM, Resident's daughter states her father is not happy with the diet and feels like he does not get enough to eat.
On 07/19/22 at 2:32 PM, Resident # 3 did not get his lunch until 2:32 PM today, and it was penne noodles and meatless red sauce. Resident # 3 stated he would be happy to eat a ham sandwich.
When he gets a hot dog, it is only one with a [NAME] on a bun two packets of mustard and catsup, portion sizes are small. Food is not always very warm.
2-2) Resident #60
During the first phase of the survey process Resident #60 reported on 07/18/22 at 2:21 PM, that the food is not good, no seasoning, not hot enough, and very small portion sizes.
2-3) Resident #56
On 07/18/22 at 12:24 PM, Resident #56 was asked if they were happy with the food. Resident #56 said, the food is awful does not taste good and in not always warm enough.
2-4) Resident #44
On 07/18/22 at 12:03 PM, Resident #44 said the food is cold, small portion sizes, taste bad because of no seasoning on it.
2-5) Temperatures
Food temperature checked on the south hall on 07/19/22 at 12:57 PM, Kitchen Manager checked the temperature of the food in the Styrofoam box. Baked Ziti 119 degrees, garden salad 62 degrees. Kitchen Manager agreed the Baked Ziti was not hot enough and the salad was too warm.
On 07/19/22 at 2:27 PM, Administrator was informed of the above findings.
G) Resident #26
During an interview on 07/18/22 at 11:22 AM, Resident #26 stated that a male Nurse Aide (whose name the Resident wanted to keep confidential) told her to stop using so much toilet paper and to only use one square. The Resident further stated she has complained several times that the housekeeper doesn't take trash out of bathroom after being asked several times or replenish the toiletries in her room (paper towels and toilet paper). The housekeeping staff told the Resident not to use the trash can in the bathroom and throw it in one by the room door instead. Resident #26 further questioned, Tell me how I can only use one square of toilet paper at a time to wipe my butt, that's not enough to even get started?
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on review of concerns/grievance reports, medical record review and staff interview, the facility failed to investigate all allegations of abuse and/or neglect. These were random opportunites of ...
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Based on review of concerns/grievance reports, medical record review and staff interview, the facility failed to investigate all allegations of abuse and/or neglect. These were random opportunites of discovery. This was true for Resident #46 and #81. Resident identifier:s: #46 and #81. Facility census: 74.
Findings included:
a) Resident #46
Review of the Concern/Complaints found a concern form for Resident # 46, dated 06/02/22 and read as follows: Registered Nurse (RN) #93 reports she asked the Nursing Assistant (NA) #51 to assist the resident to bed at 7:30 pm NA #51 reported to the nurse he doesn't usually go to bed this early, and he is a high risk for falls. RN #93 then told the NA #51 the resident's pants are soaking wet. NA #51 reports she will lay him down as soon as possible. Per the RN #93 the NA #51 did not assist resident to bed until 10-10:30 pm.
On 07/20/22 at 10:40 am the acting Director of Nursing (DON) reviewed the concern for Resident #46 dated 06/02/22. She confirmed this allegation should have been reported and investigated as possible neglect and I will do it today.
b) Resident #81
Review of the Concern/Complaints found a concern form for Resident #81, dated 06/01/22 and read as follows: Registered Nurse (RN) #45 is making me feel bullied for being here, for medication I am taking, and other needs are a burden for her to do for me. RN #45 said I was just lurking.
1. I walked up to nurses' station on May 28,2022 and asked for my night meds, and a pain reliever, to help me to sleep better. RN #45 was mean about me not having my contact lenses out for the glaucoma drops to be used. I told her I would come to my room and remove lenses and come back. RN #45 opened the med cart drawer and said, why did you say you were ready for drops I apologized then when asked for pain reliever, I am able to get it every 4 hours as needed. It was time for one and requested with my night meds, RN #45 stated, Boy you like that pain med don't ya. I said mam I am grateful for the meds because it brings the pain down some and I can function better and sleep better. She said, is therapy not helping. I said therapy halted. She said, Insurance probably won't pay. A mean attitude she had the whole time. I then said Mam you have no idea the hell I've been thru.
Today 06/01/22 I requested RN #45 not to be around me anymore. This request was made to the Director of Nursing (DON) and the Social Service Director (SSD).
Action taken to resolve concern: Resident agrees for RN #45 to have 1:1 education. Resident understands (verbalized) nurse could not be moved off her assignment, nor could resident be moved to another unit due to Covid-19 isolation measures. Resident agrees this is okay.
On 07/20/22 at 10:40 am the acting Director of Nursing (DON) reviewed the concern for Resident #81 dated 06/01/22. She confirmed this allegation of possible abuse should have been reported and investigated and she would do it today.
.
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 provide a bed hold notice to the Resident at the time of tra...
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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 a bed hold notice to the Resident at the time of transfer to an acute care facility. This failed practice was true for two (2) out of three (3) discharged residents reviewed during the long term care survey process. Resident identifiers: Resident #177, and #28. Facility census 74.
Findings included:
a) Resident #177
A review of Resident #177's medical record found the resident was discharged to the local hospital on two (2) separate occasions on 07/03/22. Further review of the record found there was no a bed hold policy provided to the resident at the time of the discharge.
On 07/21/22 at 8:25 AM, an interview with the Administrator confirmed no bed hold policy was sent with Resident #177 when they were sent to the hospital on [DATE].
b) Resident #28
Review of Resident #38S medical records found a nurses note written by Employee #54 Licensed Practical Nurse (LPN) on 07/20/22. The note read: Resident requested to go to the local emergency room (ER) She stated she was shaky inside. Vital signs where temperature was 97.8-degree, pulse was 70 beats per minute, respiration was 18, Blood pressure was 130/76, and Oxygen saturation was 91%. Resident was slumped over toward her right side a little in the chair and a little lethargic which is not unusual on dialysis days.
Physician and resident representative notified.
Additional review of the record found a bed hold policy was not sent with the resident at the time of their transfer on 07/20/22.
An interview on 07/21/22 at 08:30 AM with the acting Director of Nursing (DON) confirmed no bed hold policy was sent with the resident when they were discharged on 07/20/22.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview the facility failed to review and revise the care plan when Resident #273's Physici...
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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 review and revise the care plan when Resident #273's Physicians Orders for Scope of Treatment (POST) status changed from Attempt Resuscitation (CPR) to Do Not Attempt Resuscitation (DNR) status. Resident Identifier: #273 Facility Census: 74.
Findings Included:
a) Resident #273
On [DATE] Resident #273's POST form was completed and signed by his daughter and the Physician to reflect a DNR status. The care plan still states the Resident is a full code (CPR).
The above findings were confirmed with Registered Nurse #91 on [DATE] at 2:08 pm.
.
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 properly store a Nebulizer for Resident #26 and Resident #59. These findings were a random opportunity for discovery an...
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.
Based on observation, record review and staff interview the facility failed to properly store a Nebulizer for Resident #26 and Resident #59. These findings were a random opportunity for discovery and had the potential to affect only a limited number of Residents. Resident identifiers: #26, #59. Facility census: 74.
Findings included:
a) Resident #26
On 07/18/22 at 12:00 PM observation was made of Resident #26's Nebulizer mouthpiece (circuit) laying on the bedside table without being stored properly in a bag. The Resident states she had not used it for a couple of weeks and only uses it when she has panic attacks. Registered Nurse (RN) #8 verified 12:01 PM the Nebulizer mouthpiece (circuit) should have been stored in a bag for infection control purposes.
b) Resident #59
During an initial tour on 07/18/22 at 12:04 PM observed Resident #59's Nebulizer mask laying on his bed side table.
During an interview on 07/18/22 at 12:06 PM Registered Nurse (RN) # 8, acknowledged the Nebulizer mask should be have been placed in a storage bag.
A facility policy titled Respiratory Infection Control with an Effective Date of 04/01/12.
.5. Medication Nebulizer's/continuous Aerosol:
v. Store circuit in plastic bag, marked with date and resident's name, between uses.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected 1 resident
.
Based on record review and staff interview, the facility failed to ensure the daily staff posting was accurate and included the actual hours worked for staff directly responsible for the resident's ...
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.
Based on record review and staff interview, the facility failed to ensure the daily staff posting was accurate and included the actual hours worked for staff directly responsible for the resident's care per shift every day. This had the potential to affect all residents residing in the facility. Facility census: 74.
Findings included:
Review of daily staff schedule, assignments and timecards for staff providing direct care and actual patient per day ratio (PPD) for period of two (2) weeks beginning on 07/03/22 through 07/16/22; found on the following dates the facility failed to ensure accurate nurse staff posting:
-- 07/03/22- Staff posting reflected 2.7 PPD although timecard punches showed actual PPD of 2.52.
-- 07/08/22- Staff posting reflected 2.5 PPD although timecard punches showed actual PPD of 2.42.
-- 07/09/22- Staff posting reflected unknown (information blank) PPD although timecard punches showed actual PPD of 2.18.
-- 07/15/22-Staff posting reflect 2.97 PPD although timecard punches showed actual PPD of 2.80.
On 07/21/22 at 9:00am the staff postings and actual PPD according to timecard punches were reviewed with the Interim Administrator and Director of Nursing (DON) for period of 07/03/22 through 07/16/22. They both agreed the information was inaccurate and/or missing for the above-mentioned days. No further information was provided.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
c) Shift count for controlled medications
On 07/19/22 at 8:51 AM, during a review of the medication cart for rooms 135-150, it was found in the Blue Book (the book used to sign out controlled medicati...
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c) Shift count for controlled medications
On 07/19/22 at 8:51 AM, during a review of the medication cart for rooms 135-150, it was found in the Blue Book (the book used to sign out controlled medications and to verify a shift count was correct at the end of the shift.
On the shift count sheet there was missing signatures from both the oncoming nurse and outgoing nurse. These missing signatures were verified by Licensed Practical Nurse (LPN) #53, who said, I do not know why the nurses are not signing it they put posted notes on it all the time.
The missing signatures were as follows:
*06/15/22 no oncoming nurse signature.
*06/15/22 no off going nurse signature.
*06/16/22 no on coming nurse signature,
*06/16/22 no off going nurse signature.
*06/17/22 no on coming nurse signature.
*06/20/22 no off going nurse signature.
*06/22/22 no on coming nurse signature.
*06/27/22 no on coming nurse signature.
*07/01/22 no on coming nurse signature.
*07/02/22 no going off nurse signature.
*07/03/22 no coming on nurse signature.
*07/04/22 no going off nurse signature.
*07/06/22 no coming on nurse signature.
*07/08/22 no coming on nurse signature.
*07/08/22 no off going nurse signature.
*07/12/22 no on coming nurse signature.
*07/14/22 no off going nurse signature.
*07/16/22 no off going nurse signature.
*07/17/22 no on coming nurse signature.
*07/18/22 no off going nurse signature.
On 07/19/22 at 10:28 AM, Interim Administrator was informed of the above findings.
Based on medical record review and staff interview, the facility failed to ensure pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This practice had the potential to affect more than an isolated number of residents. Resident identifiers: #66 and #67. Facility Census: 74.
Findings include:
a) Resident #66
Resident #66's physician orders included orders for, Ativan Solution 2 milligrams/milliliters (mg/ml) give 0.6 mg every six (6) hours as needed (prn) for generalized anxiety disorder and Oxycodone 100 mg/5ml give 6 mg every four (4) hours prn for pain.
Review of Resident #66's medication administration record (MAR) and narcotic control records (NCR) found on the following dates and times the Ativan and Oxycodone was signed out on the NCR record but was not placed on the MAR, thus unable to determine if a possible diversion had occurred:
Ativan:
--06/29/22 at 5:00 pm
--06/30/22 at 7:30 pm
--07/02/22 at 3:00 pm
--07/04/22 at 10:00 am and 4:00 pm
--07/05/22 at 8:00 am and 2:00 pm and 8:00 pm
--07/11/22 at 9:00 am and 3:00 pm
--07/15/22 at 10:00 am
Oxycodone:
--06/29/22 at 5:00 pm
--06/30/22 at 7:30 pm
--07/01/22 at 3:25 pm
--07/02/22 at 9:00 am and 2:00 pm and 6:00 pm
--07/04/22 at 10:00 am and 4:00 pm
--07/05/22 at 12:00 pm and 4:00 pm
--07/11/22 at 9:00 am and 1:00 pm
--07/15/22 at 10:22 am
Review of the June and July MAR and the NCR with the acting director of nursing (DON) on 07/20/22 at 2:45 pm. The acting DON confirmed Ativan and Oxycodone was recorded on NCR but not on the MAR on the above-mentioned dates and times, the licensed nursing staff failed to document the Ativan and Oxycodone was administered to the resident. She was unable to determine if the system was in place to control to account for and periodically reconcile controlled medications to prevent loss and/or diversion of narcotics.
b) Resident #67
Resident #67's physician orders included orders for, Oxycodone 5 mg tablet every eight (8) hours prn for pain.
Review of Resident #67's June and July 2022, medication administration record (MAR) and narcotic control dispensing machine which stores narcotics and is dispensed whenever the prn narcotics are removed from the machine. On the following dates and times there is a discrepancy of when medication was removed and the documentmentation on the MAR as administered:
--06/22/22 Dispensed from the machine at 7:13 pm and recorded on the MAR as administered at 5:20 pm. (recorded as administered over two (2) hours prior to the removal of medication).
--06/23/22 Dispensed from the machine at 9:48 am and recorded on the MAR as administered at 6:40 am. (recorded as administered over three (3) hours prior to the removal of medication).
--06/23/22 Dispensed from the machine at 12:05 pm and recorded on the MAR as administered at 3:00 pm. (recorded as administered over three (3) hours after the removal of medication).
--06/30/22 Dispensed from the machine at 3:23 pm and recorded on the MAR as administered at 2:00 pm. (recorded as administered over one (1) hour prior to the removal of medication).
--07/02/22 Dispensed from the machine at 7:18 am and recorded on the MAR as administered at 11:15 am. (recorded as administered over four (4) hours after the removal of medication).
--07/03/22 Dispensed from the machine at 7:43 am and recorded on the MAR as administered at 10:45 pm. (recorded as administered over three (3) hours after the removal of medication).
--07/03/22 Dispensed from the machine at 5:06 pm and recorded on the MAR as administered at 7:00 pm. (recorded as administered over two (2) hours after the removal of medication).
--07/06/22 Dispensed from the machine at 5:58 am and recorded on the MAR as administered at 7:10 am. (recorded as administered over two (2) hours after the removal of medication).
--07/07/22 Dispensed from the machine at 5:11 am and recorded on the MAR as administered at 9:30 am. (recorded as administered over four (4) hours after the removal of medication).
--07/11/22 Dispensed from the machine at 12:11 am and recorded on the MAR as administered at 6:30 pm. (recorded as administered over six (6) hours after the removal of medication).
--07/13/22 Dispensed from the machine at 11:49 am and recorded on the MAR as administered at 2:55 pm. (recorded as administered over two (2) hours after the removal of medication).
--07/16/22 Dispensed from the machine at 11:58 am and not recorded on the MAR as administered.
Review of the June and July MAR and the narcotic dispensing log with the acting director of nursing (DON) on 07/20/22 at 2:45 pm. The acting DON confirmed Oxycodone was recorded on the narcotic dispensing machine and the MAR on the above-mentioned dates and times, the licensed nursing staff failed to document with accuracy of when the narcotic was removed from the machine and when the medication was administered to the resident. She was unable to determine if the system was in place to control to account for and periodically reconcile controlled medications to prevent loss and/or diversion of narcotics.
c) Shift count for controlled medications
On 07/19/22 at 8:51 AM, during a review of the medication cart for rooms 135-150, it was found in the Blue Book (the book used to sign out controlled medications and to verify a shift count was correct at the end of the shift.)
On the shift count sheet there was missing signatures from both the oncoming nurse and outgoing nurse. These missing signatures were verified by Licensed Practical Nurse (LPN) #53, who said, I do not know why the nurses are not signing it they put postage notes on it all the time.
The missing signatures were as follows:
*06/15/22 no oncoming nurse signature.
*06/15/22 no off going nurse signature.
*06/16/22 no on coming nurse signature,
*06/16/22 no off going nurse signature.
*06/17/22 no on coming nurse signature.
*06/20/22 no off going nurse signature.
*06/22/22 no on coming nurse signature.
*06/27/22 no on coming nurse signature.
*07/01/22 no on coming nurse signature.
*07/02/22 no going off nurse signature.
*07/03/22 no coming on nurse signature.
*07/04/22 no going off nurse signature.
*07/06/22 no coming on nurse signature.
*07/08/22 no coming on nurse signature.
*07/08/22 no off going nurse signature.
*07/12/22 no on coming nurse signature.
*07/14/22 no off going nurse signature.
*07/16/22 no off going nurse signature.
*07/17/22 no on coming nurse signature.
*07/18/22 no off going nurse signature.
On 07/19/22 at 10:28 AM, Interim Administrator was informed of the above findings and no additional information was obtained.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview the facility failed to conduct monthly drug regimen reviews for two (2) of five (5)...
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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 conduct monthly drug regimen reviews for two (2) of five (5) residents reviewed for unnecessary medications. Resident identifiers: #68, and #60. Facility census: 74.
Findings included:
a) Resident #68
On 07/20/22 at 10:21 AM Corporate Registered Nurse (RN) #91 provided monthly drug regimen reviews (MRR) February 2022 through May 2022. RN #91 stated she would have to look for previous dates.
Record review indicated the Resident was admitted to the facility on [DATE].
On 07/21/22 at 9:35 AM, Corporate RN #91 stated no additional documents were found for the time frame prior to February 2022 to indicate monthly drug regimen reviews were conducted for Resident #68.
b) Resident #60
During a review of the MRR for Resident # 60 it found this resident was admitted on [DATE]. Therefore the Facility only needed to provide one MRR.
On 07/21/22 at 10:43 AM, Interim Administrator provided a list of residents that did not have all of the MRR completed, and Resident #60 was on that list. The administrator stated there was nothing else found.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to evaluate the as needed (PRN) psychotropic medicatio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on medical record review and staff interview, the facility failed to evaluate the as needed (PRN) psychotropic medication ordered for longer than 14 days, without a documented rationale for continued use and failure to implement person-centered, non-pharmacological approaches prior to the administration of the PRN psychotropic (Ativan) medication.
Resident #66. Facility Census: 74.
Findings included:
a) Resident #66
Medical record review for Resident #66 found he was admitted to the facility on [DATE]. Diagnosis included elevated white blood cell count, adult failure to thrive, primary adrenocortical insufficiency, gastroesophageal reflux, nausea, depression, anxiety disorder, alcohol use, hypoxemia, hypertension, obstruction of duodenum, pneumonia, and atrial fibrillation.
Resident #66's physician orders included an order for, Ativan Solution 2 milligrams/milliliters (mg/ml) give 0.6 mg every 6 hours as needed (prn) for generalized anxiety disorder.
Review of Resident #66's medication administration records (MAR) for June and July 2022, were reviewed and on the following dates and times the staff failed to indicate increased anxiety (crying, wringing hands, and/or pacing, etc.) as well as failed to attempt non-pharmaceutical interventions:
--06/29/22 at 12:30 pm and 9:16 pm.
--06/30/22 at 7:30 am and 1:30 pm.
--07/01/22 at 11:24 am and 11:40 pm.
--07/02/22 at 11:20 pm.
--07/03/22 at 9:00 am and 3:00 pm and 9:00 pm.
--07/04/22 at 10:33 pm.
--07/06/22 at 9:00 am and 3:00 pm and 9:00 pm.
--07/07/22 at 9:00 am and 3:00 pm and 8:00 pm.
--07/08/22 at 8:00 am and 2:00 pm and 9:00 pm.
--07/09/22 at 8:26 am and 2:34 pm and 10:57 pm.
--07/10/22 at 12:40 pm and 11:53 pm.
--07/11/22 at 9:40 pm.
--07/12/22 at 9:15 am and 3:17 pm and 9:45 pm.
--07/13/22 at 8:30 am and 2:30 pm and 8:57 pm.
--07/14/22 at 9:16 am and 11:57 pm.
--07/16/22 at 12:45 am and 9:15 am and 8:00 pm.
--07/17/22 at 8:30 am and 10:07 pm.
--07/18/22 at 8:53 am and 11:52 pm.
Review of the June and July MAR and the narcotic control record with the acting director of nursing (DON) on 07/20/22 at 1:45 pm. The acting DON confirmed Ativan was administered on the above-mentioned dates and times, the licensed nursing staff failed to clarify increased anxiety (crying, wringing hands, and/or pacing, etc.) as well as failed to document non-pharmaceutical interventions prior to administering the Ativan.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
.
Based on record review and staff interview the facility failed to maintain the medical record in a manner that reflected a resident's progress toward achieving their person-centered plan of care obj...
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.
Based on record review and staff interview the facility failed to maintain the medical record in a manner that reflected a resident's progress toward achieving their person-centered plan of care objectives and goals and the improvement and maintenance of their clinical, functional, mental and psychosocial status. The facility did maintain a Medical Regiment Review (MRR) in the Residents chart. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medicaitons. Resident #27. Facility census 74
Finding Included:
A) Resident #27
A Review of Resident # 27 medical record failed to reveal a Medical Regiment Review (MRR) from pharmacy.
On 07/20/22 at 1:20 PM, Corporate Nurse (CN) provided emails from the facility pharmacist regarding Resident # 27's MRR that read:
07/0722: I Facility Pharmacist have completed the pharmacy MMR for the patient for the month of July 2022, please see report for specific comments, thank you
06/05/22: I Facility Pharmacist have completed the pharmacy MMR for the patient for the month of June 2022, please see report for specific comments, thank you
05/04/22: I Facility Pharmacist have completed the pharmacy MMR for the patient for the month of MAY 2022, please see report for specific comments, thank you
04/10/22: I Facility Pharmacist have completed the pharmacy MMR for the patient for the month of April 2022, please see report for specific comments, thank you
03/18/22: I Facility Pharmacist have completed the pharmacy MMR for the patient for the month of March 2022, please see report for specific comments, thank you
02/20/22: I Facility Pharmacist have completed the pharmacy MMR for the patient for the month of February 2022, please see report for specific comments, thank you
On 07/19/22 at 1:20 PM, CN acknowledged the MRR or the facility pharmacist reports were not documented in Resident # 27's medical record .
.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility's grievance/concerns, policy review, resident interviews and staff interviews, the staff failed to c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility's grievance/concerns, policy review, resident interviews and staff interviews, the staff failed to consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility, and failed to demonstrate their response and rationale for such response.
Resident identifiers: #52, #71, #12, #60, #56, #44, and #3. Facility census: 74.
Findings included:
a) Resident #52
Concern from Resident Council for Resident #53 dated 01/27/22 read: Activities: Don't like the way bingo prizes are given. Laundry: Not getting our laundry back in a timely manner. Housekeeping: Would like them to check bathroom for supplies to make sure we have enough daily. Dietary: Improve on the food quality. Would like alternate options to choose from.
Action taken was blank
b) Resident #71
Concern form from Resident Council for Resident #71 dated 01/27/22 read: Nursing short staffed and call lights not answered. Activities: Don't like how bingo prizes are given. Laundry: Not getting laundry back; gonna have to go naked. Housekeeping: Toilet paper not restocked in a timely fashion. Dietary: Hot water is not hot enough and vegetables not cooked enough.
Actions taken read: Will take temp of hot water it is 158.2. Asked resident what veggies aren't cooked enough for her. She said she wasn't sure she thinks it's sometimes not all the time. I asked her to let me know and I will get back with her.
The actions taken did not address the bingo prizes and the laundry and housekeeping issues raised.
c) Resident #12
Concern form for Resident #12 dated 02/15/22 read: Foods such as mashed potatoes don't have much taste. She added garlic and onions to her foods at home. Resident said she's lost weight since being admitted here.
Action taken read: Presented at the 02/24/22 Resident Council meeting.
d) Resident council meeting 02/24/22
Resident council minutes dated 02/24/22 read: Beauty salon/barber shop: would like to see posted hours (on the door. How does one get an appointment? Residents feel as though they are not being heard. Same issues reported repeatedly with nothing being done. Dietary: Food not proper temperature (cold). Food seasoned improperly (either bland or over salted). Presentation unappetizing (looks like mush or baby food. Laundry: Items going missing and never return, marked with names items being placed in wrong wardrobe/wrong room. Sheets not being changed weekly on shower days. Residents feel they must tear up bed and place linen on floor to get bed changed. Felt raided and disrespected with being cleaned out.
Resident council concern follow-up form dated 02/24/22 read Food not proper temp. Cold. (Example. [NAME] beans served refrigerator cold in the middle.). Food seasoned improperly. (Example- potatoes bland and chicken noodle too salty). Presentation- unappetizing (example beets cooked to mush. Sweet potatoes look like baby food.
Action taken read: Temps will be taken at all meals and review yam casserole will be cooked and seasoned to liking. Will follow-up with the residents?
e) Resident council meeting 03/31/22
Resident Council minutes for 03/31/22 read: Residents feel as though they are not being heard, same issues reported repeatedly with nothing being done. 2. Food not proper temp cold, food seasoned improperly either bland or too salty, presentation unappetizing (looks like mush or baby food). 3. Nursing shower times change and are not accurate, call lights concerning they're not being answered fast enough, and people logging things they didn't do. 4. Housekeeping soap and paper towels not restocked, and floors are sticky.
Action taken is blank.
f) Resident council minutes 04/28/22
Resident council minutes dated 04/28/22 read: Call lights is slower after meals. Staff telling residents they're too short staffed to shower residents at designated times. Waking residents up. Loud at nights Housekeeping: no change from last month (toilet paper and paper towels not restocked. Not all staff knocking before entering the room
No concern follow-up for Resident council follow-up. 04/28/22.
g) Resident council meeting minutes 05/26/22
Resident Council minutes dated 05/26/22 read: Dietary concerns- eggs cold in morning, vegetables not drained well sometimes and makes other food soggy. Nursing concerns- checking briefs in the middle of the night and call bells not answered as fast at night.
No action taken.
h) Resident council meeting minutes 06/28/22
Resident council minutes dated 06/28/22 read: Dietary- Not resolved from May- vegetables not drained well making other food soggy when put together, meals are coming cold, beverages in the dining room are cold supposed to be hot and cold beverages are warm and should be cold, and meals are inconsistent in taste and temperature at dinner and different than breakfast and lunch.
Action taken by dated 06/28/22 read: Will go over with the cooks to drain better before putting on plate, will continue to do more test trays for temperature checks, will go to the dining room and test temps on all beverages, and will go over food taste if food is tasting better or not.
Maintenance concern dated 06/28/22 read: Residents questioning how they can get in the door from the porch aside from knocking because sometimes it takes time for someone to come.
Action taken by maintenance read: Replaced the doorbell.
I) Policy for Grievances/Concern:
Policy review: Grievance/Concern (Version 5) effective date 04/14/2020.
Purpose is to establish a process for responding to a resident or resident representative to resolve grievances a resident may have.
3. The Executive Director will be the designated Grievance Officer.
4. The Grievance Officer is responsible for overseeing the grievance process .
5. Upon identification of a resident or representative concern, complete the grievance/concern form identifying the issue and forward the form to the Grievance Officer.
7. The Grievance Officer will ensure that all written grievance decisions include the date the grievance was received, a summary statement of the grievance, the steps taken to investigate the grievance, a summary of the pertinent findings concern (s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued.
8. The facility will take the appropriate actions in response to a grievance to prevent further potential violations of resident rights during an investigation and report any allegations of neglect, abuse, injuries of unknown source, and/or misappropriation of resident property as indicated.
9. The Grievance Officer forwards the grievance/concern form to the appropriate department head for investigation, follow-up and resolution and tracks the concern on the electronic grievance log.
10. The assigned department head investigates the identified concern timely to identify the root cause of the issue or concern.
11. Once the root cause of the concern is identified, corrective action is taken to resolve the issue for the identified as well as potential systemic changes to reduce risk of recurrence or occurrence for others.
12. The assigned department head contacts the appropriate party (if known). All anonymously reported concerns will have no final notification once resolution has been completed. (No longer than five (5) working days unless nature of concern dictates extension).
13. Once resolved, the grievance/concern form is updated with the resolution of the concern and return to the Grievance Officer.
14. The Grievance Officer reviews outstanding/unresolved concerns during the morning meeting to determine status.
15. The Grievance Officer
or designee may complete a follow up call or meeting with the designated party (if known) to verify that concerns have been addressed.
16. Trends from the electronic grievance log are reported to the Quality Assurance Committee monthly and action as needed.
17. The facility will maintain evidence demonstrating the resolution of complaints and grievances for at least three (3) years.
Acting Nursing Home Administrator (NHA) and the acting Director of Nursing (DON) notified of the following issues that had been voiced in the Resident Council meetings as well as individual complaint/concerns which continues to be issues during the Long=term Care Survey Process (LTCSP) The areas which continue to be issues are call light response, food temperature and unappetizing food, restocking of paper towels and toilet paper and not enough staff to provide care needed (showers and transfers). No further information received.
j) Ongoing Concerns During the LTCSP
j-1) Call lights
Observation on 07/19/22 at 12:15 PM, it was noted that three (3) call lights were on when the surveyor arrived to the floor. room [ROOM NUMBER], 110, and 113. It was also noted three staff members were on they hallway and were seen walking past the rooms with the call lights on without stopping at any of the rooms with the call lights on.
room [ROOM NUMBER] was answered at 12:33 PM, room [ROOM NUMBER] was answered at 12:37 PM, room [ROOM NUMBER]'s call light was not answered until 12:40 PM.
On 07/19/22 at 10:45 PM, call light for room [ROOM NUMBER] was on upon arrival to the facility. There was two nurse aides at the nurses station sitting in chairs at the time. It was noted that Licensed Practical Nurse (LPN) # 22 walked past room [ROOM NUMBER] without stopping at 11:00 PM, and again at 11:10 PM. On 07/19/22 at 11:20 PM, by Infection Preventionist answered the call light for room [ROOM NUMBER], after surveyor intervention. The resident was heard saying he wanted someone to turn off the lights so he could go to sleep.
J-2) Food complaints
1) Resident #3
On 07/18/22 at 2:32 PM, Resident's daughter states her father is not happy with the diet and feels like he does not get enough to eat.
On 07/19/22 at 2:32 PM, Resident # 3 did not get his lunch until 2:32 PM today, and it was penne noodles and meatless red sauce. Resident # 3 stated he would be happy to eat a ham sandwich.
When he gets a hot dog, it is only one with a [NAME] on a bun two packets of mustard and Ketchup, portion sizes are small. Food is not always very warm.
2) Resident #60
During the first phase of the survey process Resident #60 reported on 07/18/22 at 2:21 PM, that the food is not good, no seasoning, not hot enough, and very small portion sizes.
3) Resident #56
On 07/18/22 at 12:24 PM, Resident #56 was asked if they were happy with the food. Resident #56 said, the food is awful does not taste good and is not always warm enough.
4) Resident #44
On 07/18/22 at 12:03 PM, Resident #44 said the food is cold, small portion sizes, taste bad because of no seasoning on it.
5) Temperatures
Food temperature checked on the south hall on 07/19/22 at 12:57 PM, Kitchen Manager checked the temperature of the food in the Styrofoam box. Baked Ziti 119 degrees, garden salad 62 degrees. Kitchen Manager agreed the Baked Ziti was not hot enough and the salad was too warm.
On 07/19/22 at 2:27 PM, Administrator was informed of the above findings, nothing additional as provided.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
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Based on medical record review and staff interview the facility failed to ensure the Physician Orders for Scope of Treatment (POST) forms were completed per directions specified by the [NAME] Virgin...
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Based on medical record review and staff interview the facility failed to ensure the Physician Orders for Scope of Treatment (POST) forms were completed per directions specified by the [NAME] Virginia Center for End of Life Care. This is true for five (5) of 24 residents reviewed for advance directives. Resident Identifiers: Resident #49, #59, #74, #25 and #273. Facility Census: 74.
Findings Included:
a) Resident #49
On 07/18/22 at 2:33 PM Resident #49's POST form was reviewed. On the POST form in Section D, signed and dated by the physician on 08/24/21 revealed no date of resident #49's signature.
During an interview on 07/19/22 at 9:36 AM the Medical Record Staff #38 acknowledged Resident #49's POST form was not dated when signed by Resident #49.
b) Resident #59
On 07/19/22 at 8:30 AM Resident #59's POST form was reviewed. The Post form was illegible and did not dictate proper procedures to provide the advance directive request.
On the POST form in Section B titled Medical Interventions: Comfort Measure box was check marked, a line drawn through it, dated 05/18/22 with Resident #59's Health Care Surrogate initials EER. Limited Additional Inventions box was checked marked with date of 05/18/22 with Resident #59's Health Care Surrogate initials EER.
Section C titled Medically Administered Fluids and Nutrition: No IV fluids box was check marked a line drawn through it dated 05/18/22 with Resident #59's Health Care Surrogate initials EER. IV fluids for a trial period of no longer than 7 days box was checked marked with date of 05/18/22 with Resident #59's Health Care Surrogate initials EER.
During an interview on 07/19/22 at 9:36 AM, Medical Records Staff # 38 stated Resident #59's Department of Health and Human Resources (DHHR) representative marked out several places and marked new interventions when we mailed the POST form to her. It is confusing to know what the resident and the representative wants. I will do a new POST form and send it to the representative to sign.
c) Resident #74
On 07/21/22 at 8:15 AM, Resident #74's POST form was reviewed. On the POST form Section D was signed and dated by the physician on 05/10/22 and was nit signed and dated by the capacitated resident.
During an interview on 07/21/22 at 8:27 AM, MRS #38 acknowledged Resident #74 had capacity and her POST form was void of Resident #74's signature and date.
d) Resident #26
Review of Resident's Post (physicians orders for scope of treatment) form showed the POST form was completed on 05/27/22 by the Residents Medical Power of Attorney (MPOA). The Resident was not deemed incapacitated by the physician until 06/03/22.
Review of Resident's determination of capacity forms showed the Resident to have three (3) forms with the fowling dates:
Exam date 06/03/22 (lacks capacity).
Exam date 06/28/22 (has capacity).
Exam date 07/14/22 (lacks capacity).
During an interview on 07/21/22 08:52 AM Corporate RN #91 verified Resident #26 was not deemed incapacitated until after the POST form was filled out, therefore should have been the one that completed the form instead of the Medical Power of Attorney.
e) Resident #27
On 7/20/22 at 9:11 AM according to the medical records for Resident #273 the Physicians Orders for Scope of Treatment (POST) form dated 4/18/22 reflected that he was a Do Not Resuscitate (DNR). The POST was signed by his daughter. According to the medical records and confirmed on 7/19/22 at 2:08 PM with the Corporate Registered Nurse #91 there were no Medical Power of Attorney (MPOA) papers on file for Resident #273. According to the Physicians note on 4/14/22 the resident was a full code prior to this POST form being completed.
According to the Brief Interview for Mental States (BIMS) dated 4/15/22, the resident had a BIMS of 04. This was also reflected on the Minimum Data Set (MDS) Section C, Cognitive Patterns dated 4/20/22. There was no Physician Determination of Capacity forms on file for Resident #273. This was confirmed on 7/19/22 at 2:08 PM with the Corporate Registered Nurse #91.
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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
Based on record review and staff interviews the facility failed to implement their policy regarding allegations of neglect and injuries of unknown origin, which were not reported within the appropriat...
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Based on record review and staff interviews the facility failed to implement their policy regarding allegations of neglect and injuries of unknown origin, which were not reported within the appropriate time frames and to the appropriate state agencies. These failed practices to implement their abuse policy had the potential to affect more than a limited number of esidents currently residing in the facility.
Resident Identifiers: #46, #81 and #177. Facility Census: 74.
Findings included:
a) Resident #46
Review of the Concern/Complaints found a concern form for Resident # 46, dated 06/02/22 and read as follows: Registered Nurse (RN) #93 reports she asked the Nursing Assistant (NA) #51 to assist the resident to bed at 7:30 pm NA #51 reported to the nurse he doesn't usually go to bed this early, and he is a high risk for falls. RN #93 then told the NA #51 the resident's pants are soaking wet. NA #51 reports she will lay him down as soon as possible. Per the RN #93, NA #51 did not assist resident to bed until 10-10:30 pm.
On 07/20/22 at 10:40 am the acting Director of Nursing (DON) reviewed the concern for Resident #46 dated 06/02/22. She confirmed this allegation should have been reported as possible neglect and stated she would do it today.
b) Resident #81
Review of the Concern/Complaints found a concern form for Resident #81, dated 06/01/22 which read as follows: Registered Nurse (RN) #45 is making me feel bullied for being here, for medication I am taking, and other needs are a burden for her to do for me. RN #45 said I was just lurking.
1. I walked up to nurses' station on May 28,2022 and asked for my night meds, and a pain reliever, to help me to sleep better. RN #45 was mean about me not having my contact lenses out for the glaucoma drops to be used. I told her I would come to my room and remove lenses and come back. RN #45 opened the med cart drawer and said, why did you say you were ready for drops I apologized then when asked for pain reliever, I am able to get it every 4 hours as needed. It was time for one and requested with my night meds, RN #45 stated, Boy you like that pain med don't ya. I said mam I am grateful for the meds because it brings the pain down some and I can function better and sleep better. She said, is therapy not helping. I said therapy halted. She said, Insurance probably won't pay. A mean attitude she had the whole time. I then said Mam you have no idea the hell I've been thru.
Today 06/01/22 I requested RN #45 not to be around me anymore. This request was made to the Director of Nursing (DON) and the Social Service Director (SSD).
Action taken to resolve concern: Resident agrees for RN #45 to have 1:1 education. Resident understands (verbalized) nurse could not be moved off her assignment, nor could resident be moved to another unit due to Covid-19 isolation measures. Resident agrees this is okay.
On 07/20/22 at 10:40 am the acting Director of Nursing (DON) reviewed the concern for Resident #81 dated 06/01/22. She confirmed this allegation of possible abuse should have been reported and she will do it today.
c) Resident #177
During a review of medical records and reportable incidents it revealed Resident #177 had a numerous number of falls in the last four months of her stay. Resident #177 lacked capacity.
On the last day of her stay Resident #177 had two (2) falls on 07/03/22. The first at 2:15 PM, Resident #177 was found by Licensed Practical Nurse (LPN) #33, laying on the floor beside of her bed. Resident #177 was noted to be bleeding from the head and complaint of pain in right elbow. Orders were obtained to send Resident #177 to a local hospital to be evaluated.
On the same day Resident #177 was returned to the facility at 6:57 PM via Local ambulance service.
Then the next nursing note states, Resident #177 was at the facility approximately five (5) minutes. When another Resident reported to LPN #33 Resident #177 was in the floor.
It was not clear at what time the local ambulance service returned and transported Resident #177 back to the local hospital and was placed in the neuro-critical care unit.
After reviewing the facility reportable files, it revealed that the facility failed to complete and report to all state agencies within the regulatory time frame. The falls with serious injuries occurred on 07/03/22 and the reports were made on 07/09/22.
On 07/20/22 at 9:30 AM, Corporate Nurse #91 was shown the above findings and no further information was provided.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
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Based on medical record review and staff interview, the facility failed to ensure that all alleged violations involving abuse/ neglect and injuries of unknown source, were reported immediately, but ...
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Based on medical record review and staff interview, the facility failed to ensure that all alleged violations involving abuse/ neglect and injuries of unknown source, were reported immediately, but no later than 2 hours after the allegation is made to the appropriate agencies. These were random opportunities for discovery and was true for three (3) residents. Resident identifiers: #46, #81, and #177. Facility Census: 74
Findings Included:
a) Resident #46
Review of the Concern/Complaints found a concern form for Resident # 46, dated 06/02/22 and read as follows: Registered Nurse (RN) #93 reports she asked the Nursing Assistant (NA) #51 to assist the resident to bed at 7:30 pm NA #51 reported to the nurse he doesn't usually go to bed this early, and he is a high risk for falls. RN #93 then told the NA #51 the resident's pants are soaking wet. NA #51 reports she will lay him down as soon as possible. Per the RN #93, NA #51 did not assist resident to bed until 10-10:30 pm.
On 07/20/22 at 10:40 am the acting Director of Nursing (DON) reviewed the concern for Resident #46 dated 06/02/22. She confirmed this allegation should have been reported as possible neglect and stated she would do it today.
b) Resident #81
Review of the Concern/Complaints found a concern form for Resident #81, dated 06/01/22 which read as follows: Registered Nurse (RN) #45 is making me feel bullied for being here, for medication I am taking, and other needs are a burden for her to do for me. RN #45 said I was just lurking.
1. I walked up to nurses' station on May 28,2022 and asked for my night meds, and a pain reliever, to help me to sleep better. RN #45 was mean about me not having my contact lenses out for the glaucoma drops to be used. I told her I would come to my room and remove lenses and come back. RN #45 opened the med cart drawer and said, why did you say you were ready for drops I apologized then when asked for pain reliever, I am able to get it every 4 hours as needed. It was time for one and requested with my night meds, RN #45 stated, Boy you like that pain med don't ya. I said mam I am grateful for the meds because it brings the pain down some and I can function better and sleep better. She said, is therapy not helping. I said therapy halted. She said, Insurance probably won't pay. A mean attitude she had the whole time. I then said Mam you have no idea the hell I've been thru.
Today 06/01/22 I requested RN #45 not to be around me anymore. This request was made to the Director of Nursing (DON) and the Social Service Director (SSD).
Action taken to resolve concern: Resident agrees for RN #45 to have 1:1 education. Resident understands (verbalized) nurse could not be moved off her assignment, nor could resident be moved to another unit due to Covid-19 isolation measures. Resident agrees this is okay.
On 07/20/22 at 10:40 am the acting Director of Nursing (DON) reviewed the concern for Resident #81 dated 06/01/22. She confirmed this allegation of possible abuse should have been reported and she will do it today.
c) Resident #177
During a review of medical records and reportable incidents it revealed Resident #177 had a numerous number of falls in the last four months of her stay. Resident #177 lacked capacity.
On the last day of her stay Resident #177 had two (2) falls on 07/03/22. The first at 2:15 PM, Resident #177 was found by Licensed Practical Nurse (LPN) #33, laying on the floor beside of her bed. Resident #177 was noted to be bleeding from the head and complaint of pain in right elbow. Orders were obtained to send Resident #177 to a local hospital to be evaluated.
On the same day Resident #177 was returned to the facility at 6:57 PM via Local ambulance service.
Then the next nursing note states, Resident #177 was at the facility approximately five (5) minutes. When another Resident reported to LPN #33 Resident #177 was in the floor.
It was not clear at what time the local ambulance service returned and transported Resident #177 back to the local hospital and was placed in the neuro-critical care unit.
After reviewing the facility reportable files, it revealed that the facility failed to complete and report to all state agencies within the regulatory time frame. The falls with serious injuries occurred on 07/03/22 and the reports were made on 07/09/22.
On 07/20/22 at 9:30 AM, Corporate Nurse #91 was shown the above findings and no further information was provided.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview the facility failed to ensure the receiving facility received all required paperwor...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview the facility failed to ensure the receiving facility received all required paperwork to ensure a safe and orderly transfer from one facility to another. The facility failed to send physicians orders or Medication Administration Records (MAR) upon transfer. This was true for three (3) of the three (3) Residents reviewed during the long term care survey process. Resident Identifiers: # 75, # 177 and # 28. Facility Census: 74.
Findings Included:
a) Resident # 75
A review of Resident #75's medical record found the following dated entry: 5/24/22 at 8:18 PM, Nurses Note: Resident was transferred out to (Local Hospital Name) by EMS (Emergency Medical Services) resident was calm and all vitals were stable at the time of transfer, (Local Hospital Name) called to ask last application of fentanyl Patch and last meds (medication) given nurse reported transfer was completed to (Local Hospital Name).
A review of a facility provided form labeled Transfer/Discharge Report for Resident # 75 dated 05/24/22 at 8:16 PM, found no medication Administration Record (MAR) or physician orders for Resident #75 were attached to the transfer document.
On 07/20/22 at 11:16 AM, the Interim Administrator acknowledged no MAR or physician orders went with Resident # 75 during transfer.
b) Resident #177
A review of medical records for Resident #177 revealed there was not any transfer or discharge documents for Resident #177 when she was sent to the hospital on [DATE] on two (2) separate occasions. The facility failed to send physicians orders and medication administration record with the Resident.
Resident #177 was sent out to a local hospital two times on 07/03/22 and did not return.
On 07/21/22 at 8:25 AM, Administrator stated the facility did not send any type of discharge information with Resident # 177 on the two times Resident # 177 was sent out on 07/03/22. Administrator said the facility had no evidence that the Ombudsman was notified as well.
c) Resident #28
Review of Resident #38s medical records found a nurses note written by Employee #54 Licensed Practical Nurse (LPN) on 07/20/22. The note read: Resident requested to go to the local emergency room (ER) She stated she was shaky inside. Vital signs where temperature was 97.8-degree, pulse was 70 beats per minute, respiration was 18, Blood pressure was 130/76, and Oxygen saturation was 91%. Resident was slumped over toward her right side a little in the chair and a little lethargic which is not unusual on dialysis days.
Physician and resident representative notified.
Additional review found no transfer information was sent with the resident at time of transfer.
Interview on 07/21/22 at 08:30 AM with the acting Director of Nursing (DON) confirmed no transfer, or any other information was sent with the resident.
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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 send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman. ...
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Based on record review and staff interview the facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman. This was true for three (3) of three (3) Residents reviewed during the long term care survey process. Resident Identifiers: # 75, # 177 and # 28. Facility Census: 74
Findings Included:
a) Resident # 75
A review of Resident #75's medical record found the following dated entry: 5/24/2022 at 8:18 PM, Nurses Note: Resident was transferred out to (Local Hospital Name) by EMS (Emergency Medical Services) resident was calm and all vitals were stable at the time of transfer, (Local Hospital Name) called to ask last application of fentanyl Patch and last meds (medication) given nurse reported transfer was completed to (Local Hospital Name).
A further review of Resident #75's medical Record found no Ombudsman notification for the transfer to a local hospital on 5/24/2022 at 8:18 PM.
07/20/22 at 11:16 AM, The Interim Administrator acknowledged the Ombudsman was not notified regarding Resident # 75's transfer on 05/24/22.
b) Resident #177
A review of Resident #177's medical record found she was sent out to the local hospital on two (2) occasions on 07/03/22. The medical record contained no evidence the Ombudsman was notified of the transfers.
On 07/21/22 at 8:25 AM, the Administrator stated the facility did not send any type of discharge information with Resident # 177 on the two times Resident # 177 was sent out on 07/03/22. The Administrator also confirmed the facility had no evidence that the Ombudsman was notified of the transfer.
c) Resident #28
Review of Resident #38's medical records found a nurses note written by Employee #54 Licensed Practical Nurse (LPN) on 07/20/22. The note read: Resident requested to go to the local emergency room (ER) She stated she was shaky inside. Vital signs where temperature was 97.8-degree, pulse was 70 beats per minute, respiration was 18, Blood pressure was 130/76, and Oxygen saturation was 91%. Resident was slumped over toward her right side a little in the chair and a little lethargic which is not unusual on dialysis days.
Physician and resident representative notified.
Additional review found no evidence the ombudsman was notified of the transfer.
An interview on 07/21/22 at 08:30 AM with the acting Director of Nursing (DON) confirmed the ombudsman was not notified of the transfer.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
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Based on observation, resident interview, medical record review and staff interview the facility failed to develop and/or implement a comprehensive person-centered care plan with measurable objectiv...
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Based on observation, resident interview, medical record review and staff interview the facility failed to develop and/or implement a comprehensive person-centered care plan with measurable objectives, in the areas of fall prevention, Hospice, and Advance directives. This is true for three (3) out of 24 residents reviewed during the long-term care survey process. Resident Identifiers: Resident #177, # 74, and #71. Facility census: 74.
Findings included:
a) Resident #177
A review of Resident #177's medical records revealed Resident #177 had unwitnessed falls that occurred in her room on the following days:
*4/29/22
* 4/27/22
*4/29/22
*6/16/22
*6/20/22
* 6/21/22: 12:31-4:01 pm
*6/22/22
*7/3/22 2:15 pm and 7:11 PM
Further review of Resident #177's care plan found it was void of realistic interventions to prevent falls.
Resident #177 had 10 falls in a four (4) month time frame. the following are the interventions that were put in place which were contained on the care plan:
*Dycem to her wheelchair to prevent the cushion from slipping out.
*Encourage resident to attend activities of choice for engagement.
*Ensure resident's bed is made upon waking in the morning.
*Help me get to bathroom often so that I don't wait until I have an urgent need to go.
*Offer and assist with toileting every two (2) hours.
*So, I don't wait until I have urgent need to go, remind me to go to the bathroom before/after breakfast, lunch, activities, dinner, and at bed time.
*When out of bed encourage to be in common area for frequent staff observation.
There was not any mention of:
Wearing non-slip footwear.
Frequent checks and monitoring resident.
Moving resident closer to the nurse's station (the residents room was located at the end of the hall away from the nurse's station).
Fall mats.
Or keeping the bed in the lowest position. All of which are common interventions for residents with recurrent falls.
On 07/21/22 at 8:23 AM, Corporate Nurse (CN)#91 agreed more interventions could have been made. CN #91 stated she was going to look further to see if there was a reason for not using fall mats.
No additional information was provided at the close of the survey.
b) Resident #74
A medical record review on 07/21/22 at 8:45 AM ,revealed Resident #74's care plan was void focus, goals and interventions for the following physician orders; oxygen use, catheter care and hospice care.
A physician order dated 04/30/22 typed as written: Oxygen at 3L/min via NC continuous.
A physician order dated 04/30/22 typed as written: Insert (16F Foley 10 cc balloon Foley Cath) due to end of life care with closed drainage system every shift for cath care.
A physician order dated 05/06/22 typed as written: To be assessed by/admitted to (named) Hospice
During an interview on 07/21/22 at 8:58 AM, the Minimum Data Set (MDS) Coordinator #38, acknowledge no care plan was provided for hospice care, no care plan for catheter care, and no care plan for oxygen use.
c) Resident #71
A review of the Resident #71's care plan with an initiated date of 08/10/17 and revision date of 12/26/17 with a focus that reads I am unable to control my bladder at times related to my impaired mobility.
Resident #71's Care plan interventions with a initiated date of 08/10/17 and revision date of 02/03/22 that reads assist with incontinence care frequently and as needed. I use Incontinence products: panty liner. Observe for skin breakdown.
During an interview on 07/21/22 at 8:58 AM, MDS Coordinator #38, stated that Resident #71 should be wearing panty liner throughout the day not the briefs according to her care plan.
No further information was provided through the completion of the survey.
.
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 observation, staff interview, and medical record review the facility failed to follow physician orders in regard to neuro checks after a fall, providing nutritional supplemental snacks, monit...
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Based on observation, staff interview, and medical record review the facility failed to follow physician orders in regard to neuro checks after a fall, providing nutritional supplemental snacks, monitoring of blood sugars for diabetics, and administering antibiotics. Resident Identifiers: Resident #46, #70, #28, #1, #48, #40, #32, #18, #17, #30, #22, #6, #424, #7, #62, #36, #52, #68, #67, #28, and #273. Facility census 74.
Findings included:
a) Resident #46
On 07/20/22 at 11:35 PM, evening snacks were found on the food cart beside of the of the north side nursing station. These snack were undelivered to the residents.
A review of the MAR (Medication Administration Record) for Resident #46 read:
House 2.0 (pudding with higher nutrition than water, with added protein and calories) to be given three times a day at 9:00 AM, 1:00PM, and 5:00 PM.
On 07/19/22 at 5:00 PM, it was documented by Licensed Practical Nurse (LPN) #52 that Resident #46 had consumed 100 percent of the snack which was undelivered to the resident.
On 07/19/22 at 11:50 PM, Human Resource Manager (HRM) confirmed Resident #46's snack was still on the food cart and had not been delivered to the Resident.
b) Resident #70
On 07/20/22 at 11:35 PM, Resident #70's evening snack was found on the food cart beside of the of the north side nursing station and was untouched by the resident.
On 07/19/22 at 11:50 PM, Human Resource Manager (HRM) confirmed Resident #70's snack was still on the food cart and had not been delivered to the Resident.
c) Resident #28
On 07/20/22 at 11:35 PM, Resident #28's evening snack was found on the food cart beside of the of the north side nursing station and had not been delivered to the resident.
On 07/19/22 at 11:50 PM, Human Resource Manager (HRM) confirmed Resident #28's snack was still on the food cart and had not been delivered to the Resident.
d) Resident #1
On 07/20/22 at 11:35 PM, Resident #1's evening snack was found on the food cart beside of the of the north side nursing station and had not been delivered to the resident.
A review of the MAR (Medication Administration Record) for Resident #1 read:
House 2.0 (pudding with higher nutrition than water, with added protein and calories) to be given three times a day at 9:00 AM, 1:00PM, and 5:00 PM.
On 07/19/22 at 5:00 PM, it was documented by Licensed Practical Nurse (LPN) #52 that Resident #1 had consumed 100 percent of the snack which was left on the food cart the previous night.
On 07/19/22 at 11:50 PM, Human Resource Manager (HRM) confirmed Resident #1's snack was still on the food cart and had not been delivered to the Resident.
e) Resident #48
On 07/20/22 at 11:35 PM, Resident #48's evening snack was found on the food cart beside of the of the north side nursing station. and had not been delivered to the resident.
On 07/19/22 at 11:50 PM, Human Resource Manager (HRM) confirmed Resident #48's snack was still on the food cart and had not been delivered to the Resident.
f) Resident #40
On 07/20/22 at 11:35 PM, Resident #40's evening snacks was found on the food cart beside of the of the north side nursing station and was not delivered to the resident.
A review of the MAR (Medication Administration Record) for Resident #40 read:
Specify in Special instructions: At bedtime for planned snack from dietary. House 2.0 (pudding with higher nutrition than water, with added protein and calories) to be giving three times a day at 2:00 PM, and 8:00 PM.
On 07/19/22 at 8:00 PM, it was documented by Registered Nurse (RN) #58 that Resident #40 consumed 100 percent of the undelivered snack.
On 07/19/22 at 11:50 PM, Human Resource Manager (HRM) confirmed Resident #40's snack was still on the food cart and had not been delivered to the Resident.
g) Resident #32
On 07/20/22 at 11:35 PM, Resident #32's evening snack was found on the food cart beside of the of the north side nursing station and had not been delivered to the resident.
On 07/19/22 at 11:50 PM, Human Resource Manager (HRM) confirmed Resident #32's snack was still on the food cart and had not been delivered to the Resident.
H) Resident #18
On 07/20/22 at 11:35 PM, Resident #18's evening snack was found on the food cart beside of the of the north side nursing station and had not been delivered to the resident.
A review of the MAR (Medication Administration Record) for Resident #18 read:
House 2.0 (pudding with higher nutrition than water, with added protein and calories) to be giving three times a day at 9:00 AM, 1:00PM, and 5:00 PM at med pass due to weight loss.
On 07/19/22 at 5:00 PM, was documented by Licensed Practical Nurse (LPN) #52 that Resident #18 had consumed 100 percent of the undelivered snack.
The MAR also indicated Resident #18 received a house protein supplement three times a day for weight maintenance at 9:00 AM, 12:00 PM, and 5:00 PM.
On 07/19/22 at 5:00 PM, it was documented by Licensed Practical Nurse (LPN) #52 that Resident #18 had consumed 25 percent of the undelivered snack.
On 07/19/22 at 11:50 PM, Human Resource Manager (HRM) confirmed Resident #18's snack was still on the food cart and had not been delivered to the Resident.
I) Resident #17
On 07/20/22 at 11:35 PM, Resident #7's evening snack was found on the food cart beside of the of the north side nursing station and had not been delivered to the resident.
A review of the MAR (Medication Administration Record) for Resident #17 read:
House 2.0 (pudding with higher nutrition than water, with added protein and calories) to be given three times a day at 9:00 AM, 1:00PM, and 5:00 PM at med pass due to weight loss.
On 07/19/22 at 5:00 PM, it was documented by Licensed Practical Nurse (LPN) #52 that Resident #18 consumed 100 percent of the undelivered snack.
On 07/19/22 at 11:50 PM, Human Resource Manager (HRM) confirmed Resident #17's snack was still on the food cart and had not been delivered to the Resident.
j) Resident #30
On 07/20/22 at 11:35 PM, Resident #30 evening snack was found on the food cart beside of the of the north side nursing station and was not delivered to the resident.
A review of the MAR (Medication Administration Record) for Resident #30 read:
House shake to be giving three times a day at 9:00 AM, 1:00PM, and 5:00 PM at med pass due to weight loss. This shake was left on the red dietary cart untouched.
On 07/19/22 at 11:50 PM, Human Resource Manager (HRM) confirmed Resident #30's snack was still on the food cart and had not been delivered to the Resident.
k) Resident # 6
A review of Resident # 6's medical record revealed the following diet orders:
- HSG Regular diet HSG Dysphasia Advanced texture, Thin consistency.
-House Protein Supplement two times a day house shake BID (twice daily) at 2:00 PM and 8 :00 PM snack to provide 400 calories and 12 gm protein to prevent weight decline.
A review of Resident #6's POC (Point of Care) Response History for 07/19/22 at 7:00 PM revealed the evening snack documented was 76-100% eaten.
On 07/19/22 at 11:35 PM, the evening snack for Resident #6 was found on the food cart beside the north side nursing station and was not delivered.
On 07/19/22 at 11:50 PM, Human Resource Manager (HRM) confirmed Resident #6's snack was still on the food cart and had not been delivered to the Resident.
L) Resident #7
A review of Resident # 7's medical record revealed the following diet orders:
-Consistent Carbohydrate diet Regular texture, Thin consistency, for nutrition
-Specify in Special Instructions at bedtime for Planned snack from dietary.
A review of Resident #7's POC (Point of Care) Response History for 07/19/22 at 7:00 PM revealed the evening snack documented 26-50% eaten.
On 07/19/22 at 11:35 PM, evening snack for Resident #7 was found on the food cart beside the north side nursing station undelivered to the resident.
On 07/19/22 at 11:50 PM, Human Resource Manager (HRM) confirmed Resident #7's snack was still on the food cart and had not been delivered to the Resident.
M) Resident #22
A review of Resident # 22's medical record revealed the following diet orders:
-Regular diet Dysphasia Mechanical texture, Thickened Liquid Honey consistency
-Frozen Nutrition Treat in the morning Planned snack from dietary and in the afternoon Planned snack from dietary and at bedtime.
A review of Resident #22's Medication Administration Record (MAR) for 07/19/22 at 8:00 PM found the Frozen Nutrition Treat at bedtime was marked as given.
On 07/19/22 at 11:35 PM, the evening snack for Resident #22 was found on the food cart beside the north side nursing station undelivered to the resident.
On 07/19/22 at 11:50 PM, Human Resource Manager (HRM) confirmed Resident #22's snack was still on the food cart and had not been delivered to the Resident.
N) Resident #36
A review of Resident # 36's medical record revealed the following diet orders:
-Regular diet -Regular texture, Thin consistency, no salt packets
A review of Resident # 36's medical record found the following Nutritional Diagnosis review:
Resident with nutrition concern r/t (Related to) underweight status as evidenced by BMI (body mass index) <18.5.
Meds reviewed and include Cozaar, Aricept, Cymbalta, HCTZ, protonix. Supplements with MVI, iron, vitamin C and B12, folic acid.
Estimated needs to promote gradual weight gain: 1680-1965 kcal (kilocalories)/day (30-35 kcal/kg (kilograms)/d (day)), 67 gm (grams) protein/day (1.2 gm/kg/day), 1 (one) ml fluid/kcal/day.
Regular diet (NSP){non-starch polysaccharides} provides ~2330 kcal/91 gm protein/day. Resident meets combined needs with 70-75% intakes. Appears resident is meeting needs with current intakes.
Observed lunch meal- resident was eating well- stated he did not want to add ONS- says he only has partial stomach- when he eats too much it goes right through him. Did say having a planned snack at night would be good.
A review of the Care Plan Focus and interventions found:
Care Plan Focus:
· Nutritional Risk r/t hx (history) of underweight status as evidenced by BMI <18.5, recent weight gain.
Care Plan Intervention:
·Provide regular/regular NSP diet as ordered. HS (at bed time) snack to boost energy intakes.
A Review of Resident # 36's MAR (medication administration record) and POC (point of care) Response History found no documentation of a snack given on 07/19/22 at 8:00 PM.
On 07/19/22 at 11:35 PM, evening snack for Resident #36 was found on the food cart beside the north side nursing station undelivered to the resident.
On 07/19/22 at 11:50 PM, Human Resource Manager (HRM) confirmed Resident #36's snack was still on the food cart and had not been delivered to the Resident.
O) Resident #62
A review of Resident # 62's medical record revealed the following diet orders:
- Regular diet HSG Regular texture, Thin consistency, for diet
A review of Resident # 62's diagnosis revealed a diagnosis of type two (2) diabetes mellitus without complications.
A review of Resident # 62's POC (point of care) response history for 07/19/22 for the HS (Take at bedtime) Snack marked NA (not applicable).
On 07/19/22 at 11:35 PM, the evening snack for Resident #62 was found on the food cart beside the north side nursing station undelivered to the resident.
On 07/19/22 at 11:50 PM, Human Resource Manager (HRM) confirmed Resident #62's snack was still on the food cart and had not been delivered to the Resident.
p) Resident #424
On 07/19/22 at 12:33 PM, Resident # 424 call light was observed to be on. Several facility staff members were in the hallway passing lunch trays. Licensed Practical Nurse (LPN) #27 was observed to walk by Resident #424's room, look in and walk on by.
On 07/19/22 at 12:40 PM, Human Resource Manager (HRM) went into Resident #424's room with a lunch tray but did not address the call light concern.
On 07/19/22 at 12:42 PM, in an interview with Resident #424 when asked if her needs were met for the call light. Resident # 424 stated no I need changed. When asked how long her call light had been on resident # 424 stated I don't really know, but for a long time. I wanted to get changed before lunch.
On 07/19/22 12:43 PM, Business Office Manger # 3 went into Resident #424's room and answered the call light.
On 07/19/22 at 1:45 PM, HRM stated when asked about answering Resident #424's call light I didn't think about the call light, I was thinking about the tray.
On 07/19/22 at 1:50 PM, Corporate Nurse acknowledged staff passing trays should be able to answer call light needs.
Q) Resident #52
A review of Resident #52's record found an order for blood glucose monitoring that stated Blood Glucose Test Strip (Glucose Blood) - 1 application in vitro two times a day every Tue related to type 2 diabetes mellitus without complications. Notify MD [medical doctor] if BS [blood sugar] <70 or >400. Order date 10/19/21.
On 07/19/22 at 4:03 PM Licensed Practical Nurse (LPN) #52 was asked to clarify the route of in vitro as indicated for obtaining the Residents blood glucose reading. The LPN replied Nothing is happening in vitro here [at the facility], I just do a regular finger stick. That order is wrong, and needs modified.
On 07/20/22 at 3:15 PM Corporate Registered Nurse(RN) #91 stated, Yea that's definitely a typo or they just picked the wrong route. We will get that changed.
Review of the Resident's Mediation Administration Record indicated the 9:00 PM blood sugar was not obtained on 07/05/22 as ordered.
r) Resident #68
Review of Resident's medical record on 07/21/22 showed a Provider Note created 07/19/22 at 5:40 PM by the facility's physician. The note indicated the resident was seen in the room during morning rounds. An order was dictated within the note that stated the resident had a UTI (urinary tract infection) with Proteus mirabilis bacteria greater than 100 K and to start Bactrim DS (antibiotic) one (1) tablet twice a day for a total of 10 days.
Review of the Resident's Mediation Administration Record (MAR) on 07/21/22 at 8:05 AM showed the antibiotic had not been started.
On 07/21/22 at 8:30 AM LPN #47 verified at med pass the Resident was not receiving Bactrim DS at this time.
During an interview on 07/21/22 08:51 AM Corporate RN #91 verified the Bactrim DS should have been started on 07/19/22 as indicated by the physician note.
On 07/21/22 at 11:39 AM LPN #29 stated the note entered on 07/19/22 by the physician was a mistake. The Resident has already received the Bactrim DS antibiotic in May 2022 and the physician must have been looking at an old lab. LPN #29 confirmed the physician note regarding the UTI was a transcription error.
s) Resident #66
A review of Resident #66's medical record found orders of Ativan 2 milligrams per 5 milliliters (2ml/5ml)- give 0.6 mg every six (6) hours as needed for anxiety and Oxycodone 10 mg/ml- give 6mg every four (4) hours for pain.
Review of Resident #66's medical records found the as needed Ativan was documented on Narcotic Record as removed but the Ativan was not documented on the medication administered (MAR) to indicate it was administered to Resident #66 on the following occasions:
06/29/22 at 5:00 pm
06/30/22 at 7:30 pm
07/02/22 at 3:00 pm
07/04/22 at 10:00 am and 4:00 pm
07/05/22 at 8:00 am and 2:00 pm and 8:00 pm
07/11/22 at 9:00 am and 3:00 pm
07/15/22 at 10:00 am
Review of Resident #66's medical records found the as needed Oxycodone was documented on Narcotic Record as removed but the Oxycodone was not documented on the medication administered (MAR) to indicate it was administered to Resident #66 on the following occasions:
06/29/22 at 5:00 pm
06/30/22 at 7:30 pm
07/01/22 at 3:25 pm
07/02/22 at 9:00 am and 2:00 pm and 6:00 pm
07/04/22 at 10:00 am and 4:00 pm
07/05/22 at 12:00 pm and 4:00 pm
07/11/22 at 9:00 am and 1:00 pm
07/15/22 at 10:22 am
On 07/20/22 at 12:45 pm the Narcotic records and MAR for the above-mentioned dates were reviewed with the Interim Director of Nursing (DON). She confirmed the above-mentioned dates and times indicted the narcotics (Ativan and Oxycodone) were removed from the narcotic count but not administered to Resident #66.
No further information provided.
s) Resident #67
Review of Resident #67's medical records found a physician order for Novolog insulin; inject subcutaneously with meals for diabetes. Hold Novolog if blood sugar less than 150. Effective date: 05/24/22.
Review of Resident #67's Medication Administration Record (MAR) for the following dates and times the blood sugar was less than 150 and the Novolog was administered but should have been held according to the physician-ordered parameters:
06/04/22 at 5:30 pm- blood sugar- 129
06/05/22 at 5:30 pm- blood sugar- 134
06/15/22 at 12:30 pm- blood sugar- 143
06/22/22 at 8:00 am- blood sugar- 148
06/23/22 at 8:00 am- blood sugar- 134
06/27/22 at 8:00 am- blood sugar- 136
06/27/22 at 12:30 pm- blood sugar- 136
06/27/22 at 5:30 pm- blood sugar- 136
06/30/22 at 8:00 am- blood sugar- 119
06/30/22 at 5:30 pm- blood sugar- 115
07/02/22 at 8:00 am- blood sugar- 119
07/02/22 at 12:30 pm- blood sugar- 133
07/02/22 at 5:30 pm- blood sugar- 139
07/03/22 at 8:00 am- blood sugar- 147
07/03/22 at 5:30 pm- blood sugar- 109
07/06/22 at 12:30 pm- blood sugar- 147
07/10/22 at 12:30 pm- blood sugar- 133
07/14/22 at 8:00 am- blood sugar- 145
07/17/22 at 8:00 am- blood sugar- 119
07/17/22 at 5:30 pm- blood sugar- 123
07/19/22 at 8:00 am- blood sugar- 119
Additionally, on the following times and dates the blood sugars were not documented:
At 8:00 am on 06/01/22, 06/02/22, 06/05/22, 06/06/22, 06/11/22, 06/12/22, 06/13/22, 06/20/22, 06/21/22,06/24/22, 06/25/22, 06/26/22, 07/01/22, 07/05/22, 07/08/22, 07/11/22, and 07/18/22.
At 12:30 pm on 06/06/22, 06/12/22, 06/13/22, 06/20/22, and 06/28/22.
At 5:30 pm on 06/02/22, 06/06/22, 06/11/22, 06/12/22, 06/13/22, 06/18/22, 06/19/22, 06/20/22, 06/25/22, 06/29/22, 07/08/22, 07/15/22, and 07/18/22.
On 07/20/22 at 12:45 pm the MAR for Resident #67 for the above-mentioned dates was reviewed with the Interim Director of Nursing (DON). She confirmed the above-mentioned dates and times it indicted the Novolog was administered when blood sugar was less than 150 and it should have been held. She also confirmed the above-mentioned dates and times the blood sugars were not recorded. No further information provided.
t) Resident #28
Review of Resident # 28's medical records found an order for No blood pressures to be obtained in the left arm, effective date was 01/22/22.
Review of Resident #28's electronic vital sign (blood pressure) found the blood pressure was obtained in the left arm on the following dates: 06/06/22, 06/10/22, 06/12/22, 06/13/22, 06/15/22, 06/18/22, 06/21/22, 06/24/22, 07/01/22, 07/16/22, 07/18/22, and 07/19/22.
On 07/20/22 at 12:45 pm the electronic vital signs (blood pressures) for Resident #28 for the above-mentioned dates were reviewed with the Interim Director of Nursing (DON). She confirmed the above-mentioned dates the blood pressures were taken in the left arm. She also confirmed the blood pressure should not have been obtained in the left arm. No further information provided.
w) Resident #273
Resident #273 had 2 (two) falls on 4/25/22. One at 6:19 PM and according to the nurses progress note dated 4/25/22 at 1:38 AM another fall at 10:40 PM.
When the resident fell at 10:40 PM, the facility failed to complete the appropriate documentation. There was no Risk Management System report completed, no neurological checks completed (it was an unwitnessed fall) and no Interdisciplinary Team (IDT) notes.
According to the Nurses note on 4/25/22 at 10:40 PM. there were orders from the Physicians Assistant to complete neurological checks, bilateral floor mats by the bed and enter the residents name in the Physicians book for further evaluation in the morning by the Physician. There were no neurological checks performed according to lack of documentation.
This was confirmed with the Corporate Registered Nurse #91 on 7/20/22 at 11:58 AM.
.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to maintain an environment that was free of accident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to maintain an environment that was free of accidents and hazards. Medication was left unattended in Resident #68's room. A Medication cart was left unlocked and unattended for an extended period. Fall protocol was not followed for Resident #6. Resident #22 consumed a snack not permitted within his diet order. The facility failed to modify and monitor the effectiveness of fall interventions for Resident #273 and Resident #177. These findings were a random opportunity for discovery and had the potential to affect more than a limited number of Residents. Resident identifiers: #68, #6, #22, #273, and #177. Facility census: 74.
Findings included:
a) Resident #68
On 7/18/22 at 12:33 PM an observation was made of Phytoplex protectant z-guard paste (used for wetness protection to prevent and treat diaper rash) laying on the Resident's wheeled over bed table in the Resident's room. The tube of paste had the Resident's last name written on it with black marker. Registered Nurse (RN) #37 verified the medication should not have been left out on the over bed table and removed it from the room. Warning label on back of medication stated for external use only and to keep out of reach of children.
On 7/19/22 at 9:43 AM the following list of wandering Residents that could have had access to the medication left at bedside was provided by Registered Nurse (RN) #37: R #51, #22, #37, #6, #29, #38, #9, #24, #27, #58, #55, #30, and #34.
The Material Safety Data Sheet (MSDS) provided by the facility for the Phytoplex protectant z-guard paste stated if eye contact was made to flush eyes with water for 15 minutes and seek immediate attention. If swallowed, call physician immediately.
b) Medication Cart
Upon an after hour visit to the facility on [DATE] at 10:45 PM, the medication cart (labeled Medication Cart South 101-117) was found unattended and unlocked setting at the nurse's station. Resident #22 was roaming the area of the nurse's station at that time. At 11:05 PM, Licensed Practical Nurse (LPN) #22 came out of the covid unit and placed a laptop on top of the cart. LPN #22 was asked if she could identify anything wrong with the mediation cart and she stated, Oh I left it unlocked.
C) Resident #6
A review of the form provided by the facility called Falls-Clinical Protocol found the following:
.2. In addition, the nurse shall assess and document/report the following:
g. Frequency and number of falls since last physician visit;
h. Precipitation factors, details on how fall occurred;
j. All active diagnoses .
On 07/18/22 at 1:10 PM, during the long term care survey process interview, Resident # 6 stated I fell off bed while I was sleeping. They have taken my side rails. I need them back or something to keep me from falling on the floor.
A Review of Resident # 6's Care Plan Focus found the following: I have fallen and am at high risk for more falls r/t (related to) weakness in BLE (bilateral extremities), non healed right tri-malleolar fracture, right knee prosthesis, abnormalities of gait and mobility, muscle weakness, difficulty in walking, visual disturbance, and Antidepressant use.
A review of Resident # 6's medical record found an entry dated 6/5/22 at 1:33 PM, which read as follows: Nurses Note: This nurse spoke with MPOA about facility discontinuing side rails. MPOA voiced understanding without concern.
A continued review of the medical record found an entry dated 7/17/22 at 3:30 PM, which read as follows: .Change in Condition Fall : Background / General Information: Nursing was called to room by roommate to alert us of fall. Upon entering the room this resident was sitting upright on the floor on the right side of the bed. Her roommate stated that she simply rolled out of bed in her sleep. Resident denies any pain. She was assisted back to bed and a skin check and their assessment was done as well as vitals taken. Physician Notification: (Name, Date and Time): Name of facility physician at 7:00 AM
Interventions:: Bed lowered to floor
Family / Representative Notification: (Name, Date and Time): Attempted to call daughter MPOA
Family Response:: No answer.
07/19/22 at 9:05 AM, Corporate Nurse #91 acknowledged no preventions or assessments were done or put in place after Resident # 6's fall.
D) Resident #22
A review of Resident #22's capacity form found the following: Resident #22 lacks sufficient mental or physical capacity to appreciate the nature and implication of health care decisions. Expected duration of incapacity long term.
A review of Resident # 22's medical record revealed the following diet orders:
-Regular diet Dysphasia Mechanical texture, Thickened Liquid Honey consistency
-Frozen Nutrition Treat in the morning Planned snack from dietary. AND in the afternoon Planned snack from dietary. AND at bedtime.
A review of Resident #22's Medication Administration Record (MAR) for 07/19/22 at 8:00 PM found the Frozen Nutrition Treat at bedtime was marked as given.
On 07/19/22 at 11:06 PM this surveyor along with two (2) other surveyors observed Resident #22 ambulate to the undelivered 7:00 PM snacks found on the food cart beside the north side nursing station. Resident #22 then pick up Resident #36's peanut butter and jelly sandwich and ate it. Resident # 22 then walked down the hallway agitated. Licensed Practical Nurse (LPN) #5 asked Resident # 22 if he wanted a chocolate milk. LPN#5 then proceeded to obtain a chocolate milk from the refrigerator from behind the nurse's desk on the north side. Resident #22 was then given a single serving carton of regular chocolate milk. Resident # 22 then proceeded to drink the chocolate milk.
On 07/20/22 at 9:19 AM, When asked what would be served with mechanical texture diet. Account Manger# 92 stated we would give them things like pudding, nutritional ice cream and peanut butter and jelly sandwiches. When asked if the facility staff or the kitchen staff thickens the milk Account Manager #92 stated I do, but I leave thickener in the refrigerant for night shift. When asked when evening snacks were dropped off, Account Manger #92 stated evening snacks are dropped off around 7:30 PM to 8:00 PM.
On 07/20/22 at 9:20 AM, When asked if regular chocolate milk would be given on a Regular Dysphasia Mechanical texture, Thickened Liquid Honey consistency diet Speech therapy # 70 stated no chocolate milk should be given unless it is honey thickened.
On 07/20/22 at 10:34 AM when asked if it was OK to give Resident # 22 chocolate milk. Facility Physician stated Resident #22 was OK to have regular milk that he (facility physician) needed to change Resident #22's diet to Regular; his diet was changed to mechanical due to his medications and they have now regulated his medications .
07/20/22 at 1:05 PM, Corporate Nurse #91 acknowledged no preventions were in place to prevent Resident # 22 from obtaining food that was not on his ordered diet.
e) Resident #273
Resident #273 had a fall on 5/01/22 during breakfast meal tray pass. The fall was an unwitnessed fall with no injury. There were no neurological checks performed for this unwitnessed fall. The Interdisciplinary Team note dated 5/01/22 at 9:51 AM reads nursing to complete bed positioning observation every 2 (two) hours for 72 hours. There is no documentation of this being completed.
These findings were confirmed on 7/20/22 at 10:10 AM with the Interim Administrator #90.
f) Resident #177
Review of medical records revealed Resident #177 had unwitnessed falls that occurred in her room on the following days:
*04/29/22
*04/27/22
*04/29/22
*06/16/22
*06/20/22
* 06/21/22: 12:31-4:01 pm
*06/22/22
*07/3/22 2:15 pm and 7:11 PM
On 07/03/22 Resident #177 had two falls the last one was approximately five minutes after returning to the facility from (named local hospital), which ended with this resident being admitted into the neuro critical care unit. In addition, this resident still has not returned to the facility.
Resident # 177 was in room [ROOM NUMBER] which is not visible or in close proximity to the nurse's station.
Resident #177 had 11 falls in a four (4) month time frame. the following are the interventions that were put in place per the care plan:
*Dycem to her wheelchair to prevent the cushion from slipping out.
*Encourage resident to attend activities of choice for engagement.
*Ensure resident's bed is made upon waking in the morning.
*Help me get to bathroom often si that I don't wait until I have an urgent need to go.
*Offer and assist with toileting every two (2) hours.
*So, I don't wait until I have urgent need to go, remind me to go to the bathroom before/after breakfast, lunch, activities, dinner, and at bedtime.
*When out of bed encourage to be in common area for frequent staff observation.
There was not any mention of:
Wearing non-slip footwear.
Frequent checks and monitoring resident.
Moving resident closer to the nurse's station (was located at the end of the hall away from the nurse's station).
Fall mats.
Bed kept in lowest position. All of which are common interventions to help prevent falls and/or injuries from falls.
On 07/21/22 at 8:23 AM, Corporate Nurse (CN)#91 agreed more interventions could have been made. CN #91 stated she was going to look farther to see if there was a reason for not using fall mats.
No additional information was provided at the close of the survey.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
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Based on record review and staff interview, the facility failed to assure that all nursing staff possess the competencies and skill sets to provide care and services to meet the residents' needs saf...
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Based on record review and staff interview, the facility failed to assure that all nursing staff possess the competencies and skill sets to provide care and services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being. (In relationship with reporting and resolving grievances, abuse and neglect policies including following policy, prevent, reporting and investigating of allegations of abuse/neglect, transfer requirements and use of Bedhold policy to ensure a safe and effective transfer/discharge of residents, following physician orders, providing appropriate respiratory care, provide pharmacy needs concerning monthly review and use of unnecessary prn psychotropic prn medication use, proper labeling and storage of medication, an effective infection control program, and appropriate education and administration of Covid-19 vaccinations . This deficient practice had the potential to affect all residents residing in the facility. Facility census: 74
Findings include:
a) Cross Reference 585
b) Cross Reference 578
c.) Cross Reference 607
d) Cross Reference 609
e) Cross Reference 610
f) Cross Reference 622
g) Cross Reference 623
h) Cross Reference 625
i) Cross Reference 684
J) Cross Reference 689
k) Cross Reference 695
L) Cross Reference 755
m) Cross Reference 756
n) Cross Reference 761
o) Cross Reference 880
q) Cross Reference 887
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
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Based observation, policy, and staff interview, the facility failed ensure all multi-dose vials which have been opened or accessed (e.g., needle-punctured), and medications designed for multiple adm...
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Based observation, policy, and staff interview, the facility failed ensure all multi-dose vials which have been opened or accessed (e.g., needle-punctured), and medications designed for multiple administrations (e.g., inhalers, eye drops) are dated with the initial date they were opened and accessed. This was a random opportunity for discovery and had the potential to affect more than a limited number of newly admitted residents. Resident identifiers: #49, #21, #18, #68, #39, #9, #29, #71, #424, #67, and #4. Facility census 74.
Findings included:
a) Medication cart 135-150
On 07/19/22 at 8:51 AM, an observation of the medication cart 135-150, with Licensed Practical Nurse (LPN) #52. LPN #52 verified the following:
No open dates on the any of the multi-dose medications.
Two (2) out of eight (8) insulin pens:
Resident # 49's Lantus
Resident # 21's Lantus
One (1) out of two (2) tubes of eye ointment:
Resident # 18's Gentle tear ointment,
One (1) out of two (2) bottles of nitroglycerin:
Resident # 68's nitro
Seven (7) out of eight (8) inhalers:
Resident # 39's Albuterol
Resident # 49's Pro air
Resident # 9's Combivent and Budes/format and Symbicort
Resident # 25's Incruse
Resident # 68's Incruse
On 07/19/22 10:28 AM, Interim Administrator was informed of the above findings.
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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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, food temperature measurement, resident and staff interview the facility failed to provide food and dri...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, food temperature measurement, resident and staff interview the facility failed to provide food and drink that is palatable, attractive, and at a safe and appetizing temperature. This was true for seven (7) out of 10 residents reviewed for food. Resident identifiers: Resident #3, #60, #56, #44, #67, #29, and #71. Facility census 74.
Findings included:
a) Resident #3
On 07/18/22 at 2:32 PM, Resident #3's daughter stated her father is not happy with the diet and feels like he does not get enough to eat.
On 07/19/22 at 2:32 PM, Resident # 3 did not get his lunch until 2:32 PM today, and it was penne noodles and meatless red sauce. Resident # 3 stated he would be happy to eat a ham sandwich.
When he gets a hot dog, it is only one with a [NAME] on a bun two packets of mustard and ketchup, portion sizes are small. Food is not always very warm.
b) Resident #60
During the first phase of the survey process Resident #60 reported on 07/18/22 at 2:21 PM, that the food is not good, no seasoning, not hot enough, and very small portion sizes.
c) Resident #56
On 07/18/22 at 12:24 PM, Resident #56 was asked if they were happy with the food. Resident #56 said, the food is awful does not taste good and is not always warm enough.
d) Resident #44
On 07/18/22 at 12:03 PM, Resident #44 said the food is cold, small portion sizes, taste bad because of no seasoning on it.
e) Temperatures
Food temperature checked on the south hall on 07/19/22 at 12:57 PM, Kitchen Manager checked the temperature of the food in the Styrofoam box. Baked Ziti 119 degrees, garden salad 62 degrees. Kitchen Manager agreed the Baked Ziti was not hot enough and the salad was too warm.
On 07/19/22 at 2:27 PM, the Administrator was informed of the above findings.
f) Resident #67
Concern form for Resident #67 dated 02/22/22 read: Food not served at correct temps. Cold food is warm and hot food is cold.
Action taken read: Met with resident during mealtime to test the temps of her food items. Chicken was 141 degrees; green beans was 143 degree and fruit cup were 38 degrees. I told her to please let me know if she gets any other foods she feels is not at temps.
On 07/17/22 at 2:10 pm an interview with Resident #67, revealed she receives cold meals a lot of times.
On 07/20/22 at 12:40 pm, the Dietary Manager was observed by this surveyor, obtained temperature of Resident #67's tray which revealed the Hot dog [NAME] was cold at 124 degrees. The preferred and safe temperature should be 135 degrees or higher. The DM confirmed the above-mentioned temperatures in which he obtained with the facility's thermometer.
g) Resident #29
On 07/20/22 at 12:40 pm, the Dietary Manager was observed by this surveyor, obtained temperature of Resident #29's tray which revealed the green bean soup was cold at 131 degrees. The preferred and safe temperature should be 135 degrees or higher. The DM confirmed the above-mentioned temperatures in which he obtained with the facility's thermometer.
h) Resident #71
During an interview on 07/18/22 at 1:54 PM, Resident #71 stated that dinner was dry and overdone last night with no taste. The resident further stated the only alternative is hotdogs, and they are tough skinned and hard to eat. The Resident stated, They put gravy on everything, I guess to cover up the taste.
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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, and staff interview, the facility failed to properly store food in a sanitary manner in accordance with professional standards for food service safety. The facility also failed...
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Based on observation, and staff interview, the facility failed to properly store food in a sanitary manner in accordance with professional standards for food service safety. The facility also failed to correctly document the three compartment sink temperatures, the walk-in refrigerator and two freezer temperatures. This deficient practice has the potential to affect more than a limited number of residents. Facility Census: 74.
Findings Included:
a) Walk-In Refrigerator
During an initial visit of the kitchen on 07/18/22 at 11:10 AM with Account Manager (AM) #92 the walker-in refrigerator revealed a plastic bin labeled employee drinks with:
-one (1) two (2) liter bottle of opened mountain dew
-one (1) two (2) liter bottle of unopened mountain dew
-one (1) unopened can of sprite
-one (1) unopened can of mountain dew
-one (1)unopened can of coke.
During an interview AM #92 stated The Health department said as long as they are in a separate bin we can store the employee drinks in the same refrigerator as the residents food.
b) Three- Compartment Sink Temperatures
On 07/18/22 at 11:10 AM the Three-Compartment Sink Temperature Log was completed for the lunch and dinner section with the following temperatures.
Lunch:
Time: 12
Wash: 120
PPM: 300
Initials: LG
Dinner:
Time: 6
Wash: 120
PPM: 300
Initials: LG
During an interview with the AM #92 acknowledged the temperature log for the sink was completed for the day and should not have been.
c) Refrigerator Temperature
On 07/18/22 at 11:10 AM the Refrigerator Temperature Log was completed for the PM shift section with the follow temperatures:
PM Temperature:
Temp: 38
Initials:LG
During an interview on 07/18/22 with AM #92 acknowledged the temperature log was completed for the PM shift and should not have been.
d) Walk-in Freezer Temperature
On 07/18/22 at 11:10 AM the Walk-In Freezer Temperature Log was completed for the PM shift section with the follow temperatures:
PM Temperature:
Temp: -1
Initials:LG
During an interview on 07/18/22 with AM #92 acknowledged the temperature log was completed for the PM shift and should not have been.
e) Freezer Temperature
On 07/18/22 at 11:10 AM the freezer Temperature Log was completed for the PM shift section with the following temperatures:
PM Temperature:
Temp: 1
Initials:LG
During an interview on 07/18/22 with AM #92 acknowledged the temperature log was completed for the PM shift and should not have been.
No further information or policies was provided through the completion of the survey.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, observation and staff interview the facility failed to implement and maintain visitor and employee sur...
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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 and maintain visitor and employee surveillance for COVID-19 and to ensure and maintain an infection prevention control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. The facility failed to monitor employees entrance screening surveillance for COVID-19, Staff was not wearing PPE upon surveyor entry to the facility, Residents in Isolation for COVID-19 rooms had doors open and gowns hanging on outside of door, perform hand hygiene before meals, Hand wipe container taken into Resident rooms, staff coming out of Resident room without N95 mask on and staff wearing PPE (personal protective equipment) improperly. This had the potential to affect more than a limited number of residents residing in the facility. Facility Census 74.
Findings Included:
a) entrance screening
A Review of 07/19/22 Tuesday's Facility assignments showed Licensed Practical Nurse (LPN) #18 worked 11 PM to 7 AM as a Nurse Aide (NA).
A review of the facility's COVID-19 Tracker screening form for employees does not show LPN #18 being screened in on 07/19/22 before starting work.
On 07/20/22 at 8:16 AM, when asked if LPN # 18 had been screened for COVID-19 before starting work. Human Resource Manager stated No, she walked right by the desk on her way in.
b) Night time facility survey
On 07/19/22 at 10:45 PM this surveyor along with two (2) other surveyors went to the facility and rang the door bell for entrance. CNA (certified nurse aide) # 42 answered the door without any PPE (personal protective equipment) on. The sign on the front door announced the facility to be in COVID outbreak. Upon walk through the following infection prevention control issues were noted:
-Staff was not wearing PPE upon surveyor entry to the facility,
-Residents in Isolation for COVID-19 rooms had doors open and gowns hanging on outside of door,
-Licensed Practical Nurse (LPN) #5 wearing a surgical mask under a N95 mask,
-LPN #22 had personal items on top of Medication cart,
-Clean linens were on top of dirty linen cart
Signs on isolations doors read as follows:
1)Pleas keep door shut!!!
2)Enhanced Precautions
To Prevent the spread of infection,
Anyone entering this room must wear:
N95, gloves, gown, eye protection
Applies whether or not contact with the patient or the patients's environment is anticipated.
Applies to all persons who enter the room including visitors
On 07/19/22 at 11:45 PM Infection Preventionist (IP) stated when asked why there is a hanger for the gowns on the outside to the doors They (facility staff) keep doing this. I keep taking the hangers off the doors, but the staff keep putting them back on.
ON 07/20/22 at 7:45 AM the interim Administrator acknowledged the breaks in infection control.
c) Resident Hand Hygiene
An observation on 07/19/22 at 12:20 PM during the serving of lunch meal trays no sanitizing of resident hands on North Hall.
During an interview on 07/19/22 at 12:25 PM Nurses Aide (NA) #32 stated I assume someone wash their hands, I am unsure if someone done it. NA #32 went to nurses station to obtain a container of sani hand wipes and started going into residents rooms to clean their hands. NA #32 went to Resident #59 room and this surveyor followed her in the room.
An interview on 07/19/22 at 12:27 PM with Resident #59 stated, No they don't wash my hand, they don't use those wipes, no they have not wash my hands today or any other day.
On 07/19/22 at 12:39 PM informed the Staff Development Coordinator #29 of no hand hygiene prior to lunch meal being served.
d) Facility
On 7/19/22 it was witnessed when employee #87 from housekeeping and laundry entered the building at 10:00 AM without an N95 mask on as they are in outbreak. She did not stop at the screening station located in the front lobby. As she proceeded down the hallway, the surveyor said You need to have a mask on and she replied I know, I'm going to get it back there. At which time the surveyor said you need to get it here. The employee turned back and went to the screening station. Upon review of the employee screening log at that time it was found to have only 2 (two) of the 15 (fifteen) nursing-skilled employees scheduled to come in at 7:00 AM on 7/19/22 on the screening.
Scheduled for 7/19/22 7:00 AM and not screened were:
Licensed Practical Nurse (LPN) #54
LPN #52
Certified Nurse Aide (CNA) # 42
CNA #40
Medical Records Staff #38
Minimum Data Set Coordinator #37
LPN #31
Staff Development Coordinator #29
CNA #23
LPN #17
CNA #16
Registered Nurse #8
CNA #59
This was confirmed on 7/19/22 at 10:15 AM with the Interim Administrator #90.
e) Licensed Practical Nurse (LPN) #49
On 07/21/22 at 9:46 AM LPN #49 was observed coming out of room [ROOM NUMBER] on the covid unit with mask down around her chin blowing air out of her mouth. Surveyor asked LPN #49 if she should wear her N95 mask like that while on the covid unit? LPN #49 stated, It's so hot in here I am sick. The facility was currently in a Covid-19 outbreak.
At 10:30 AM on 07/21/22, the facility's staff educator stated she will be counseling LPN# 49 on the proper use of N95 masks while in the facility.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected multiple residents
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Based on record review and staff interview the facility failed to educate and obtain consent prior to administering their COVID-19 vaccinations. This was true for 4 (four) of 5 (five) residents revi...
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Based on record review and staff interview the facility failed to educate and obtain consent prior to administering their COVID-19 vaccinations. This was true for 4 (four) of 5 (five) residents reviewed for vaccinations. Resident Identifiers: #14, #32, #52, and #71 Facility Census: 74
Findings Included:
On 7/20/22 while reviewing vaccinations records on 5 (five) randomly selected residents the following information was gathered.
Consents and refusals were reviewed and correct for influenza, pneumonia, and Prevnar vaccinations.
However, COVID vaccine education and consents could not be located for 4 (four) of the 5 (five) records reviewed. This was confirmed with the Interim Administrator #90 on 7/20/22 at 10:00 AM and again with the Staff Development Coordinator #29 on 7/21/22 at 10:40 AM. The following residents were found to be out of compliance:
-- Resident #14
influenza 10/11/21
pneumonia refused refusal reviewed
Prevnar refused refusal reviewed
COVID 1) 12/23/20 2) 1/20/21 3) 11/23/21 no education or consents
-- Resident #52
influenza 10/11/21
pneumonia 2/1/12
Prevnar 12/4/17
COVID 1) 12/23/20 2) 1/20/21 3) 11/23/21 no education or consents
-- Resident #71
influenza 10/11/21
pneumonia 9/24/15
Prevnar 12/4/17
COVID 1) 12/12/20 2) 1/20/21 3) 11/23/21 no education or consents
-- Resident #32
influenza 10/11/21
pneumonia refused refusal reviewed
Prevnar refused refusal reviewed
COVID 1) 8/24/21 2) 9/29/21 3)4/7/22 no education or consents
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected multiple residents
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Based on observation and staff interview the facility failed to ensure the call light system used for communication was functioning properly throughout the facility. This failed practice was a rando...
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Based on observation and staff interview the facility failed to ensure the call light system used for communication was functioning properly throughout the facility. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility census: 74.
Findings Included:
During an after-hour survey on 07/19/22 at 11:34 PM an observation was made of call lights constantly alarming (beeping) with no indicator lights on the panel box to specify what room. Licensed Practical Nurse (LPN) #5 stated That's the ghost light it does that. One of the bathroom lights may not be pushed up all the way, it beeps all the time. It has been doing it for a long time.
On 07/20/22 at 8:12 AM Maintenance Director #21 stated that the call lights not working properly was nothing new. Maintenance Director #21 further stated that the main panel was just replaced on June 23rd, 2022, and the staff know that if it is alarming all the time, the bath stations may need reset. Maintenance Director #21 stated, They [staff] have to take the time to reset them, they are supposed to reset the bath stations in each room when they put the Resident to bed before leaving the room. Maintenance Director (MD) #21 further clarified the call bell would have to be reset in the all the bathrooms, including resident bathrooms, shower rooms and anywhere in the facility where a pull station was found.
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Apr 2021
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
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Based on observation and interview, the facility failed to ensure one (1) of three (3) residents with a urinary drainage system was provided care with dignity. The urine drainage container was not c...
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Based on observation and interview, the facility failed to ensure one (1) of three (3) residents with a urinary drainage system was provided care with dignity. The urine drainage container was not covered, and urine was visible in the canister. Resident #25. Facility census: 69
Findings included:
An observation, on 04/05/21 at 12:40 PM, revealed Resident #25 in bed. A urinary drainage canister, with urine present, was located on the bedside table that was visible to anyone entering the room. The drainage canister was not covered.
An interview, with the Director of Nursing (DON), on 04/06/21 at 02:33 PM, revealed the DON was aware the canister was uncovered exposing the urine but was not sure what to use to cover the urine container.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
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Based on resident interview, observation and staff interview, the facility failed to provide one (1) of twenty-one sampled residents a safe, clean, comfortable and homelike environment. The facility...
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Based on resident interview, observation and staff interview, the facility failed to provide one (1) of twenty-one sampled residents a safe, clean, comfortable and homelike environment. The facility failed to change Resident #271's soiled bed linens in a timely fashion. Resident identifier: #271. Facility census: 69.
Findings included:
a) Resident #271
During a resident interview on 04/05/21 at 12:12 PM, Resident #271 stated, If I had my own linens, I would change my own sheets. My bed linens haven't been changed since Friday [04/02/21]. Resident #271 showed Surveyor a small brown spot approximately the size of a pencil eraser on her top sheet and two brown smudges approximately ½ inch in length on the cloth chucks [absorbent fabric] lying on her bed saying, My knee wound has been bleeding a little and it's getting all over my bedding.
On 04/06/21 at 10:00 AM, Resident #271's top sheet had an additional brown smudge approximately the size of a fifty-cent piece that was immediately noticeable when Surveyor entered the room. Resident #271 was up in her wheelchair and expressed agitation about her bedding not being changed even though it was visibly soiled. Resident #271 stated, They came yesterday [04/05/21] to offer me a shower but did not offer to change my bloody sheets. Now there is even more blood on my sheets. Resident #271 went on to say that she would never leave soiled linens on her bed in her own home noting, It's just not sanitary.
LPN #26 entered resident's room on 04/06/21 at 10:15 AM. Resident #271's concern regarding soiled bedding was brought to LPN #26's attention. LPN #26 apologized to resident and stated she would immediately change the bedding.
During an interview on 04/07/21 at 9:30 AM, the Director of Nursing acknowledged that it is the responsibility of all facility staff to create a homelike environment and promptly address any cleaning needs which would include changing soiled bed linens in a prompt fashion.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, documentation review and staff interview the facility failed to report an allegation of abuse and a disc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on observation, documentation review and staff interview the facility failed to report an allegation of abuse and a discrepancy of missing narcotics. This has the potential to affect a limited number of residents. Resident identifiers: #46 and #367. Facility census 69.
Findings included:
a) Review of the facility Abuse and Neglect Prohibition:
Reporting and response: The facility will report all allegations and substantiated occurrences of abuse, neglect, exploitation, mistreatment including injury of unknown origin, and misappropriation of property to the administrator, state service agency, and law enforcement officials and adult protective services.
If the event that causes the allegations involve abuse or result in serious bodily injury, a report in made not later than 2 hours after being notified of the allegation.
If the event that caused the allegation do not involve abuse and do not result in serious bodily injury, a report is made not later than 24 hours after being notified of the allegation.
b) Resident #46
During the initial tour on 04/05/21 01:13 PM, an observation in Resident #46's room revealed two (2) nursing assistances (NA) conversation. NA #25 stated, If you are going to put Resident #46 in bed, she needs to go to the bathroom first. NA #16 responded; we are not supposed to take Resident #46 to the bathroom unless she asks. NA #25 then ask, what do we do, let her use the bathroom in her depend? NA #16 shook her head yes and said that they could let her use the bedpan. This surveyor and NA #25 stepped out of Resident #46's room at this time.
An observation on 04/05/21 at 01:18 revealed, NA #25 closed the door as we were stepping out of Resident #46's room. Resident #46 was assisted directly to bed by NA #16.
A record review on 04/06/21 found, the 03/08/21 Significant Change Minimum Data Set (MDS), found the resident's brief interview for mental status was twelve (12) with Moderate Impairment. Section G functional status of the MDS revealed, Resident #46 needs extensive assistance of one (1), staff to provide weight bearing support for toileting and transfers.
A continued record review revealed Resident #46's Care Plan and [NAME] had extensive assist of one (1) staff for transfers and toileting.
During an Interview on 04/06/21 at 03:20 PM with the DON, This Surveyor reported the conversation between NA #16 and NA #25. The DON stated that it was inappropriate to make these comments. The DON said that she was unsure where this information about Resident #46 not being able to go to the toilet, unless she would ask, came from. The DON stated that we need to interview and educate our staff about this issue.
04/07/21 at 09:00 AM during an Interview with the DON she stated that she reported the incident to the Administrator on 04/06/21, when this surveyor reported it to her. The DON stated that she was going to write-up the two (2) NA staff members involved with a level one (1) and, re-educate the staff.
During an interview on 04/07/21 at 09:15AM with the Administrator and [NAME] Clinical Care Coordinator (RCCC) #86, The administrator stated she was informed of incident late in the day on 04/06/21 after the staff involved and the surveyors were already gone. The administrator stated NA #16 was off today and not back to work yet for the DON to interview her.
On 04/07/21 at 09:25 AM RCCC #86 stated she was going to get the DON and interview the Resident #46, at this time.
On 04/07/21 at 10:20 AM an Interview was conducted with Physical Therapist (PT) #60. PT #60 stated Resident #46 did have a decline in mobility, but there is no recommendation from Therapy Services about Resident #46 not being able to go the toilet unless she ask, and only to use a bed pan.
During an interview on 04/07/21 at 10:25 AM with Social Worker (SW)#63 stated that she went to talk to Resident #46 about the care she has received. SW #63 stated that resident #46 reported she can put on her call light when she wants to go to the bathroom and does not need to use a bed pan.
04/07/21 at 12:08 PM during an Interview with the Administrator and SW #63 the Administrator stated NA #16 and NA #25 was interviewed and suspended during the investigation. SW #63 stated the allegation was reported to Adult Protective Services (APS), OHFLAC and Nurse Aid Registry.
b) Resident #367
A review of facility documentation of the control medication utilization record, on 04/07/21 at 8:40 AM, revealed Resident had a quantity of 30 milliliter (ml) of morphine on 12/22/21. Resident #367 was given a dose of .5 ml on 01/22/21. A fixed count was conducted on 03/05/21 with the remaining amount of 26 ml in the locked medication box. The destruction of the medication box occurred on 03/12/21 with a remaining amount of 25.5 ml when destroyed.
A review of facility documentation of the pharmacy services shipment summary, on 04/07/21 at 8:45 AM, revealed Morphine Sulfate 20 mg/1 ml solution was delivered to the facility on [DATE].
A record review of the Medication Administration Record (MAR), on 04/07/21 at 8:50 AM, revealed one (1) dose of .5 ml was administered to Resident #367 on 01/22/21 with a pain level of six (6). The MAR revealed Resident #367 did not receive any other other doses of morphine in the months of February 2021 or March 2021.
A record review, on 04/07/21 at 8:55 AM, of the physician order dated 03/27/20 stated, Morphine Sulfate (Concentrate) Solution 20 MG/ML *Controlled Drug* Give 0.5 ml by mouth every one (1) hours as needed for Pain 7-10
An interview with Director of Nursing (DON), on 04/07/21 9:00 AM, revealed the discrepancy in morphine dosage was reported to the pharmacist. DON stated that the pharmacist did not seem concerned about the seven (7) missing morphine doses. DON stated that re-education was given to staff on not to hold the vial to read dosage in case in was read wrong. DON stated no report was completed for the missing morphine doses on 03/05/21 and the discrepancy was only discussed with the pharmacist so no reportable was completed.
An Interview with the Administrator, on 04/07/21 9:15 AM, revealed the discrepancy in the amount of morphine should have been investigated as to why there were missing doses. The Administrator stated the discrepancy should have been resolved and documented as to why there was a discrepancy. Administrator did not have any documentation to provide as to why there were missing morphine doses.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview the facility failed to accurately reflect a resident's status. The facility failed ...
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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 accurately reflect a resident's status. The facility failed to accurately assess residents on the minimum data set (MDS) for depression and oxygen. This was true for two (2) of 21 sampled residents. Resident identifiers: #26 and #61. Facility census: 69.
Findings included:
a) Resident #26
A record review, on 04/06/21 at 12:00 PM, revealed a physician order dated 02/20/21 that stated, oxygen at 2L/min via nose cannula qhs every night shift for COPD.
An additional record review, on 04/06/21 at 12:15 PM, revealed a medication administer record (MAR) for the month of March 2021. The MAR revealed Resident #26 was administered oxygen every night during the month of March 2021.
A record review, on 04/06/21 at 12:30 PM, revealed a quarterly minimal data set (MDS) dated [DATE] coded No for oxygen in section O0100 of the MDS.
An interview with Registered Nurse (RN) #62, on 04/06/21 at 12:50 AM, revealed oxygen should have been coded yes on the MDS dated [DATE].
b) Resident #61
A record review, on 04/06/21 at 1:45 PM, revealed a care plan that stated, I receive antidepressant medication because I have depression.
Further record review, on 04/06/21 at 2:00 PM, revealed a physician order for Sertraline HCI Tablet 100 MG give 100 mg by mouth one time a day for depression.
A record review, on 04/06/21 at 2:15 PM, revealed a modified quarterly minimum data set (MDS) dated [DATE] coded No for depression.
An interview with Social Worker #63, on 04/06/21 at 2:30 PM, confirmed Resident # 26 had depression at a level of Moderately Severe Depression as indicated on the Patient Health Questionnaire (PHQ-9 dated 02/10/21.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview the facility failed to provide pain management in accordance with professional standard. The facility failed to provide pain medication as prescribed by th...
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Based on record review and staff interview the facility failed to provide pain management in accordance with professional standard. The facility failed to provide pain medication as prescribed by the physician order. This was true for one (1) of three (3) sampled residents reviewed for hospitalization. Resident identifier: #367. Facility census: 69
Findings included:
a) Resident #367
A record review of the Medication Administration Record (MAR), on 04/07/21 at 8:50 AM, revealed one (1) dose of .5 ml was administered to Resident #367 on 01/22/21 with a pain level of six (6).
A record review, on 04/07/21 at 8:55 AM, of the physician order dated 03/27/20 stated, Morphine Sulfate (Concentrate) Solution 20 MG/ML *Controlled Drug* Give 0.5 ml by mouth every one (1) hours as needed for Pain 7-10
An interview, on 04/07/21 at 9:30 AM, with Registered Nurse (RN) #54 revealed based on the physician order morphine should not have been administered to Resident #367 on 01/22/21 with a pain level of six (6).
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
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Based on record review, staff interview and observation, the facility failed to implement an effective infection control program to prevent the development and transmission of communicable diseases ...
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Based on record review, staff interview and observation, the facility failed to implement an effective infection control program to prevent the development and transmission of communicable diseases and infections. Resident #137 was placed on the admission Hall of the facility. All residents on the admission Hall of the facility are placed on a fourteen (14) day quarantine related to COVID-19 precautions. Resident #137 had an order for contact isolation above and beyond the fourteen (14) day quarantine mentioned above. However, there was no signage to alert staff, other residents, or visitors that additional precautions were required when entering the resident's room. This was a random opportunity for discovery. Resident identifier: #137. Facility census: 69.
Findings included:
a) Resident #137
On 04/05/21 at 11:25 AM, an initial walk-thru of the facility revealed Resident #137's room was part of the admission Hall, where new residents are placed on fourteen (14) day quarantine related to COVID-19 precautions.
Review of Resident #137's medical record found an active physician's order stating: As of 3/24/2021 resident to be in contact isolation for CRE in urine and contact isolation for C-Diff.
Observation of Resident #137's room on 04/06/21 at 9:55 AM, revealed there was no signage to alert staff, visitors, or other residents that extra precautions were required when entering Resident #137's room.
Interview with Resident Care Specialist (RCS) #67 on 04/06/21 at 12:43 PM, revealed the employee was not aware Resident #137 was under any isolation precautions other than the fourteen (14) day quarantine related to COVID-19 precautions. When asked if there was anything she does differently when providing care for Resident #137 compared to other residents on the admission Hall, RCS #67 stated she does nothing different and that all residents are under a fourteen (14) day quarantine because they are new admissions.
When questioned, on 04/06/21 at 2:30 PM, about any special contact precautions Resident #137 was on that may be different from any other resident on the admission Hall for fourteen (14) day quarantine as new admits, LPN #26 reported that any staff in contact with Resident #137 should wash their hands with soap and water when performing hand hygiene explaining that alcohol-based hand rub (ABHR) would not be appropriate given the resident's diagnosis of C-Diff. Surveyor questioned if there was any signage outside of resident's room indicating the described protocol. LPN #26 acknowledged that there was no signage because everyone on the admission Hall was under isolation. When questioned how every staff member entering the room would know that ABHR would not be appropriate and that washing hands with soap and water was necessary, LPN #26 reported that if Resident #137's room was anywhere else in the facility there would normally be a sign on the door indicating the appropriate protocol.
On 04/07/21 at 9:45 AM, the Director of Nursing (DON) confirmed there was an active order for Resident #137 to be on contact isolation for CRE in urine and contact isolation for C-Diff. The DON acknowledged there was no signage on the door.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to ensure five (5) of twenty-one residents reviewed during 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 five (5) of twenty-one residents reviewed during the long-term care survey process had advance directives completed as recognized by State Law. Resident identifiers: #52, #64, #269, #271, #272. Facility census: 69.
Findings included:
a) Resident #64
Record review, on [DATE] at 1:50 PM, found a [NAME] Virginia Physician Orders for Scope of Treatment (POST) form signed and dated on was on Resident #64's chart.
Section A of the POST form directed Resident #64 wished to receive Cardiopulmonary Resuscitation (CPR) in the event she had no pulse and was not breathing.
Section B entitled, Medical Interventions, was left blank.
Section C entitled, Medically Administered Fluids and Nutrition was left blank. No directive was given regarding Resident #64's expressed wishes regarding either receiving or not receiving IV fluids as well as either receiving or not receiving tube feeding.
Section D was also left blank. This section would normally note who the POST form was discussed with (patient/resident, health care surrogate, medical power of attorney, etc.)
The POST form was signed by Resident #64, but no date was provided. The physician signed and dated the POST form on [DATE].
In 2002, the POST form was incorporated into the [NAME] Virginia Health Care Decisions Act, which was enacted to ensure that a patient's right to self-determination in healthcare decisions be communicated and protected (§16-30-2).
On [DATE] at 12:52 PM, the Director of Nursing (DON) acknowledged there was no way to know what Resident #64's treatment wishes are in the areas left blank. The DON confirmed the POST form was not completed in its entirety, did not adequately reflect Resident #64's treatment preferences, and the form should be updated.
b) Resident #269
Record review, on [DATE] at 2:08 PM, found a [NAME] Virginia Physician Orders for Scope of Treatment (POST) form signed and dated on [DATE] was on Resident #269's chart.
Section A of the POST form directed Resident #269 wished to receive Cardiopulmonary Resuscitation (CPR) in the event she had no pulse and was not breathing.
Section B entitled, Medical Interventions, directed Resident #269 was to have Full Interventions. It further clarified that full interventions included intubation, advanced airway interventions, mechanical ventilation, cardioversion as indicated, transfer to hospital if indicated, and include intensive care unit.
Section C entitled, Medically Administered Fluids and Nutrition was left blank. No directive was given regarding Resident #269's expressed wishes regarding either receiving or not receiving IV fluids as well as either receiving or not receiving tube feeding.
In 2002, the POST form was incorporated into the [NAME] Virginia Health Care Decisions Act, which was enacted to ensure that a patient's right to self-determination in healthcare decisions be communicated and protected (§16-30-2).
On [DATE] at 12:51 PM, the Director of Nursing (DON) acknowledged that there was no way to know what Resident #269's treatment wishes are regarding IV fluids or a feeding tube. The DON confirmed the POST form was not completed in its entirety, did not adequately reflect Resident #269's treatment preferences, and the form should be updated.
c) Resident #271
Record review, on [DATE], at 2:13 PM found a [NAME] Virginia Physician Orders for Scope of Treatment (POST) form signed and dated on [DATE] was on Resident #271's chart.
Section A of the POST form directed Resident #271 wished to receive Cardiopulmonary Resuscitation (CPR) in the event she had no pulse and was not breathing.
Section B entitled, Medical Interventions, directed Resident #271 was to have Full Interventions. It further clarified that full interventions included intubation, advanced airway interventions, mechanical ventilation, cardioversion as indicated, transfer to hospital if indicated, and include intensive care unit.
Section C entitled, Medically Administered Fluids and Nutrition was left blank. No directive was given regarding Resident #271's expressed wishes regarding either receiving or not receiving IV fluids as well as either receiving or not receiving tube feeding.
In 2002, the POST form was incorporated into the [NAME] Virginia Health Care Decisions Act, which was enacted to ensure that a patient's right to self-determination in healthcare decisions be communicated and protected (§16-30-2).
On [DATE] at 12:53 PM, the Director of Nursing (DON) acknowledged that there was no way to know what Resident #271's treatment wishes are regarding IV fluids or a feeding tube. The DON confirmed the POST form was not completed in its entirety, did not adequately reflect Resident #271's treatment preferences, and the form should be updated.
d) Resident #272
Record review, on [DATE] at 2:00 PM, found a [NAME] Virginia Physician Orders for Scope of Treatment (POST) form on was on Resident #272's chart.
Section A of the POST form directed Resident #272 wished to receive Cardiopulmonary Resuscitation (CPR) in the event she had no pulse and was not breathing.
Section B entitled, Medical Interventions, was left blank.
Section C entitled, Medically Administered Fluids and Nutrition was left blank. No directive was given regarding Resident #272's expressed wishes regarding either receiving or not receiving IV fluids as well as either receiving or not receiving tube feeding.
Section D was also left blank. This section would normally note who the POST form was discussed with (patient/resident, health care surrogate, medical power of attorney, etc.)
The POST form was not signed and dated by Resident #272. The physician signed and dated the POST form on [DATE].
In 2002 the POST form was incorporated into the [NAME] Virginia Health Care Decisions Act, which was enacted to ensure that a patient's right to self-determination in healthcare decisions be communicated and protected (§16-30-2).
On [DATE] at 12:54 PM, the Director of Nursing (DON) acknowledged there was no way to know what Resident #272's treatment wishes are in the areas left blank. The DON confirmed the POST form was not completed in its entirety, did not adequately reflect Resident #272's treatment preferences, and the form should be updated.
e) Resident #52
A record review, on [DATE] at 3:41 PM, of the Physician Orders for Scope Treatment (POST) revealed Resident #52's name, Physician's name and date. The post form had no other medical information completed and was blank.
An Interview with licensed practical nurse (LPN) #23, on [DATE] 3:45 PM, confirmed the POST form should have been completed on admission and the POST form was incomplete.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
.
Based on observation, resident interview and staff interview, the facility failed to provide respiratory care and services in accordance with professional standards. The facility failed to properly ...
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Based on observation, resident interview and staff interview, the facility failed to provide respiratory care and services in accordance with professional standards. The facility failed to properly store a nasal cannula in a bag when oxygen was not in use. The facility failed to post cautionary and safety signs of oxygen in use signs on the doors of residents that were ordered oxygen. This was a random opportunity for discovery. The failed practice was true for 15 of 15 residents who were physician ordered oxygen. Resident identifiers: #3, 18, 19, 26, 33, 35, 39, 43, 55, 59, 61, 64, 267, 269 and 368. Facility census: 69.
A policy review, on 04/06/21, titled Oxygen Storage and Assembly with revision date 01/2017, stated, Post an oxygen safety warning sign outside the room where oxygen is stored or in use.
Findings included:
a) Oxygen Storage
An observation, on 04/05/21 at 12:17 PM, revealed Resident #61's oxygen nose piece was on the floor.
An immediate interview with Resident #61, on 04/05/21 at 12:18 PM, revealed the staff made her bed and it fell off into the floor and no one picked it up. Resident #61 stated, staff always comes in to make my bed and the nasal cannula falls into the floor.
An interview with Resident Care Specialist (RCS) #25, on 04/05/21 at 12:20 PM, confirmed the oxygen tubing and nasal cannula should not have been on the floor. RCS #25 stated the nasal cannula should be placed in the bag located in front of the oxygen concentrator.
b) Oxygen In-Use Signs
Multiple observations on 04/06/21 was completed throughout the facility and revealed no cautionary/safety signs on residents' doorways indicating the use of oxygen. Residents who were ordered oxygen included Resident #3, #18, #19, #26, #33, #35, #39, #43, #55, #59, #61, #64, #267, #269, and #368.
An interview with Director of Nursing (DON), on 04/06/21 at 1:10 PM, revealed there are no signs on the residents doors that have oxygen because the facility did not have enough oxygen in use signs so more will need to be ordered.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**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...
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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. Medications stored in a medication storage room were expired and two (2) of two (2) medication carts inspected did not have medications dated when opened when put in to use.
This practice had the potential to effect more than a limited number of residents. Facility census: 69.
Findings included:
a. Medication Cart Observation
1.) An observation of the South 2 Medication cart, on [DATE] at 07:46 AM, revealed a bottle of Vitamin E that was open and being used but was not dated when opened and put in to use.
An interview with Licensed Practical Nurse #23 (LPN #23) on [DATE] at 7:06 AM, confirmed the bottle was not dated when opened and according to policy should have been.
2. An observation of the North 1 Medication cart, on [DATE] at 08:20 AM, revealed a bottle of Liquid Robitussin opened with no date of when the bottle was opened and put into use.
An interview with Registered Nurse #23 (RN #23), on [DATE] at 08:20 AM, revealed the bottle of Robitussin had no date and was being used. It was further stated all stock medications are to be dated when opened.
b. South Medication Storage Room
An observation of the South Medication Storage Room, on [DATE] at 09:30 AM , revealed seven (7) expired Acetaminophen suppositories with a date of expiration of [DATE].
An interview, with the Director of Nursing, (DON), on [DATE] at 09:30 AM, verified the medication was expired and should have been discarded.
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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, 2 life-threatening violation(s), Special Focus Facility, 1 harm violation(s), $148,460 in fines. Review inspection reports carefully.
- • 80 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $148,460 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 Morgantown Heights Of Journey's CMS Rating?
CMS assigns MORGANTOWN HEIGHTS 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 Morgantown Heights Of Journey Staffed?
CMS rates MORGANTOWN HEIGHTS OF JOURNEY's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes.
What Have Inspectors Found at Morgantown Heights Of Journey?
State health inspectors documented 80 deficiencies at MORGANTOWN HEIGHTS OF JOURNEY during 2021 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, 76 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Morgantown Heights Of Journey?
MORGANTOWN HEIGHTS 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 100 certified beds and approximately 78 residents (about 78% occupancy), it is a mid-sized facility located in MORGANTOWN, West Virginia.
How Does Morgantown Heights Of Journey Compare to Other West Virginia Nursing Homes?
Compared to the 100 nursing homes in West Virginia, MORGANTOWN HEIGHTS 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 Morgantown Heights 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 Morgantown Heights Of Journey Safe?
Based on CMS inspection data, MORGANTOWN HEIGHTS 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 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in West Virginia. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Morgantown Heights Of Journey Stick Around?
MORGANTOWN HEIGHTS 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 Morgantown Heights Of Journey Ever Fined?
MORGANTOWN HEIGHTS OF JOURNEY has been fined $148,460 across 1 penalty action. This is 4.3x the West Virginia average of $34,563. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Morgantown Heights Of Journey on Any Federal Watch List?
MORGANTOWN HEIGHTS OF JOURNEY is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.